Pacifica Hospital Of The Valley Dp Snf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely use side rails for five of six sampled residents (Resident 6, 8, 24, 29, 55) by failing to: 1.Having a physician's order for Resident 55 and Resident 6's use of side rails and follow the physician's order for bilateral side rails up at all times, when all four side rails were observed up. 2. Assess Residents 6, 8, 24, 29, and 55 for risk of entrapment from bed rails prior to installation and obtain informed consent prior to use of side rails. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm (mental, emotional, or physical injuries caused by social factors, or stressful interactions, rather than physical accidents), physical harm and risk for entrapment (getting stuck). Findings:
a. During a review of Resident 6's Patient Registration Form, the Registration Form indicated the facility admitted the resident on 6/3/2022.
During a review of Resident 6's History and Physical (H&P), dated 1/26/2026, the H&P indicated Resident 6 had diagnoses including tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe). and dysphagia (difficulty swallowing). The H&P further indicated Resident 6 did not have the capacity to make his own decisions.
During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/8/2026, the MDS indicated Resident 6 had some cognitive decline but is able to make himself understood and understand others.
During a review of Resident 6's Order Summary Report, the report included and order dated 6/3/2026 for bilateral side rails up at all times every shift.
During a review of Resident 6's Side Rails Care Plan (CP), initiated on 6/27/2026, the CP had an intervention to use side rails as indicated.
During an observation on 2/9/2026, at 9:58 a.m., inside Resident 6's room, Resident 6 was sitting up in bed with four side rails up (upper and lower).
During a concurrent observation and interview on 2/9/2026, at 10:33 a.m., inside Resident 6's room with Registered Nurse (RN 1), RN 1 looked at the bed rails and stated four side rails are up, but that she believed it should be only two.
During a concurrent interview and record review on 2/9/2026 at 1:05 p.m. with RN 1, RN 1 reviewed Resident 6's electronic and paper medical record. RN 1 stated there was an order for only bilateral (two) side rails up and all four should not have been up for Resident 6's safety. RN 1 searched and stated there was not a consent for the use of bed rails or an assessment for entrapment. RN 1 stated residents should be assessed for entrapment to prevent injuries, and the responsible party should have the opportunity to consent for the use of side rails after being informed of the risks and benefits prior to use.
During an interview on 2/10/2026, at 10:08 a.m., with the Director of Nursing (DON), the DON stated prior to installation of the side rails on the resident's bed they should have had a physician's order, consent for the use of the bedrail, and assessment for entrapment, to ensure appropriate use and safe use of the bedrail for the residents.
During a review of the facility's recent policy and procedure (P&P) titled, Side Rail Assessment, last reviewed on 1/29/2026, the P&P indicated a siderail assessment was to be completed every 3 months.
During a review of the facility's recent policy and procedure (P&P) titled, Informed Consent, last reviewed on 1/29/2026, the P&P indicated there must be a signed a signed consent for all treatments and procedures.
During a review of the facility's recent policy and procedure (P&P) titled, Orders, Physicians, last reviewed on 1/29/2026, the P&P indicated accuracy must be assured with all physician's orders.
b. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli.
During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed).
During an observation on 2/9/2026, at 12:10 p.m., in Resident 8's room, Resident 8 was lying down in bed with four side rails up (upper and lower).
During a review of Resident 8's Order Summary Report dated 2/26/2025, the Order Summary Report indicated physician order for bilateral (two sides) side rails up at all times every shift.
During a concurrent observation and interview on 2/10/2026 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 6 and Registered Nurse (RN) 4 in Resident 8's room, Resident 8's bed was observed having four side rails up. LVN 6 stated four side rails were up to prevent Resident 8 from falling.
c. During a review of Resident 24's Patient Registration Form, the Patient Registration Form indicated Resident 24 was admitted to the facility on [DATE].
During a review of Resident 24's H&P dated 10/13/2025, the H&P indicated Resident 24 was admitted to the facility with diagnoses including traumatic encephalopathy following head injury(permanent brain damage that happens after many head injuries), history of respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), permanent tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The H&P indicated Resident 24 was awake, responsive, able to verbalize slightly.
During a review of Resident 24's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 24 had moderately impaired cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 24 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 24 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed).
During an observation on 2/9/2026, at 12:15 p.m., in Resident 24's room, Resident 24 was lying down in bed with four side rails up (upper and lower).
During a review of Resident 24's Order Summary Report dated 12/22/2025, the Order Summary Report indicated a physician order for bilateral padded side rails for seizure precautions every shift.
During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with LVN 6 and RN 4 in Resident 24's room, Resident 24's bed was observed having 4 side rails up with no padding. LVN 6 stated four side rails were up to prevent Resident 24 from falling. LVN 6 stated Resident 24 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure episode.
d. During a review of Resident 29's Patient Registration Form, the Patient Registration Form indicated Resident 29 was admitted to the facility on [DATE].
During a review of the H&P report dated 12/10/2025, the H&P indicated Resident 29 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic subdural hemorrhage (a head injury causes blood vessels to tear and leak blood between the brain and its outer covering), dysphagia (difficulty swallowing).
During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had moderate cognitive impairment. The MDS indicated Resident 29 was dependent from staff with all ADL, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 29 was dependent with chair/bed-to-chair transfer.
During an observation on 2/9/2026, at 12:20 p.m., in Resident 29's room, Resident 29 was lying down in bed with four side rails up (upper and lower) with no padding.
During a review of Resident 29's Order Summary Report dated 5/5/2024, the Order Summary Report indicated physician order for bilateral (two sides) padded side rails at all times every shift.
During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with Licensed Vocational Nurse (LVN) 6 in Resident 29's room, Resident 29's bed was observed with all 4 side rails up with no padding. LVN 6 stated four side rails were up to prevent Resident 29 from falling. LVN 6 stated Resident 29 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure.
e. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE].
During a review of the H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was comatose. Resident 55 was dependent from staff with all ADLs, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to lying on back on the bed).
During an observation on 2/9/2026, at 12:20 p.m., in Resident 55's room, Resident 55 was lying down in bed with four side rails up (upper and lower) with no padding.
During a concurrent interview and record review on 2/10/2026 at 2:06 p.m. with LVN 6 of Resident 55's Care Plan Report dated 6/20/2026, the Crae Plan Report indicated bilateral padded side rails were to remain up all times for seizure precautions. However, the Physician Order Summary did not indicate documentation of an order to maintain padded side rails up at all times for seizure precautions. LVN 6 stated Resident 55 had a history of seizure disorder.
During a concurrent observation and interview on 2/10/2026 at 2:07 p.m. with LVN 6 in Resident 55's room, Resident 55's bed was observed having 4 siderails up with no padding on any of the siderails. LVN 6 stated without an order and padding in place, Resident 55 could be at increased risk for head injury or trauma in the event of seizures.
During a concurrent interview and record review on 2/10/2026 at 2:10 p.m. with RN 4, RN 4 reviewed Resident 24, Resident 8, Resident 29 and Resident 55's electronic and paper medical records. RN 4 stated there was an order for bilateral padded side rails up for seizure precautions and having four side rails raised without padding was not according to the physician's order for Resident 24 ,8 , 29 and 55. RN 4 stated there was no documented entrapment risk assessment and no documented consent for the use of bed rails. RN 4 stated this practice had the potential to place Resident 24,8, 29 and 55 at risk for injury and entrapment. RN 4 further stated residents/RP should have the opportunity to consent for side rails to ensure the benefits outweigh the risks.
During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated side rails must have doctors order before they are used. The DON stated that if a physician's order indicates bilateral side rails, staff should not raise all four side rails by default. Using all four side rails considered a restraint. The DON stated it was not acceptable to maintain side rails up at all times without documented consent from the residents or RP. Residents/RPs must be aware of possible risks, benefits, and other available options. The DON added that the facility must assess residents for entrapment risk or admission, at lease quarterly, and on an ongoing basis. If residents become trapped between mattress and the side rail, it can lead to serious harms and even death.
During a review of the facility's recent policy and procedure (P&P) titled, Side Rail Assessment, last reviewed on 1/29/2026, the P&P indicated a siderail assessment was to be completed every 3 months.
During a review of the facility's policy and procedure (P&P) titled, Informed Consent for Procedures and Treatments, reviewed in December 2025, the P&P indicated there must be a signed consent for all treatments and procedures.
During a review of the facility's P&P titled, Orders, Physicians, reviewed in December 2025, the P&P indicated accuracy must be assured with all physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: Label one (1) open insulin (medication used to regulate blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar pen (a type of device containing insulin) stored at room temperature for Resident 4, in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) Store eye drop and ear drop medications separately, in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) These deficient practices increased the risk that Resident 4 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and increase the risk of contamination and receiving medications via the wrong route for residents in the facility, resulting in the negative impact to their health and well-being possibly leading to health complications, hospitalization, or death. Based on observation, interview, and record review the facility failed to: 1.Label one (1) open insulin (medication used to regulate blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar pen (a type of device containing insulin) stored at room temperature for Resident 4, in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) 2. Store eye drop and ear drop medications separately, in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) These deficient practices increased the risk that Resident 4 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and increase the risk of contamination and receiving medications via the wrong route for residents in the facility, resulting in the negative impact to their health and well-being possibly leading to health complications, hospitalization, or death. Findings: During an observation on [DATE] at 1:48 p.m., in Medication Cart Subacute 2 Cart 2 , and in the presence of Licensed Vocational Nurse (LVN) 3, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: -One (1) open and used insulin Lantus for Resident 4 was found stored at room temperature without a date indicating when storage or use at room temperature began. According to the manufacturer's product labeling, open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen. Three (3) insulin Lantus Solostar pens, one (1) earwax softener drops, and one (1) lubricant eye drops were stored in the same bin/compartment of the medication cart. During a concurrent interview with LVN 3, LVN 3 stated insulin Lantus Solostar pen for Resident 4 was open, used, stored at room temperature, and not labeled with a date when use at room temperature began. LVN 3 stated insulin pen was considered a multi-dose (having more than one [1] dose) medication. LVN 3 stated according to manufacturer directions the Lantus pen needed to be discarded after 28 days of use, and after that day the insulin loses potency (the strength of medication) and considered expired. LVN 3 stated that LVN 3 was unaware when the insulin Lantus Solostar pen for Resident 4 was opened or stored at room temperature therefore unknown when it would expire. LVN 3 stated administering expired insulin in error will not be effective in keeping the blood sugar stable and can harm Resident 4 by causing high blood sugar levels, leading to shock and coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. LVN 3 stated the Lantus Solostar pen needed to be removed from the medication cart and replaced with new ones from pharmacy to ensure expired insulin was not administered in error to Resident 4. During the same interview, LVN 3 stated that internally administered medications, such as oral tablets and injections, and externally administered medications, such as eye drops and ear drops, should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible infections/contaminations. LVN 3 acknowledged one (1) medication bin containing three (3) insulin pens, one (1) ear drop and one (1) eye drop. LVN 3 stated the facility failed not to separate and store ear drops separate from eye drop medications. During an interview on [DATE] at 3:45 p.m., with the Director of Nursing (DON,) the DON stated the insulin Lantus Solostar pen for Resident 4 was not labeled with a date when the pen was first opened and used. The DON stated several LVN's failed to label the date the pen was opened and used. The DON stated without knowing when the Lantus Solostar pen was opened it was unknown when it would expire, increasing the risk of administration of expired insulin to Resident 4. The DON stated expired insulins have lost potency and effectiveness and when administered in error were not effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar level) and adverse effects for Resident 4, potentially resulting in hospitalization due to Diabetic Ketoacidosis ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening.) The DON stated the Lantus Solostar pen needed to be replaced with a new one from pharmacy. During the same interview, the DON stated ear drops and eye drops should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store ear drop and eye drop medication in separate bins/compartments in Medication Cart Subacute 2 Cart 2. During a review of the facility's Policy & Procedures (P&P,) titled Storage of Medications, last reviewed [DATE], the P&P indicated Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier. e. Eye medications shall be kept separate from ear medications. ii. Once a refrigerated item such as multi-dose insulin vials are opened, the nurses write down the open date and it must be discarded according to storage table 1 below from the date open. If the refrigerated item is a unit dose item such as pens, then each individual pen may have its own date opened and be discarded according to storage table 1 from the date opened. During a review of the facility's appendix to Storage of Medications P&P titled Storage Table 1, last reviewed [DATE], the table indicated: Lantus (glargine) - Good for 28 days after opening or removing from refrigerator. During a review of manufacturer guideline, titled Highlights of Prescribing Information for Lantus, dated 6/2022, the guide listed the following: Only use your pen for up to 28 days after its first use. Throw away the LANTUS SoloStar pen you are using after 28 days, even if it still has insulin left in it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of four residents (Residents 44, 29 and 55) reviewed under the accident care area by failing to: a. Provide upper bed rail padding for Resident 44, who had a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). b. Apply bed side rail padding for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions as ordered by the physician for Resident 29. c. Ensure implementation of appropriate seizure precautions for Resident 55 with a documented history seizure disorder, as Resident 55 was observed with side rail up without padding and had no order for padded side rails. These deficient practices placed Residents 44, 29 and 55 at risk of injury and trauma during seizures. Findings:
a. During a review of Resident 44's Patient Registration Form, the Patient Registration Form indicated the facility admitted Resident 44 on 3/27/2025.
During a review of Resident 44's History and Physical (H&P), dated 1/26/2026, the H&P indicated Resident 44's had diagnoses including seizures assessment plan included seizures and tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe). The H&P further states Resident 44 was unable to make his own decisions.
During a review of Resident 44's Minimum Data Set (MDS – an assessment and care screening tool) dated 11/20/2025, the MDS indicated the resident rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 44 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 44's Physician's Order printed on 2/11/2026, the Physician's Order indicated an order dated 5/20/2025, for bilateral padded side rails up at all times.
During an observation on 2/9/2026 at 9:26 a.m. in Resident 44's room, Resident 44 was lying in bed with his eyes closed. The upper bed rails on Resident 44's bed were made of metal and were not padded.
During a concurrent observation and interview on 2/9/2026 at 9:33 a.m. in Resident 44's room with Registered Nurse (RN 1), RN 1 stated Resident 44's bed did not have the necessary padding on his bedrails to keep him safe during a seizure. RN 1 stated the padding is to protect the resident's head and body from the uncontrolled shaking from seizures.
During an interview on 2/9/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON stated the facility staff did not follow the physician's instructions to apply padding to Resident 44's side rails and without them Resident 44 could sustain injuries if he had seizure.
During a review of the facility provided Policy and Procedure (P&P) titled, Seizure Precautions last reviewed on 1/29/2026, the P&P indicates to provide a safe environment and pad side rails as indicated.
b. During a review of Resident 29's Patient Registration Form, the Patient Registration Form indicated Resident 29 was admitted to the facility on [DATE].
During a review of the H&P report dated 12/10/2025, the H&P indicated Resident 29 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic subdural hemorrhage (a head injury causes blood vessels to tear and leak blood between the brain and its outer covering), dysphagia (difficulty swallowing).
During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had moderate cognitive impairment (decisions poor; cues/supervision required). The MDS indicated Resident 29 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 29 was dependent with chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair).
During a review of Resident 29's Order Summary Report dated 5/5/2024, the Order Summary Report indicated physician order for bilateral (two sides) padded side rails at all times every shift.
During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with Licensed Vocational Nurse (LVN) 6 in Resident 29's room, Resident 29's bed was observed with all 4side rails up with no padding. LVN 6 stated Resident 29 was at risk for seizures. LVN 6 stated Resident 29 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure.
c. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].

During a review of the H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was comatose. Resident 55 was dependent from staff with all ADLs, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to lying on back on the bed).

During a concurrent interview and record review on 2/10/2026 at 2:08 p.m. with LVN 6 of Resident 55's Care Plan Report dated 6/20/2026 indicated bilateral padded side rails were to remain up all times for seizure precautions. However, the Physician Order Summary did not indicate documentation of an order to maintain padded side rails up at all times for seizure precautions. LVN 6 stated Resident 55 had a history of seizure disorder.

During a concurrent observation and interview on 2/10/2026 at 2:10 p.m. with LVN 6 in Resident 55's room, Resident 55's bed observed having 4 siderails up with no padding on any of the siderails. LVN 6 stated without an order and padding in place, Resident 55 could be at increased risk for head injury or trauma in the event of seizures.

During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated that Residents 29, 44, and 55 were on seizure precautions. The DON stated that seizure precautions should follow the physician's orders and individualized assessments. The DON stated that failure to follow ordered interventions and implement seizure precautions, including padded side rails when indicated, could place residents at serious risk of harm. The DON added that unpadded side rails during a seizure could cause injuries such as head trauma, fractures, skin breakdown or even death.

During a review of the facility's policy and procedure (P&P) titled, Seizure Precautions, reviewed/revised on December 2025, the P&P indicated, It is the policy of the facility to provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible. Identify residents with potential for seizure activity on the resident's care plan. Provide safe environment. Pad side rails as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 1 and Resident 8) by failing to keep Resident 1 and Resident 8's urinary indwelling catheter (a tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. This deficient practice had the increased potential for Resident 1 and Resident 8 to develop catheter associated urinary tract infection (CAUTI - UTI developed in a resident with an indwelling catheter).
Findings:
a. During a review of Resident 1's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 1 to the facility on [DATE].
During a review of the History and Physical (H&P) report completed on 12/1/2025, the H&P indicated Resident 1 was admitted to the facility with diagnosis that included acute hypoxemic respiratory failure (a medical emergency where the lungs suddenly cannot transfer enough oxygen into the bloodstream to preserve normal organ function), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and history of urinary tract infection (UTI – an infection of the urinary system, which includes the kidneys, ureters, bladder and urethra).
During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 1's cognitive skills for decision making are severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing.
During a review of Resident 1's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 11/29/2025 for Foley catheter size 16x10 every shift for wound management.
During a concurrent observation and interview on 2/10/2026 at 4:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 was lying down in bed with a urinary catheter bag hanging on the left side of the resident's bed frame with amber yellow liquid. Observed a dependent loop (is when a tubing dips downward and traps fluid, which can block proper drainage) with urine collecting in the catheter tubing close to the resident's urethral meatus (external opening at the end of the penis in male or above the vaginal opening in females where urine exits the body). Resident 1 had an empty leg strap (band that secures a catheter or drainage bag to the thigh or calf to ensure the bag stays in the correct position for drainage) on his left thigh without the catheter attached. LVN 1 stated the leg strap should be holding the catheter to prevent dislodgement and maintain the position of the catheter where the urine flows downward from when it empties from the resident's bladder. LVN 1 stated improper placement of urine catheter may cause urine to flow back to the resident and cause a UTI. LVN 1 also stated that there is a risk of it becoming clogged if urine cannot flow freely.
During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated that urine catheter should be secured with a leg strap with the urinary catheter bag hanging below the level of the bladder. The DON emphasized that the catheter tubes should not be kinked or contain any dependent loops, as this may cause urine to flow back and potentially result in a urinary tract infection (UTI).
During a review of Resident 1's care plan (CP) titled, The resident has indwelling urinary catheter indicated for wound management. At risk for urinary tract infection. At risk for urine backflow due to resident moving catheter, the CP indicated to apply leg strap as indicated and maintain proper alignment of indwelling catheter free of kinks.
b. During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE].
During a review Resident 8's H&P dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), and diabetes mellitus. Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli.
During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was comatose. Resident 8 was dependent from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right.
During a concurrent observation and interview on 2/10/2026 at 10:55 a.m. with RN 3 in Resident 8's room, Resident 8 was observed to have suprapubic indwelling urinary catheter (urinary catheter inserted through the area just above the pubic bone) securely attached to Resident 8's left thigh then to the drainage tube (the tube connecting a urine catheter to a drainage bag) laid over a positioning wedge (a firm foam triangle used to support, stabilize, or elevate specific body parts while a person is in bed). RN 3 stated the tubing was above the level of Resident 8's bladder, and urine was visibly backing up toward the resident's body. RN 3 further stated this positioning of the tubing could increase the risk for UTIs and CAUTIs.
During an interview on 2/12/2026 at 3:00 p.m. with the DON, the DON stated it was not acceptable practice for catheter tubing to be positioned above the level of residents' bladder level. The DON explained that the tubing must remain below bladder level and the drainage bag should not touch the floor. The DON further stated that positioning the tubing above the bladder can interfere with urine flow, potentially causing obstruction and increasing the risk of CAUTIs.
During a review of the facility's P&P titled, Infection Control Plan 2025 last reviewed 1/29/2026, the P&P indicated, Pacifica Hospital of the Valley to maintain a comprehensive and effective program of surveillance, prevention, and control of infection.The organization will employ a coordinated process to reduce the risks of endemic and epidemic, or healthcare-associated infection(s) in patients and healthcare workers. Infection Prevention will be comprehensive and address issue(s) identified as epidemiologically significant and demographically sound. These issues include but are not limited to the following: Device-related infections, especially those associated with intravascular devices, urinary catheters, and ventilators.Risk Mitigation: Adherence to CDC guidelines and toolkits: Catheter-associated urinary tracts infections (CAUTI).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1.Have immediate access to controlled substances ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) and medication emergency kit ([eKIT] - kit containing medications needed to be used during emergencies) stored in the refrigerator in one (1) of two (2) observed Medication Rooms (Medication Room Subacute 2.) 2. Include the verifying signatures of two (2) licensed nurses on the Facility Medication Destruction Form observed in Medication Room Subacute 2, for four (4) of four (4) sampled records. As a result, control and accountability of medications disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. 3. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication eKITs containing CSs for February 2026, in two (2) of two (2) inspected Medication Rooms (Medication Room Subacute 2 and Medication Room Subacute 3.) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. 4.Complete an accurate CS reconciliation at shift change on 2/9/2026 in one (1) of three (3) observed Medication Carts (Medication Cart Subacute 2 Cart 2.) As a result, control and accountability of CSs did not follow facility policy and procedures. These deficient practices increased the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increased the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. Findings: During a concurrent observation and interview on 2/9/2026 at 11:30 a.m., with Registered Nurse (1), in Medication Room Subacute 2, RN 4 could not open the double locks on a plastic clear rectangular container inside the refrigerator. RN 4 stated the container with the double lock contained CSs for several residents and an eKIT. RN 4 asked several other nurses to open the locks but none of the keys opened the container. The pharmacy department and engineering departments were called to assist in opening the container. During a concurrent record review and interview on 2/9/2026 at 11:40 a.m., with RN 4, in Medication Room Subacute 2, RN 4 reviewed four (4) Facility Medication Destruction Form records dated 1/2/2026 and 2/9/2026. RN 4 stated RN 4 was unable to locate the signatures or names of the licensed nurses on the four (4) logged disposition records. RN 4 stated that licensed nurses failed to follow state requirements and facility policy of signing the logs with a witness when disposing medications. During a review of Facility Medication Destruction Form, dated 1/2/2026, 1/2/2026, 2/9/2026 and 2/9/2026, the four (4) forms indicated the prepared by, checked by and verified by sections were empty, not signed or identified who completed the destruction of the listed medications. During an observation on 2/9/2026 at 12:08 p.m., in Medication Room Subacute 2, the Director of Pharmacy (DOP) arrived and stated that the DOP does not have keys to the plastic container inside the refrigerator. During an observation on 2/9/2026 at 12:25 p.m., in Medication Room Subacute 2, the Engineering department arrived and stated that Engineering department does not have keys to the container. During an observation and concurrent interview on 2/9/2026 at 12:30 p.m., with Registered Nurse (RN) 4, in Medication Room Subacute 2, there was one (1) medication eKIT stored in the refrigerator and labeled 2, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. During a concurrent interview, RN 4 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. RN 4 stated the eKIT labeled 2 containing CSs in Medication Room Subacute 2 was not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During a concurrent record review and interview on 2/9/2026 at 12:40 p.m., with Licensed Vocational Nurse (4), LVN 4 reviewed the Floor Narcotic Release log in Medication Cart Subacute Cart 2. LVN 4 stated the Floor Narcotic Release log was the facility's CS accountability record was used for the daily CS reconciliation (review of inventory by 2 people to identify discrepancies) at each shift change and signed with the on-coming and retiring (out-going) nurses, after completing all CS inventory, including refrigerated CSs. LVN 4 stated that LVN 4 (on-coming) and LVN 5 (out-going) could not open the locked plastic clear rectangular container containing CSs inside the refrigerator, and as a result could not verify the count of the CSs inside the refrigerator. LVN 4 stated that LVN 4 and LVN 5 signed the log at 7 a.m. on 2/9/2026 for Medication Cart Subacute Cart 2 without verifying the CS inventory count in the refrigerator. LVN 4 stated that accurate CS reconciliation was important to know the amount of medications available, and if not done properly it can lead to delayed medication treatment and harm residents by not treating their condition requiring hospitalization and leading to possible death. During a review of the Floor Narcotic Release log labeled Cart 2, the log indicated LVN 4 and LVN 5 signed for the completion of the CS reconciliation on 2/9/2026 at 7 a.m. and indicated that the narcotic counts were accurate and that there were no shortages or overages. During an observation on 2/9/2026 at 1 p.m., with RN 4 in Medication Room Subacute 2, the plastic clear rectangular container inside the refrigerator was open. RN 4 stated the keys would get stuck but after several attempts the locks opened. RN 4 acknowledged the following medications were stored inside the container: midazolam (a CS used for seizures [sudden, uncontrolled body movements caused by abnormal electrical activity in the brain leading to loss of muscle control and shaking]) 5mg/ml one (1) ml vial for Resident 11 midazolam 5mg/ml one (1) ml vial for Resident 43 midazolam 5mg/ml one (1) ml vial for Resident 44 midazolam 5mg/ml one (1) ml vial for Resident 49 midazolam 5mg/ml one (1) ml vial for Resident 55 eKIT labeled 24 containing Ativan (a CS used for seizure and anxiety) 2mg/ml one (1) ml vial for facility stock. During a concurrent interview, RN 4 stated it was important to have access to critical medications to provide immediate care to residents. RN 4 stated the facility could not open the locks to the plastic container inside the refrigerator on 2/9/2026 between 11:30 a.m. and 1 p.m. RN 4 stated midazolam and Ativan were used for seizures and need to be administered immediately upon a physician's order. RN 4 stated seizure was considered an emergency and not having timely access to midazolam and Ativan could lead to delay in care and harm Resident 11, 43, 44, 49, 55 and others experiencing seizures, by not controlling the seizure, and leading to hospitalization and/or potential death. During an observation and concurrent interview on 2/9/2026 at 1:57 p.m., with RN 2, in Medication Room Subacute 3 there was one (1) medication eKIT stored in the refrigerator and labeled 24, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. During a concurrent interview, RN 2 stated that all CSs, including medication eKITs containing CSs, should be reconciled at every shift. RN 2 stated the eKIT labeled 24 containing CSs in Medication Room Subacute 3 was not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an interview on 2/9/2026 at 3:45 p.m., with the Director of Nursing (DON,) the DON stated that medication eKITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated the eKITs labeled 2 and 24 containing CSs in Medication Room Subacute 2 and 3 were not reconciled at every shift in February 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During the same interview, the DON stated that LVN 4 and LVN 5 failed to notify the DON that the keys do not unlock the clear plastic container inside the refrigerator in Medication [NAME] Subacute 2 that day (2/9/2026) at 7 a.m. The DON stated, as a result LVN 4 and LVN 5 failed to complete a physical inventory and reconciliation of the CSs at shift change but documented that the reconciliation was completed with no discrepancies. The DON stated it was important to complete an actual physical count of all CSs and reconcile at each shift change to prevent CS diversions, and to know the amount of medications available for residents to prevent delay in care and harm such as hospitalizations and death. During the same interview, the DON reviewed the four (4) Facility Medication Destruction Form records dated 1/2/2026 and 2/9/2026. The DON stated the DON was unable to locate the witness signatures on the logs. The DON stated licensed nurses failed to include the signatures of witnesses when destroying medications. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. During a review of the Policy and Procedures (P&P,) titled Controlled Medication Storage, last reviewed 1/29/2026, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. The DON and the consultant pharmacist shall maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. At each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurses and is documented on the controlled substance accountability record. During a review of the Policy and Procedures (P&P,) titled Emergency Pharmacy Services/Emergency Kits, last reviewed 1/29/2026, the P&P indicated: A locked and sealed emergency supply shall be maintained at one or more designated areas Emergency controlled substances are kept in a sealed, portable container. Refrigerated emergency supplies are kept in a sealed, portable container. when an emergency or starter dose of a medication is needed, the nurse shall break the container seal and remove the required medication. During a review of facility's P&P, titled Discontinued Medications - Disposal, last reviewed 1/29/2026, the P&P indicated: b. With the exception of controlled substances, the facility should have at least two licensed nurses prepare the destruction of medications that would be picked up by a licensed reverse distributor like medical waste services. During a review of facility's P&P, titled Destruction of Medications - Non controlled, last reviewed 1/29/2026, the P&P indicated: All non-controlled medication will be properly recorded and prepared before its destruction and placement in a designated collection receptacle. d. Nurses will record all medications for destruction on the medications destruction record form and keep a copy at the facility. The following information will include: 1. Facility Name 2. Date of preparation 3. Name of the patient 4. Rx number 5. Medication name 6. Amount to be disposed 7. Who prepared the medications.

Based on interview and record review, the facility failed to ensure one of one sampled Certified Nursing Assistant (CNA) reviewed for sufficient and competent nurse staffing was provided the required annual in-service training for dementia (a condition characterized by decline in mental ability such as memory, reasoning and communication) management. The deficient practice had the potential to negatively affect the quality of care received by residents with dementia. Findings: During a concurrent interview and record review on 2/12/2026 at 1:50 p.m. with the Human Resources Supervisor (HRS), Restorative Nursing Assistant (RNA- a CNA who has received additional training in restorative care) 2's employee file was reviewed. The HRS stated there was no record of RNA 2 having received dementia training in the last 12 months. During an interview on 2/12/2026 at 3:03 p.m. with the Director of Staff Development (DSD), the DSD stated he is responsible for ensuring required trainings are completed. The DSD stated that dementia training was not provided to RNAs in the last 12 months and will ensure dementia management training is provided annually moving forward. The DSD stated dementia training enhances staff knowledge about dementia and how to care for residents with this condition. The DSD stated that without proper dementia training, staff may misinterpret residents' behaviors and fail to implement appropriate interventions. The DSD stated that dementia management training equips staff with the necessary knowledge to provide effective care tailored to the specific needs of residents with dementia. During a review of the facility's P&P titled, Sub-Acute Staff Training last reviewed 1/29/2026, the P&P indicated, All Sub-acute staff must participate in initial orientation and annual in-service training.All staff are required to participate in regular in-service education.The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhance the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training.Required training topics include the following: (3) dementia management and resident abuse prevention.Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment.Completed training is documented by the staff development coordinator, or his or her designee and includes: the date and time of the training; the topic of the training; a summary of the competency assessment; and the hours of training completed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship Program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [medications that fight infections caused by bacteria]) for one of one sampled resident (Resident 8) by not completing an Antibiotic Time-Out (a scheduled check-up, treatment is paused to re-evaluate if the medication is still necessary, effective, or needs adjustment) between 48 to 96 hours of therapy initiation as indicated in facility's policies and procedures (P&P). This deficient practice had the potential to result in inappropriate or prolonged antibiotic use, increased risk of side effects (unwanted effects of medications), and antibiotic resistance (occurs when bacteria evolve to survive drugs designed to kill them, making infections difficult or impossible to treat). Findings: During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed). During a concurrent interview and record review on 2/11/2026 at 11:15 a.m. with the Infection Preventionist Nurse (IPN), the Resident 8's Order Summary Report dated 1/21/2026 indicated Physician order for Zosyn (an antibiotic medicine used to treat serous bacterial infections) solution 3-0.375 Gm/50 ml (unit of measurement) to be used 1 dose intravenously (through veins) every 8 hours for elevated white blood cells ([WBC] - a blood cell that helps attack infection or injury in the body) for 7 days. The IPN stated that it was the facility's policy to conduct antibiotic time-off within 48 to72 hours of antibiotic treatment initiation to assess if the treatment had been effective. The IPN reviewed Resident 8's electronic and paper medical records. The IPN stated there was no documentation of antibiotic time-off assessment. The IPN stated this could lead to unnecessary use of antibiotics, increased risk of side effects and antibiotic resistance. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated it was the facility's policy to perform and document an antibiotic time-out for Residents who are currently on antibiotics. Time out expected to be completed within two to four days of starting the antibiotic treatment. The DON stated if the time-out is not done or documented, staff may not know treatments efficiency, which can lead to inappropriate antibiotic use, increased risk of antibiotic resistance, and possible adverse reactions. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, reviewed/revised in January 2026, the P&P indicated the facility will utilize a process for completion of an Antibiotic Time-Out between 48 and 96 hours of therapy initiation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions (rules to prevent spreading infections) in accordance with facility policy and infection prevention standards to prevent the spread of infection, when the facility failed to ensure: 1.Licensed Vocational Nurse (LVN) 3 removed soiled gloves before pressing the call light reset button while giving morning care to Resident 55 who was on Enhanced Barrier Precautions (infection control steps requiring staff to wear gowns and gloves during high-contact care [like bathing, dressing, or changing catheters] for residents with, or at high risk of having, hard-to-treat germs) and did not pour visibly contaminated fluids into the shared sink in Resident 55's room. 2. Resident 22 did not have multiple disposable face masks hanging from the wheelchair or touching its wheels. 3. Infection outcomes were documented in the infection surveillance logs (a record-keeping tool used by nursing homes to track, analyze, and manage infections among residents). 4. Infection surveillance data is analysis (the ongoing, systematic collection and review of disease reports to track, understand, and stop the spread of infections) conducted and reports are generated at least quarterly, following facility policies and procedures (P&P). 5. The facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written. 6. Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed on 2/6/2026 as scheduled per physician orders. These failures placed residents, staff, and visitors at risk for exposure to and transmission of infectious organisms, incomplete monitoring and follow up of infections, missed trends or outbreaks due to lack of surveillance data analysis, contamination of equipment and unsafe water conditions.
Findings:
1. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE].
During a review of the History and Physical (H&P) dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 55's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 55 was comatose. Resident 55 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed).
During a concurrent observation and interview on 2/9/2026 at 10:17 a.m. with LVN 3 in Resident 55's room, observed LVN 3 and LVN 4 providing morning care to Resident 55. While doing so, Resident 55's head activated the touch pad call light (an alerting device for nurses or other nursing personnel to assist a patient when in need). LVN 3 was observed pressing the call light reset button without changing soiled gloves and then continuing morning care. LVN 3 stated that touching the call light reset button with contaminated gloves could lead to cross-contamination and spread of infection to residents, staff, and visitors.
During a concurrent observation and interview on 2/9/2026 at 10:25 a.m. with LVN 3 in Resident 55's room, LVN 3 was observed disposing of visibly contaminated fluids into a shared sink after completing Resident 55's morning care. LVN 3 stated that disposing of contaminated water into a shared sink could contaminate the sink and surrounding surfaces, potentially spreading pathogens and increasing the risk of cross-contamination for residents, staff, and visitors.
2. During a review of Resident 22's Patient Registration Form, the Patient Registration Form indicated that Resident 22 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE].
During a review of the H&P dated 7/11/2025, the H&P indicated Resident 22 was admitted to the facility with diagnoses including chronic respiratory failure, tracheostomy, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).
During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 was cognitively intact with little to no cognitive impairment. The MDS indicated Resident 22 was independent (resident completes the activity by themselves with no assistance from a helper) with oral hygiene, upped body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. The MDS indicated the resident requires substantial/maximal assistance (helper does more than half the effort) with shower/bath.
During a concurrent observation and interview on 2/10/2026 at 10:42 a.m. with Resident 22, Resident 22 was observed self-propelling in a wheelchair with multiple disposable face mask hanging from the wheelchair break handle. The masks were coming into contact with the wheelchair wheels. Resident 22 stated he takes extra disposable face masks from the nurses' station and keeps them on his wheelchair. Resident 22 further stated he changes masks frequently due to excessive mucus related to his tracheotomy.
During an interview on 2/10/2026 at 10:45 a.m. with Registered Nurse (RN) 3, RN 3 stated disposable masks should not be hung on the wheelchair brake handle or touch the wheelchair wheels. RN 3 stated this could contaminate the masks. RN 3 further stated using potentially contaminated masks could increase the risk of infection for the resident.
3. During a concurrent interview and record review on 2/11/2026 at 11:15 a.m. with Infection Preventionist (IP), the facility's Infection Surveillance Logs indicated no documentation of outcomes for identified infections. IP stated that outcomes for identified infections should be documented int the infection surveillance log to ensure interventions and treatments are effective.
4.During a subsequent interview and record review on 2/11/2026 at 11:30 a.m. with IP, the IP stated she was unfamiliar with the Infection Surveillance Analysis and Reports and was not aware that Surveillance Analysis needed to be completed. Record review indicated the facility had no documented Infection Surveillance Analysis Reports.
5. During a concurrent interview and record review on 2/12/2026 at 8:00 a.m. with Plant Operator Director (POD), the POD stated water temperatures are checked daily. The POD stated chlorine residual levels were not tested in the facility. The POD further stated the facility did not maintain a schedule for water testing and the facility did not have logs for water testing and the results as indicated in the facility's WMP. The POD stated failure to routinely test and document water quality, including chlorine residuals, may allow the growth and spread of waterborne pathogens (bacteria, viruses, or parasites found in contaminated water), which could place residents, staff and visitors at risk for waterborne infections (illnesses caused by bacteria, viruses, or parasites from human or animal waste that contaminate drinking or recreational water).
During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated the call light reset button was considered a high touch surface. The DON stated pressing the call light reset button with soiled gloves could lead to contamination of the surface and increase the risk of cross-contamination and the spread of pathogens to residents, staff and visitors.
During a subsequent interview with DON on 2/12/2026 at 3:00 p.m., the DON stated disposing contaminated water into a resident's sink can contaminate the sink basin and surrounding surfaces. The DON stated that subsequent use of the contaminated sink for hand hygiene or resident care could expose residents and staff to pathogens, increase the risk of infections, leading to serious complications. The DON stated that infection surveillance logs should track the outcome, treatment response and follow up for each identified infection. The DON further stated without documenting infection outcomes in the surveillance logs the facility would not be able to determine if treatments are effective, if proper infection control processes are being followed, or if resident care interventions are meeting the residents' needs. The DON stated that it was the facility's policy to analyze infection surveillance data and generate reports and trends. The DON stated that failure to analyze surveillance data could affect the facility's ability to identify infection patterns or trends. The DON was uncertain about how often the surveillance data should be analyzed. The DON stated failure to follow the facility's WMP could compromise water quality, allow bacterial growth including Legionella (a type of bacteria found in water that can cause a severe, pneumonia-like lung infection), and result in residents being exposed to contaminated water, increasing the risk of waterborne infections.
During a review of facility's P&P titled, Personal Protective Equipment (PPE) dated October 2025, the P&P indicated, Gloves shall be removed immediately and hands washed after each task was completed. If gloves are not removed, contamination of the environment, other patients, or other body sites on the same patient can occur.
During a review of facility's P&P titled, Infection Control Plan 2025, dated May 2025, the P&P indicated, The Infection Preventionist will be responsible for data collection, evaluation and follow up. Surveillance data will be collected and recorded in the appropriate fashion. The Infection Preventionist will analyze and present the surveillance data to the Infection Control Committee and appropriate medical staff committees at least quarterly.
During a review of facility's P&P titled, Isolation Precautions, dated May 2025, the P&P indicated, Use Standard Precautions for the care of all patients. Handle used patient care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments.
During a review of facility's WMP, dated January 2024, the WMP indicated, Control measures and limits have been established to limit growth and spread of Legionella, such as maintaining domestic hot water temperatures in the storage tanks, hot water return temperatures, frequent flushing of hot water faucets and Pacifica Hospital - Water Management Plan (January 2024 updated) Page 9 of 13 showers in low-use area, maintaining chemicals in cooling tower to inhibit bacteria growth, monitoring hot water temperatures at distal locations throughout all buildings, and monitoring residual monochloramine levels in the cold water distal locations.
6. During a review of Resident 13's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 13 to the facility on [DATE].
During a review of the History and Physical (H&P) Note completed on 9/21/2023, the H&P indicated Resident 13 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), cerebral vascular accident (CVA –stroke, loss of blood flow to a part of the brain), and post percutaneous endoscopic gastrostomy (PEG – medical device inserted into the stomach to provide essential nutrition, fluids, and medication or require long term feeding). The H&P indicated Resident 13 is unable to make decisions.
During a review of Resident 13's Minimum Data Set (MDS – a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 13 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 13 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing.
During an observation on 2/9/2026 at 8:33 a.m. at Resident 13's bedside, a bubble humidifier dated 2/4 was observed connected to Resident 13's oxygen tubing.
During an interview on 2/9/2026 at 11:13 a.m. with Respiratory Therapist (RT), RT 1 stated the date on the bubble humidifier indicates when it was last changed. RT 1 stated that Resident 13's bubble humidifier was dated 2/4, indicating that it was last changed on 2/4/2026 and had not been changed on 2/6/2026 as scheduled per physician orders.
During a review of Resident 13's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 12/18/2023 to change the bubble humidifier in the morning every Monday, Wednesday, and Friday.
During a review of Resident 13's MAR dated February 2026, the MAR indicated that on 2/6/2026 for the 9 am administration time, there were staff initials in the box for the order to change bubble humidifier in the morning of every Monday, Wednesday, and Friday, indicating the task had been completed.
During an interview on 2/12/2026 at 11:19 a.m. with RT 2, RT 2 stated he documented on Resident 13's MAR on 2/6/2026 at 9am that he changed the bubble humidifier before he went to Resident 13's bedside to perform the task. RT 2 explained that when he went to Resident 13's bedside, Resident 13 was occupied and receiving care from another staff. RT 2 stated he did not change the bubble humidifier and meant to return later but forgot. RT 2 stated, It slipped my mind. RT 2 stated the bubble humidifier was not changed at all on 2/6/2026 as ordered. RT 2 stated it is important to change the bubble nebulizer regularly as scheduled to prevent bacterial or any other unwanted growth.
During a review of the facility's P&P titled, Infection Control Plan 2025 last reviewed 1/29/2026, the P&P indicated, the facility is to maintain a comprehensive and effective program of surveillance, prevention, and control of infection .The organization will employ a coordinated process to reduce the risks of endemic, and epidemic, or healthcare-related infections(s) in patients and healthcare workers.Risk Mitigation: Practices to Decrease the Risk of Transmission.Adherence to appropriate infection prevention measures (e.g. hand hygiene, barrier precautions, aseptic techniques).

Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of an ongoing quality assurance and performance improvement (QAPI) program. This deficient practice increased the risk of failing to identify areas in which the facility needed to improve which had the potential to negatively impact the care residents received as well as their quality of life. Findings: During a concurrent interview and record review on 2/12/2026 at 11:22 a.m. with the Director of Nursing (DON) and Director of Staff Development (DSD), the facility's QAPI Minutes, dated 11/25/2025, 12/16/2025, and 1/29/2026, were reviewed. The DON stated these were the only documented QAPI meetings from the past year, as she started doing QAPI again after she was hired in the fall of 2025. The DON stated the importance of a well-developed QAPI program is to give department leaders time to discuss issues, identify potential gaps in care, and brainstorm ideas to implement in order to improve care for the residents. The DSD stated before the current DON started in the fall of 2025, there was a QAPI program, but it was not documented properly and there were only sign in sheets showing the staff that was present. The DSD stated the QAPI meetings should be documented so they know what they have discussed before in previous meetings and can continue to act on it. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Committee 2025, last reviewed 1/29/2026, the P&P indicated one goal of the QAPI committee is to establish, maintain, and oversee organizational systems and processes to support the delivery of quality of care and services. The P&P further indicated the committee shall maintain minutes of all meetings that include the date and time the committee met, the names of committee members present and absent, a summary of the reports and findings, a summary of any approaches and action plans to be implemented, conclusions and recommendations from the committee, and the time the meeting adjourned.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS) in the third quarter (4/1/2025-6/1/2025) of 2025. The deficient practice had the potential to not provide the required staffing to ensure residents' care and safety. Findings: During a concurrent interview and record review on 2/12/2026 at 11:40 a.m., with the Staffing Coordinator (SC), the 2025 Payroll-Based Journal (PBJ) Staffing Report for quarter 1 (10/1/2024-12/31/2024), quarter 2 (1/1/2025-3/31/2025), quarter 3 (4/1/2025-6/20/2025), and quarter 4 (7/1/2025-8/30/2025) were reviewed. The 2025 PBJ Staffing Report for quarter 3 was triggered for failing to submit data for the quarter. The SC stated it is a requirement to submit PBJ data quarterly. During an interview with Director of Staff Development (DSD) on 2/12/2026 at 12:08 p.m., the DSD stated the initial PBJ data submitted to CMS for quarter 3 did not go through because of an issue with the data file sent. The DSD stated the facility fixed the problem and resubmitted it, but it missed the deadline. The DSD stated the purpose of submitting PBJ data is to provide the number of staffing hours taking care of the residents. The DSD explained that when PBJ data is not submitted, the facility fails to show compliance with staffing hours which affects the facility's Centers for Medicare & Medicaid Services (CMS) star rating (evaluation of the quality and performance of nursing homes to help consumers compare facilities). During an interview on 2/12/2026 at 12:25 p.m., with the Director of Nursing (DON), the DON stated the facility does not have a policy regarding submission of PBJ staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 13) when Respiratory Therapist 2 (RT 2) documented on the Medication Administration Record (MAR - a daily documentation record used by licensed staff to document medications and treatments given to a resident) that Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed when the bubble humidifier had not changed. This deficient practice resulted in inaccurate documentation in Resident 13's medical record. Findings: During a review of Resident 13's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 13 to the facility on [DATE]. During a review of the History and Physical (H&P) Note completed on 9/21/2023, the H&P indicated Resident 13 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), cerebral vascular accident (CVA -stroke, loss of blood flow to a part of the brain), and post percutaneous endoscopic gastrostomy (PEG - medical device inserted into the stomach to provide essential nutrition, fluids, and medication or require long term feeding). The H&P indicated Resident 13 is unable to make decisions. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 13 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 13 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. During an observation on 2/9/2026 at 8:33 a.m. at Resident 13's bedside, a bubble humidifier dated 2/4 was observed connected to Resident 13's oxygen tubing. During an interview on 2/9/2026 at 11:13 a.m. with Respiratory Therapist (RT), RT 1 stated the date on the bubble humidifier indicates when it was last changed. RT 1 stated that Resident 13's bubble humidifier was dated 2/4, indicating that it was last changed on 2/4/2026 and had not been changed on 2/6/2026 as scheduled per physician orders. During a review of Resident 13's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 12/18/2023 to change the bubble humidifier in the morning every Monday, Wednesday, and Friday. During a review of Resident 13's MAR dated February 2026, the MAR indicated that on 2/6/2026 for the 9am administration time, there were staff initials in the box for the order to change bubble humidifier in the morning of every Monday, Wednesday, and Friday, indicating the task had been completed. During an interview on 2/12/2026 at 11:19 a.m. with RT 2, RT 2 stated he documented on Resident 13's MAR on 2/6/2026 at 9am that he changed the bubble humidifier before he went to Resident 13's bedside to perform the task. RT 2 explained that when he went to Resident 13's bedside, Resident 13 was occupied and receiving care from another staff. RT 2 stated he did not change the bubble humidifier and meant to return later but forgot. RT 2 stated, It slipped my mind. RT 2 stated that he should not have documented the bubble humidifier was changed as accuracy in MAR documentation is important because it informs the healthcare team of the completion status of the physician's orders. RT 2 stated that the inaccurate documentation on Resident 13's MAR implied the bubble nebulizer was changed, and it did not require another RT to perform the task, which resulted in Resident 13's bubble nebulizer not being changed at all on 2/6/2026. During an interview on 2/12/2026 at 3:35pm with the Director of Nursing (DON), the DON stated that documentation should be done only after the intervention has been performed. The DON stated that the task must first be completed, then documented. During a review of the facility's P&P titled, Oxygen Therapy last reviewed 1/29/2026, the P&P indicated, To deliver supplemental oxygen to aid the relief of tissue hypoxia or hypoxemia.Equipment:.Bubble humidifier or aerosol humidifier, if trach resident.Procedure: 6. Connect humidifier to outlet of flowmeter. Label with date opened.Documentation: Date and time oxygen therapy is in use. During a review of the facility's P&P titled, Medication Administration: last reviewed 1/29/2026, the P&P indicated, Ordering medications - Medications and treatments shall be administered only upon the written order of a person lawfully authorized to prescribe for and treat human illnesses.Administration - All medications and treatments shall be administered by licensed health care professionals as followed by state law.These policies and procedures are established to assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner. General Policy a. All entries in the health record involving medications shall be made by licensed personnel.d. Documentation of medication doses administered shall be charted as soon as possible after administration to any individual resident.

Based on interview and record review, the facility failed to review and update their facility assessment at least annually. This deficient practice had the potential to result in residents not receiving necessary care and services in a timely manner due to the facility's failure to evaluate the resident population and identify the resources needed to provide appropriate care and services.Findings: During a concurrent interview and record review on 2/11/2026 at 8:25 a.m. with the Director of Staff Development (DSD), the document titled Facility Assessment Tool, updated 2/9/2026, was reviewed. The DSD stated the document Facility Assessment Tool was used to create a facility assessment during the week of 2/9/2026. During a concurrent interview and record review on 2/11/2026 at 3:34 p.m. with the Director of Nursing (DON) and DSD, the DSD and DON were unable to provide the previous facility assessment document or the date it was completed or last reviewed. The DSD stated he was not sure if a facility assessment had been completed in 2025. The DSD stated a staff member that last worked in the facility in 2024 was in charge of completing the facility assessment and no one had access to the last version of the facility assessment at this time. The DSD stated the facility did not have a policy or procedure regarding how and when to conduct a facility assessment. The DON stated the facility assessment should be completed regularly and should involve input from residents and their families so the residents can feel like they have a voice and the facility can be assessed as a whole. During an interview on 2/12/2026 at 11:22 a.m. with the DSD, the DSD stated the facility assessment should be updated yearly in case there are new issues or concerns so the facility can address and accommodate them.

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 purchased bags of ice, still on their original packaging, were placed on top of the ice made by the ice maker and used for 14 of the 60 residents that eat and drink food prepared by the kitchen, These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) for 14 of the 60 medically compromised residents who received food from the kitchen. Findings: During an initial kitchen tour observation on 2/9/2026 at 7:42 a.m., observed three bags of purchased ice still in their original bags mixed with ice made by the ice maker. During a concurrent observation and interview with the Dietary Manager (DM) on 2/9/2026 at 7:44 a.m., the DM looked into the ice maker and stated there were three bags of ice mixed with the fresh ice made by the ice maker. The DM stated sometimes the ice maker does not work well and they have to purchase separate bags of ice but that the ice should have been removed from the bags to prevent cross contamination. During a review of the policy and procedure (P&P) titled, Ice Machine, last revised on 1/29/2026, the P&P indicated when ice comes in contact with food and beverages shall be from a sanitary source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for four out of four sampled residents (Residents 1, 30, 49, and 64) when: 1. The facility failed to ensure Resident 1's Foley catheter (a specific type of tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via catheter) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). 2. The facility failed to ensure a Restorative Nursing Assistant (RNA 1) knocked or requested permission before entering Resident 30's room. 3. LVN 2 failed to provide privacy while administering medications through Resident 49's gastrostomy tube (g-tube, a medical device inserted directly into the stomach through the abdomen to deliver nutrition, fluids, and medication). 4. The facility failed to honor Resident 64's right to be informed and involved in his care planning, when the resident was not provided with ongoing information regarding the status of his requested transfer to another facility. These deficient practices violated the residents' rights to be treated with respect and dignity and had the potential to negatively affect the residents' sense of self-worth and self-esteem. Findings:
1. During a review of Resident 1's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 1 to the facility on [DATE].
During a review of the History and Physical (H&P) report completed on 12/1/2025, the H&P indicated Resident 1 was admitted to the facility with diagnoses that included acute hypoxemic respiratory failure (a medical emergency where the lungs suddenly cannot transfer enough oxygen into the bloodstream to preserve normal organ function), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and history of urinary tract infection (UTI – an infection of the urinary system, which includes the kidneys, ureters, bladder and urethra).
During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 1's cognitive skills for decision making are severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing.
During an observation on 2/10/2026 at 4:05 p.m., Resident 1's Foley catheter collection bag was attached to the side of the bed rail, with the urine visible inside. The urine collection bag was observed to be attached to a dignity bag, with the collection bag placed outside of the dignity bag.
During a concurrent observation and interview on 2/10/2026 at 4:10 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the urine collection bag observed outside the dignity bag should be inside the dignity bag. LVN 1 explained the purpose of the dignity bag is to hide the urine draining from the resident from other people's view. LVN 1 stated that privacy is a resident's right and the dignity bag provides privacy.
During a review of Resident 1's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 11/29/2025 for Foley catheter size 16x10 every shift for wound management
During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated that dignity bags are expected to be used for all residents with foley catheters.
During a review of the facility's P&P titled, Patient's Rights - Residents last reviewed 1/29/2026, the P&P indicated, It is the policy of the Patient Care Services, Subacute Units, to have policies and procedures on residents' rights to ensure that each resident is able to fully exercise his or her rights as resident and as a citizen. Ensuring that residents are afforded these rights contribute to their quality of life and this to the overall quality of care provided in the facility.5. This facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality.
2. During a review of Resident 30's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 8/28/2021.
During a review of Resident 30's History and Physical (H&P) dated 2/9/2026, the H&P indicated Resident 30 had the diagnoses of tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe) with ventilator (a machine that helps you breathe) dependence and cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain). The H&P further indicated Resident 30 was unable to make his own decisions.
During a review of Resident 30's MDS, the MDS indicated the resident rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 30 was completely dependent (helper does all the effort) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During an observation and interview on 2/9/26 at 9:57 a.m., in the hallway near the entrance of Resident 30's room with RNA 1, RNA 1 was observed entering Resident 30`s room without knocking on the door and asking permission to go in. At this time Resident 30 was on his bed. Upon exiting the room and when interviewed, RNA 1 stated she forgot to knock on the resident's room and stated that she should have knocked and asked permission to go in since this is the resident's home and they deserve privacy.
During an interview on 2/10/26 at 11:26 a.m. with the Director of Nursing (DON), the DON stated that anyone entering a resident`s room must knock and ask permission prior to entering the resident`s room. The DON stated resident`s privacy should be respected to avoid embarrassment. The DON stated that residents should be treated with respect and dignity.
During a review of the facility`s policy and procedure (P&P) titled Patient's Rights - Residents, last reviewed on 1/29/2026, the P&P indicated that the facility shall treat each resident with respect and full recognition of dignity and staff will knock prior to entering the room.
3. During a review of Resident 49's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 2/18/2022.
During a review of Resident 49's History and Physical (H&P), dated 7/11/2025, the H&P indicated Resident 49 had diagnoses including, but not limited to, chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), was dependent on a ventilator (a medical device to help support or replace breathing), and required a g-tube to receive nutrition. The H&P further indicated Resident 49 had an impaired mental status and was unable to make decisions.
During a review of Resident 49's Minimum Data Set (MDS – a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 49 was in a persistent vegetative state (a disorder of consciousness following severe brain injury where the person is awake but completely unaware of themselves or their environment) and was dependent (helper does all of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a concurrent observation and interview on 2/11/2026 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 entered Resident 49's shared room to administer medications via her g-tube. LVN 2 closed the resident's curtain to the resident's left side but left the foot of the bed and the resident's right side exposed. LVN 2 then lifted the resident's gown exposing her abdomen and g-tube and began administering medications. LVN 2 stated the resident should have been provided privacy during medication administration. LVN 2 stated residents should be given privacy because it is one of their basic rights.
During an interview on 2/11/2026 at 3:34 p.m. with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated the resident should have been provided privacy during medication administration. The DON stated residents have the right to privacy, and they may not want anyone else to know they have a g-tube. The DSD stated residents deserve dignity and should be given privacy when being exposed.
During a review of the facility's policy and procedure (P&P) titled, Patient's Rights - Residents, last reviewed 1/29/2026, the P&P indicated the facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality. The P&P further indicated all treatments and personal care are given in privacy.
4. During a review of Resident 64's Patient Registration Form, the Patient Registration Form indicated the facility originally admitted the resident on 4/18/2025 and readmitted to the facility on [DATE].
During a review of Resident 55's H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of deep venous thrombosis ([DVT] - a serious medical condition where a blood clot forms in a deep vein), history of pulmonary embolism (a sudden, often life-threatening blockage in one or more arteries in the lungs).
During a review of Resident 64's MDS, the MDS indicated Resident 64 was cognitively intact (able to make clear decisions). The MDS indicated that Resident 64 was dependent (helper does all the effort) from staff with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated that Resident 64 was dependent with sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to-chair transfer (he ability to transfer to and from a bed to a chair (or wheelchair).
During an interview on 2/9/2026 at 9:30 a.m. with Resident 64, Resident 64 expressed dissatisfaction with the lack of communication regarding his care plan and transfer process. Resident 64 stated that he informed the social worker of his request to be transferred to a facility closer to his family approximately two months ago. Resident 64 stated he had not received any updates or information about the status of his request.
During a concurrent interview and record review on 2/10/2026 at 3:35 p.m. with Social Worker (SW) 1, Resident 64's Social Service Notes for January and February 2026 were reviewed. The Social Service Notes indicated no documentation that Resident 64 was provided with information about the transfer referrals and was updated on the status of the transfer process. SW 1 stated the transfer process in progress had not been communicated to Resident 64. SW 1 stated it is Resident 64's right to be informed and updated regarding his care plan.
During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated it was the facility's policy to review and communicate care plan updates with residents and resident representatives. The DON stated residents have the right to be informed, and that staff were expected to discuss care plan updates and obtain the residents' input when changes occur. The DON further stated that residents and their families should be involved in care planning and kept aware of progress of all aspects of care.
During a review of facility's policies and procedures (P&P) titled, Patient's Rights – Residents dated December 2025, the P&P indicated, This facility shall recognize and respect individuality of each resident and encourage expression of capabilities and independence. Therefore, compliance with the Federal and State regulations for residents' rights shall be maintained and utilized to enhance the comfort and wellbeing of each patient. Failure to ensure these rights will not be tolerated by facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation for resident needs and preferences for two of four sampled residents (Resident 24 and Resident 5) by failing to: Ensure Resident 5's call light (an alerting device that allows a resident to call for help) was within reach. 2. Ensure Resident 24 was provided with a push button call light despite Resident 24 having wrist contractures (a condition where the muscles, tendons, or skin around the wrist tighten, shorten, and scar, causing the joint to become stiff and locked in a bent position) that limited the ability to grasp and activate the call light. This deficient practice had the potential to prevent Resident 5 and Resident 24 from summoning assistance, placing the residents at risk for unmet needs and delayed care.
Findings:
1.During a review of Resident 5's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 5 to the facility on 9/6/2025.
During a review of the History and Physical (H&P) report completed on 9/8/2025, the H&P indicated Resident 5 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), dependence on respirator/ventilator status (unable to breathe independently and requires a machine to help or fully take over a resident's breathing when they cannot do so on their own), and [NAME] Barre syndrome (a condition in which the body's system that protects from infection attack the nerves). The H&P stated Resident 5 was bedbound (confirmed to bed due to illness) state.
During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 5 has the ability to express ideas and wants and understands (clear comprehension) others. The MDS indicated Resident 5 was dependent (Helper does all of the effort. Resident does none of the effort to complete the task) with eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 5 is dependent for roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed).
During a concurrent observation and interview on 2/9/2026 at 10:10 a.m. with Resident 5, Resident 5 was lying in bed with a touch-activated call light (easy-to-activate communication device alerting staff when resident needs help) on the left side above his head. Resident 5 stated he taps the call light with his head when he needs help. Resident 5 stated he sometimes cannot reach it because of where it is placed. Resident 5 stated that he would verbally call out loud to get staff attention when unable to reach the call light.
During a concurrent observation and interview on 2/9/2026 at 10:20 a.m. in Resident 5's room, the call light was observed on the left side above the resident's head, out of Resident 5's reach. LVN 8 stated the touch-activated call light is what Resident 5 uses to let staff know he needs help and should always be within reach of the resident. LVN 8 stated that without the call light, Resident 5 does not have a device to let staff know that he needs help. LVN stated because of this, staff will not know what may be going on with him and/or may miss something.
During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated staff are expected to make sure call lights are always within residents' reach and responded to timely. The DON stated you never know what a resident is calling help for, and it may be an emergency, so it is important that residents have a call device within reach to call at all times.
During a review of Resident 5's care plan (CP) titled, Risk for falls related to impaired mobility, incontinence of bowel, chronic respiratory failure on trach, muscle spasms, neuropathy, side effects of medications initiated 6/24/2023 the CP indicated an intervention ensure call light is available to resident.
During a review of Resident 5's care plan (CP) titled, The resident has an alteration in musculoskeletal status muscle cramping of lower extremities, quadriplegia initiated 01/1/2024, the CP indicated an intervention be sure call light is within reach and respond promptly to all requests for assistance.
During a review of Resident 5's care plan (CP) titled, Self-Care Deficit: Totally dependent with bed mobility, bathing, dressing, eating, transfer, toilet use and personal hygiene due to physical and medical condition. Resident uses adaptive call light initiated 01/09/2024, the CP indicated an intervention touch-activated call light, place the call light within easy reach of the patient's bedside.
During a review of Resident 5's care plan (CP) titled, Side rail use for safety to prevent falls initiated 7/15/2025, the CP indicated an intervention place call light within reach and respond timely.
During a review of the facility's P&P titled, Call Light System last reviewed 1/29/2026, the P&P indicated, It is the policy of this facility to provide each resident with a call system to enable them to request assistance. To provide a mechanism for residents to communicate to staff a need for assistance.Procedure: b. Make sure call cords are placed within the residents' reach at all times.
2. During a review of Resident 24's Patient Registration Form, the Patient Registration Form indicated Resident 24 was admitted to the facility on [DATE].
During a review of Resident 24's H&P, dated 10/13/2025, the H&P indicated Resident 24 was admitted to the facility with diagnoses including traumatic encephalopathy following head injury(permanent brain damage that happens after many head injuries), history of respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), permanent tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The H&P indicated Resident 24 was awake, responsive, able to verbalize slightly.
During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24 had moderately impaired cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 24 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 24 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed).
During a concurrent observation and interview on 2/9/2026 at 10:37 a.m. with Resident 24 in Resident 24's room, observed standard push button call light tied to the right upper side rail, resting next to Resident 24's right shoulder. Resident 24's wrists and fingers were observed contracted bilaterally. Resident 24 stated he was calling for help by yelling for a nurse. Resident 24 stated he did not know where the call light was located or how to use it.
During a concurrent observation and interview on 2/9/2026 at 10:52 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 24 demonstrated his ability to move his arms but could not move his wrists and fingers. LVN 6 stated Resident 24 was able to move left hand fingers slightly. LVN 6 placed the standard push button call light in Resident 24's left hand. Resident 24 was unable to use the standard call light. LVN 6 stated not having a type of a call light that Resident 24 could use may prevent Resident 24 from calling for assistance, resulting in unmet needs and delayed care.
During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated staff were required to provide accommodation or alternative devices when residents were unable to use standard equipment. The DON stated residents being unable to use their call light to request assistance can lead to increased stress, unmet physiological needs, delayed care, and in increased risk for injuries.
During a review of facility's Policies and Procedures (P&P), the P&P titled, Call light system dated October 2025, the P&P indicated, It is the policy of this facility to provide each resident with a call system to enable them to request assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy titled, Advance Directives, by not providing assistance with creating an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two of four sampled residents (Residents 2 and 27) reviewed under the Advance Directive care area. This deficient practice resulted in Residents 2 and 27 not receiving assistance with creating advance directives, increasing the risk that the residents' wishes regarding their medical care would not be known or honored if they became unable to make or communicate their own decisions Findings: During a review of Resident 2's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 6/11/2022. During a review of Resident 2's History and Physical (H&P), dated 7/11/2025, the H&P indicated Resident 2 had diagnoses including, but not limited to, a history of assault with a spinal cord injury (damage to the bundle of nerves and nerve fibers that transmit signals between the brain and the body resulting in temporary or permanent loss of sensation and motor function) and chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with dependence on a ventilator (a medical device to help support or replace breathing). The H&P further indicated Resident 2 had an impaired mental status, was able to make his needs known, and was able to make some decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2025, the MDS indicated Resident 2 was cognitively intact (able to think, learn, and remember clearly) and was dependent (helper does all of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 27's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 9/19/2024. During a review of Resident 27's H&P, dated 5/21/2025, the H&P indicated Resident 27 had diagnoses including, but not limited to, chronic respiratory failure and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. The H&P further indicated Resident 27 was alert and oriented (awake, responsive, and aware). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was cognitively intact and was dependent for all ADLs except eating in which she required moderate assistance (helper does less than half of the effort). During a concurrent interview and record review on 2/12/2026 at 12:02 p.m. with Social Worker (SW) 1, reviewed Resident 2's Advance Health Care Directive Acknowledgement, dated 3/4/2025 and Resident 27's Advance Health Care Directive Acknowledgment, dated 2/12/2025. Resident 2's and Resident 27's Advance Health Care Directive Acknowledgements both indicated that the residents did not have an advance directive, but both residents' Advance Health Care Directive Acknowledgment indicated: However, I would like to discuss Advance Directives further: Nursing to refer for follow up. SW 1 stated there was no documentation of having met with either Resident 2 or 27 to follow up about an advance directive and neither have an advance directive on file now. SW 1 stated the usual process is for nursing to ask the resident if they have an advance directive when they are admitted , and if they do not, but want more information to refer them to social services so that a social services staff can provide education regarding making an advance directive, give them a blank one, and can contact the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) to help complete the advance directive. SW 1 stated it is important to meet with the resident and give them education regarding creating an advance directive, as this is their right and ensures staff are aware of their wishes and able to act accordingly if the resident becomes unable to make or communicate their own decisions. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed 1/29/2026, the P&P indicated if the resident indicates that he or she has not established an advance directive, the facility will offer assistance to establish one. The P&P indicated the resident will be given the option to accept or decline the assistance. The P&P indicated nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline the assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards for one (1) of one (1) sampled residents (Resident 26) investigated for gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) care by failing to flush the tube with the prescribed volume of water. This deficient practice increased the risk that Residents 26 could experience adverse effects (unwanted, unintended result) from lower volume of water, possibly leading to clogging of the G-tube and requiring procedures for declogging (removing a blockage) or replacement of the tube. Findings: During an observation on 2/9/2026 at 9:20 a.m. in Medication Cart 4, licensed vocational nurse (LVN) 7 was observed flushing Resident 26's G-tube with 25 milliliter ([ml] - a unit of measure of volume) followed by administering amiodarone (a medication used for middle cerebral artery (mca) occlusion (a blood clot blocking the largest brain artery, not allowing blood flow to major brain areas,) losartan (a medication used for high blood pressure,) polyethylene glycol 3350 (a medication used for constipation,) amlodipine (a medication used for high blood pressure,) docusate (a medication used for constipation,) ferrous sulfate (a medication used for anemia,) metoprolol (a medication used for high blood pressure,) magnesium oxide (a medication used for constipation,) via G-tube with 5 ml water flushes in between each medication, and flushing the G-tube with an additional 25 ml water after the last medication. During an interview on 2/9/2026 at 10:30 a.m., with LVN 7, LVN 7 stated flushing G-tube with water before and after medication administration was a standard of practice to prevent clogging the tube and ensuring medication has cleared the tube. LVN 7 stated the flushes usually range between 20 and 30 ml. LVN 7 stated LVN 7 decided to flush with 25 ml since it falls in between 20 and 30 ml. LVN 7 acknowledged the physician order for Resident 26 indicated to flush with 30 ml water before and after medication administration through the G-tube. LVN 7 stated LVN 7 failed to flush with the prescribed amount increasing the risk of clogging Resident 26's G-tube, requiring declogging or potential tube preplacement. During an interview on 2/9/2026 at 3:45 p.m., with the Director of Nursing (DON,) the DON stated flushing G-tube with water before and after medication administration and in between each medication was a standard of practice. The DON stated Resident 26's order indicated to flush before and after medication administration through the G-tube with 30 ml water. The DON stated LVN 7 failed to flush Resident 26's G-tube with 30 ml water that day (2/9/2026) during medication administration increasing the risk of clogging Resident 26's G-tube, requiring declogging or potential tube preplacement. During a review of Resident 26's History and Physical ([H&P] - a document containing resident health history, diagnosis and treatment plan,) dated 4/30/2025, the H&P indicated the facility originally admitted the resident to the facility on 3/24/2025 and re-admitted on [DATE] with diagnoses including respiratory distress, mca occlusion, and dysphagia (difficulty swallowing.) During a review of Resident 26's Order Summary Report, dated 2/9/2026, the report indicated Resident 26 was prescribed to Flush tube with 30 ml of water before and after medication administration pass, starting 5/3/2025. During a review of Resident 26's Medication Administration Record ([MAR] - a record of mediations administered to residents), for February 2026, the MAR indicated Resident 26 was prescribed Flush tube with 30 ml of water before and after medication administration pass, daytime and nighttime. During a review of Resident 26's Care Plan (a person-centered guide identifying a resident's health and daily needs,) dated 5/1/2025, the care plan indicated: The resident will remain free of side effects or complications related to tube feeding. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. During a review of the facility's Policy & Procedures (P&P,) Medication Administration, last reviewed 1/29/2026, indicated: 10. Flush the tube with approximately 30 ml of water using a catheter tipped syringe. 15. Rinse medication cup and administer rinsing to assure complete dose 16. Flush tube with a minimum of 30 ml of water. During a review of the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, titled ASPEN Safe Practices for Enteral Nutrition Therapy, dated January 2017, the guideline indicated: Feeding tubes (known as [NAME]) are prone to clogging for a variety of reasons. The risk of clogging may result from .insufficient water flushes. Develop protocols that call for proper flushing before and after medication administration .Develop protocols for proper administration of medications through an EAD, as well as appropriate water flushes and EAD reclogging procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide preventative care for one of one sampled resident (Resident 64) by not applying sequential compression device (SCD-inflatable sleeves wrapped around the legs that automatically inflate and deflate to mimic muscle movement, increasing blood flow and preventing deep vein thrombosis [DVT-a condition where a blood clot [clump of blood cells in blood stream] forms in a deep vein]) at all times to prevent DVT as ordered by the physician. This deficient practice had the potential to increase the risk of developing blood clots, causing pain, poor blood circulation and serious harm to Resident 64's health. Findings: During a review of Resident 64's Patient Registration Form, the Patient Registration Form indicated that Resident 64 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of deep venous thrombosis ([DVT] - a serious medical condition where a blood clot forms in a deep vein), history of pulmonary embolism (a sudden, often life-threatening blockage in one or more arteries in the lungs). During a review of Resident 64's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 64 was cognitively intact (able to make clear decisions). The MDS indicated that Resident 64 was dependent (helper does all the effort) from staff with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated that Resident 64 was dependent with sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to-chair transfer (he ability to transfer to and from a bed to a chair (or wheelchair). During an observation on 2/9/2026, at 9:30 a.m., in Resident 64's room, Resident 64 was lying down in bed with two side rails up. Observed SCD hanging over the footboard of Resident 64's bed. The SCD was not connected to Resident 64 and was off. During a review of Resident 64's Order Summary Report dated 1/29/2026, the Order Summary Report indicated the physician order for SCD on for DVT prophylaxis (prevention) at all times. During a concurrent observation and interview on 2/10/2026 at 2:45 p.m. with Registered Nurse (RN) 4, in Resident 64's room, the SCD was observed on Resident 64's bed hanging on the footboard. RN 4 stated the SCD was disconnected from Resident 64 and was turned off. RN 4 stated Resident 64 had a history of DVT. RN 4 emphasized the importance of using SCD for Resident 64 at all times. RN 4 stated not using SCD put Resident 64 at great risk for developing blood clots and lead to serious health problems. During a concurrent interview and record review on 2/10/2026 at 2:50 p.m. with RN 4, Resident 64's Care Plan Report did not indicate documentation for SCD use. RN 4 stated not developing a care plan for SCD use could lead to staff not using the SCD consistently, increasing the risk for Resident 64 developing blood clots. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated not applying SCD as ordered by physician for Resident 64 with a history of DVT can increase the risk of Resident 64 developing blood clots, which could lead to pulmonary embolism and other serious health problems. During a review of facility's Policies and Procedures (P&P), the P&P titled, Sequential Compression Device (SCD) Application and Management, dated December 2025, the P&P indicated, Nurses will remove sleeves every shift to look at skin and when bathing. Otherwise, SCD device and sleeves should remain in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide appropriate services, equipment and assistance to one of three residents (Resident 8) reviewed under the care area of Position/Mobility, to maintain or improve mobility by not applying ankle-foot orthosis ([AFO] - a brace made of plastic or metal to support the lower leg and foot) in accordance with the facility's splinting protocol (rules for temporary, rigid immobilization of a joint to prevent further damage, reduce pain, and protect soft tissue) and physician's order. This deficient practice had the potential to increase the risk for decreased Range of Motion ([ROM] - the full distance and direction a joint can move comfortably, measuring how far you can bend, straighten, or rotate it), discomfort and worsening of Resident 8's contractures (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff, deformed, and limited in movement). Findings: During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed). During an observation on 2/9/2026, at 9:26 a.m., in Resident 8's room, Resident 8 observed having bilateral (both sides) wrist and ankle contractures with no splints applied. During a concurrent interview and record review on 2/10/2026 at 10:50 a.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 8's electronic and paper medical records. RN 3 stated Order Summary Report dated 2/1/2026, indicated the physician ordered to continue Restorative Nursing Assistant (RNA)/Nursing program for application of bilateral AFOs per splinting protocol. RN 3 stated that per facility's splinting protocol, splints must be applied per physician's order, removed every 2 hours by RNA to check for skin integrity and blood circulation. During a concurrent observation and interview on 2/10/2026 at 10:55 a.m. with RN 3 in Resident 8's room, Resident 8 was observed not having splints applied to his ankles. RN 3 stated that not having the splints applied to Resident 8's feet and ankles as ordered by the physician could place the resident at risk for worsening contractures and reduce mobility. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated not applying splints as ordered by the physician was not acceptable practice. The DON stated not applying splinting can lead to worsening of contractures, increased muscle spasms and further loss of function. During a review of facility's Policies and Procedures (P&P), the P&P titled, Splint Application & Use, dated December 2025, the P&P indicated, Splints are to be worn according to the schedule determined by written order of the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1's conservator was included in the decision to cancel a long-awaited medical appointment.This failure had the potential to result in Resident 1 to have a delay in his medical care due to the unplanned rescheduling. During a review of Resident 1's History and Physical (H&P), dated 6/8/2022, the H&P indicated Resident 1 admitted to the facility on [DATE] for long term care and management related head trauma (bodily injury) resulting in cerebral (relating to the brain) swelling (abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid) and right temporal (portion of brain) contusion (bruising).During a review of Resident 1's Surgical Consult, dated 6/17/2025, the consult indicated the reason for consultation was for a skin lesion (type of wound) on his back related to dermatitis (skin inflammation).During a review of Sub Acute Appointment June 2025 calendar, dated June 2025, the calendar indicated, Resident 1 was scheduled for a dermatology appointment on 6/23/2025 at 3:00 PM.During a review of Resident 1's Letter of Conservatorship, dated 2/14/2023, the document indicated, Resident 1's conservator is his appointed conservator with exclusive authority to give consent for and to require the conservatee to receive medical treatment that the conservator in good faith based on medical advised determines to be necessary. During an interview on 7/1/2025 at 3:20 PM with the social worker (SW), the SW stated Resident 1 had a dermatology appointment scheduled for 6/23/2025 but she was instructed to cancel the appointment and transportation due to a lack of staff available to accompany Resident 1 to his appointment. The SW stated there was no communication with Resident 1's conservator prior to the decision to cancel his dermatology appointment; only notification of the need for rescheduling the appointment was sent to his conservator. During an interview on 7/1/2025 at 4:06 PM with the Director of Staff Development (DSD), the DSD stated, prior to cancelling Resident 1's dermatology appointment, the facility should have called Resident 1's conservator to notify them of the situation regarding low staffing and to present the available options to inquire on how they would like to proceed regarding Resident 1's care.During a concurrent interview and record review on 7/1/2025 at 4:10 PM with the DSD, Resident 1's California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities, dated 6/13/2025 was reviewed. The document indicated, Resident 1, including his conservator, have resident rights that include the right to:- effective communication and to participate in the development and implementation of your plan of care .- make decisions regarding medical care, and received as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment .- reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care.The DSD stated the facility cancelling Resident 1's appointment prior to speaking to his conservator displayed the facility's lack of communication, which was a violation of Resident 1's resident rights. The DSD stated the importance of clear communication is to ensure the resident's needs are being met and that the conservator is included in the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to inform the family of Patient 1 ' s plan of care and change of condition. This deficient practice led to anxiety while the family had no input into Patient 1 ' s treatment for an extended period of time.
Findings:
During an observation on 2/20/205 in Patient 1 ' s room at 11:49 AM, Patient 1 was seen to have a tracheostomy (an incision on the front of the neck to open a direct airway to the trachea and lungs) and was able to speak in short sentences. A staff member had just returned Patient 1 to his room from the activity room and placed Patient 1 on the end of the bed.
During an interview on 2/20/2025 at 11:49 AM, Patient 1 stated he did not have any problems with the medical care at this facility but could not recall the last time a medical physical came to visit him. Patient 1 said his mother visits him every day; the only plan his mother had mentioned to him was to recover and go back to work. Finally, Patient 1 stated his mother has talked to doctors about surgery but does not know about the outcome of that discussion.
During an interview on 2/20/2025 at 12:00 PM, the Cheif Nursing Officer (CNO) stated he has not had any direction conversations with Patient 1 ' s mother but has been a candidate for transfer to a lower level of care for some time since Patient 1 was decannulated (removing a tracheostomy tube, also known as a trach, from the trachea or windpipe. This procedure is typically performed when a patient no longer needs the tube to breathe). The CNO subsequently said there has been a problem with the patient ' s placement to another facility.
During an interview on 2/20/2025 at 12:07 PM, the CAO stated, after looking through Patient 1 ' s medical record, she could not locate any record of social service communicating with the mother of Patient 1 regarding Patient 1 ' s current medical condition.
During an interview on 2/20/2025 at 12:22 PM, the Social Worker stated the facility had attempted to get a neurosurgery (surgical specialty that focuses on the diagnosis and treatment of injuries affecting the nervous system, including the brain, spinal cord) consultation; there is a delay getting this appointment due to Patient 1 ' s insurance not consenting to this consultation. The Social Worker then stated family members of Patient 1 will be included in the next IDT (Inter-Disciplinary Team, all staff members involved in treatment of a patient) meeting this week; Up until this time the family had not been invited to these meetings.
During a review of the form ' Patient Information ' , this document indicated Patient 1 had been admitted to the facility on [DATE]; the reason for admission was listed as respiratory failure (condition where the lungs adequately intake oxygen and expel carbon dioxide) while being ventilator dependent (process where a machine, ventilator, assists or takes over the work of breathing) after trauma (physical injury or a psychological response to an event).
During a review of the document ' IDT Quarterly ' dated 3/25/2024, this document indicated the meeting team members present were: Social Services, Recreation Therapy, Speech Therapy, Respiratory Therapy, Dietary. Patient 1 diagnosis was listed as Traumatic SDH (subdural hemorrhage, condition where blood pools beneath a layer of tissue under the skull). Patient 1 medical history included: traumatic SDH right craniectomy (procedure in which a portion of the skull is removed to relive pressure on the brain) performed May in 2022, chronic respiratory failure. The 3/25/2024 ' IDT Quarterly ' indicated Patient 1 had been decannulated and needed to be transferred to a facility that provides a lower level of care (place where less assistance is required than currently located) but Patient 1 ' s mother is unable to care at home.
During a review of the document ' IDT Quarterly ' dated 1/27/2025, this document indicated the meeting team members present were: Nursing, Social Services, Recreation Therapy, Respiratory Therapy, Dietary. The 1/27/2025 ' IDT Monthly ' report indicated Patient 1 had been decannulated and needed to be transferred to a facility that provides a lower level of care (place where less assistance is required than currently located) but Patient 1 ' s mother is unable to care at home.
During a review of the ' H&P Note ' dated 7/1/2024, this document indicated Patient 1 was admitted to this facility 5/17/2022 after sustaining a head injury. Radiology examination of Patient 1 ' s head showed massive SDH; Patient underwent emergent Hemicraniectomy for SDH. This document indicated the plan of care for head trauma included (not all inclusive), monitoring neurological status (testing patient for strength and sensation) and neurosurgery consultation for cranioplasty (repairing or replacing a defect in the skull) evaluation.
During a review of the ' H&P Note dated 2/14/2025, this document indicated Patient 1 was admitted to this facility 5/17/2022 after sustaining a head injury. Radiology examination of Patient 1 ' s head showed massive SDH; Patient underwent emergent Hemicraniectomy for SDH. This document indicated the plan of care for head trauma included (not all inclusive), monitoring neurological status (testing patient for strength and sensation) and neurosurgery consultation for cranioplasty (repairing or replacing a defect in the skull) evaluation.
During a review of the ' Job Description ' for ' Social Worker ' , revised January 2025, this document indicated the social worker provides direct social work services and counseling to residents, families and/or groups to enhance psychosocial functioning, financial, grief support, cultural, family and health needs, in order to formulate a written assessment with 24 hours of admission to the unit; the social worker conducts regular room visits to residents and maintains weekly contact with family or collateral contact by phone whenever possible (or) reasonable. This job description indicated one standard of social worker performance is to conduct open, timely and professional communication and relationships with residents/family, team members, and others to facilitate team work, to assure resident self-determination, and to update any significant changes or concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for three of five sampled residents (Residents 30, Resident 34, and Resident 18) by failing to:
1. Ensure padding was applied to Resident 30 and 34`s bed side rails for seizure precaution (the safety measures taken before an individual experiences a seizure).
2. Repair or replace Resident 18`s broken wheelchair.
These deficient practices had the potential to place Residents 30, 34 and 18 at risk for injuries.
Findings:
1.a During a review of Resident 30's History and Physical (H&P) dated 7/1/2024, the H&P indicated that the facility admitted the resident on 7/15/2022, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 30 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, Showering/ bathing, and personal hygiene. The MDS indicated that Resident 30 had a diagnosis of seizure disorder.
During a review of Resident 30's Medication Review Report (physician order), dated 3/7/2023, the medication review report indicated to apply bilateral (both sides) padding to the resident`s side rails at all times.
During a review of Resident 30's care plan (a document outlining a detailed approach to care customized to an individual resident's need) for risk for seizure activity, initiated on 8/24/2023 and last revised on 8/12/2024, the care plan indicated a goal that Resident 30 will not experience any seizure activity. The care plan interventions were to administer medication as ordered, implement seizure precautions per facility guidelines, keep bed side rails up while in bed to prevent from falling, and monitor for sign and symptoms of seizure activity.
During an observation on 1/27/2025 at 11:15 a.m., inside Resident 30`s room, Resident 30 was observed lying on his bed. Resident 30's bed side rails did not have any padding as a precaution for seizures.
During a concurrent observation and interview on 6/22/2024 at 11:33 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 30's bed side rails without any padding. LVN 2 stated Resident 30's bed side rails were not padded. LVN 2 stated Resident 30's is supposed to have padded side rails in place because he has a diagnosis of seizure. LVN 2 stated the padded side rails protect the resident from injuries in the event of a seizure.
1.b During a review of Resident 34's physician`s History and Physical (H&P) dated 7/1/2024, the H&P indicated that the facility admitted the resident on 2/3/2022, with diagnoses including tracheostomy, gastrostomy, and seizure disorder.
During a review of Resident 34's MDS dated [DATE], the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 34 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, Showering/ bathing, and personal hygiene. The MDS indicated that Resident 34 had a diagnosis of seizure disorder.
During a review of Resident 34's Medication Review Report (physician order), dated 3/7/2023, the medication review report indicated to apply bilateral padding to the resident`s side rails at all times.
During a review of Resident 34's care plan for risk for seizure activity, initiated on 7/14/2023, and last revised on 8/9/2024, the care plan indicated a goal that Resident 34 will not experience seizure activity. The care plan interventions were to administer medication as ordered, implement seizure precautions per facility guidelines, keep bed side rails up at all times, monitor the resident for complications such as resident getting hurt by side rails if seizure occurs, and monitor for sign and symptoms of seizure activity.
During a concurrent observation and interview on 1/27/2024 at 11:38 a.m., with LVN 2, Resident 34's bed rails were observed. LVN 2 stated Resident 34's bed side rails must be padded as ordered by the physician to prevent the resident from injuries if the resident has a seizure.
During an interview on 1/30/2025 at 2:22 p.m., with the Director of Nursing (DON), the DON stated staff are required to follow physician orders for seizure precautions. The DON stated Residents 30 and 34 had orders for padded sided rails and these orders were not implemented by the staff. The DON stated the potential outcome is injuries during seizure activity.
2. During a review of Resident 18's Patient Information Form (face sheet), the information form indicated that the facility admitted the resident on 11/4/2016, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and dysphagia (difficulty swallowing).
During a review of Resident 18's MDS dated [DATE], the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 18 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair), and sit to stand ( the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS indicated that Resident 18 had limitation in Range of Motion (ROM- full movement potential of a joint) on one side of his body.
During a review of Resident 18's care plan for risk for injury from falls related to right sided weakness, initiated on 6/26/2023, and last revised on 12/27/2024, the care plan indicated a goal that Resident 18 will free of falls during every shift. The care plan interventions were to ensure the bed is kept in the lowest position, evaluate the resident`s environment to identify factors known to increase risk of falls and educate on the importance of maintaining a safe environment, free of potential fall hazards.
During a resident council meeting conducted on 1/28/2025 at 10:36 p.m., Resident 18, present at the meeting, voiced a concern regarding his broken wheelchair hand break.
During a concurrent observation and interview on 1/28/2025 at 3:02 p.m., inside Resident 18`s room, Resident 18 was observed lying on his bed and his wheelchair was placed to the left of the bed. Resident 18`s wheelchair had an arm and footrest on the right side but did not have either on the left side. A green rubber band was observed connecting the right-hand break to the right arms rest. Resident 18 stated that his wheelchair hand break has been broken for two (2) weeks. Resident 18 stated that he has placed the green rubber band on his wheelchair to hold the hand break in place. Resident 18 stated that it is difficult for him to use the hand break because it is broken. Resident 18 stated he has voiced his concern regarding the broken hand break to nursing staff. Resident 18 stated that his wheelchair was previously sent to the engineering department for repair. However, even after the repair, the wheelchair hand break fails to function properly.
During a concurrent observation and interview on 1/28/2025 at 3:10 p.m., with Registered Nurse 1 (RN1), Resident 18 `s wheelchair was observed. RN 1 stated she (RN) has seen the green rubber band on the resident`s wheelchair and she is aware that the right-hand break is broken. RN 1 attempted to reposition Resident 18`s wheelchair right footrest and it fell down. RN 1 stated the footrest is broken as well. RN 1 stated that about two months ago Resident 18 reported to her regarding the broken hand break on his wheelchair. RN 1 stated that she sent the resident`s wheelchair to engineering for repair. RN 1 stated she did not follow up to see whether or not the hand break on Resident 18`s wheelchair was functioning properly. RN 1 stated that staff is required to monitor a resident`s wheelchair to ensure that it is properly functioning at all times. RN 1 stated that the potential outcome of a resident using a wheelchair without a properly functioning hand break and footrest is a fall, potentially resulting in injuries to the resident.
During an interview on 1/30/2025 at 2:35 p.m., with the DON, the DON stated staff are required to monitor a resident`s mobility devices such as cane, and wheelchair to ensure the devices are functioning properly and safe to use. The DON stated Resident 18`s wheelchair hand break and footrest were broken, and staff did not conduct any interventions to repair or replace it immediately. The DON stated Resident 18 was given a new wheelchair on 1/28/2025 after the concern was [NAME] up by the surveyor. The DON stated that the potential outcome of a resident using a wheelchair without a properly functioning hand break and footrest is a fall and possible injuries to the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Seizure Precautions, revised 8/2024, the P&P indicated that it is the policy of the facility t provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible. Identify residents with potentials for seizure activity on the resident`s care plan. Provide safe environment. Pad side rails as indicated.
During a review of the facility's Policy and Procedure (P&P) titled, Safety Precautions-Nursing Services, revised 12/2009, the P&P indicated that the following safety precautions have been established for all personnel to follow when providing nursing care/services. Reports unsafe acts or conditions to your supervisor as soon as possible and report all broken or defective equipment to your supervisor.

Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one out of one sampled resident (Resident 11).
This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being
Findings:
During a review of Resident 11's Inpatient Registration Form, the Inpatient Registration Form indicated the facility admitted Resident 11 on 5/4/2015 and readmitted Resident 11 on 5/9/2017.
During a review of Resident 11's History and Physical (H&P), dated 7/1/2024, the H&P indicated Resident 11 was admitted with diagnosis included Guillain-Barre (GBS- a rare autoimmune disease that occurs when the body's immune system attacks the peripheral nervous system), diabetes mellitus type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and hypertension(a condition in which blood pressure is higher than normal) . The H&P indicated Resident 11 had the capacity to understand and make decisions.
During a review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/11/2024, the MDS indicated the Resident 11 had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 11 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 11's self-care deficit care plan initiated on 01/28/2024, the care plan indicated an intervention to place the call light within easy reach of resident's bedside.
During a concurrent observation and interview on 10/27/2024, at 12:45 p.m., in Resident 11's room, observed the resident in bed, covered with blanked with the adaptive call light (a specially designed call button or call light system that can be used by individuals with physical disabilities or limited mobility to easily signal for assistance) on the left side of Resident 11' s head of the bed. The resident stated that he is able to move only his head, and he could not reach the adaptive call light because it is not close to his head.
During an interview on 1/27/2025 at 12:46 p.m., with Registered Nurse 3 (RN 3), RN 3 confirmed that the adaptive call light was not within reach of Resident 11. RN 3 stated the call light should have been close enough that Resident 11 can use it by turning his head. RN 3 stated the deficient practice had the potential for the resident not able to ask for help when needed and could result in the resident falling.
During an interview on 1/28/2025 at 4:13 p.m. with the Director of Staff Development (DSD), the DSD stated that when making rounds, staff should ensure the residents' call light should always be reachable by clipping the call light on the pillow. The DSD stated that when the call light is not within reach of the resident, the resident may be unable to ask for assistance and could risk falling when attempting to reach for the call light.
During a review of the facility's recent policy and procedure (P&P) titled Call System last reviewed on 1/2025, the P&P indicated: It is the policy of this facility to provide each resident with call system to enable them to request assistance .Make sure call cords are placed within the resident's reach at all times.

Based on interview, and record review, the facility failed to follow the facility`s policy and procedure titled Advanced Directives, for two of five sampled resident (Resident 46 and Resident 35) by failing to:
1. Ensure that Resident 46 was provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive (AD-a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themself) upon admission.
2. Maintain a current copy of Resident 35`s advance directives in the resident's clinical record.
These deficient practices had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 35 and 46's wishes regarding health care.
Findings:
1. During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 46 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.
During a concurrent interview and record review on 1/29/2025 at 11:07 a.m., with Registered Nurse 1 (RN1), Resident 46's medical chart was reviewed. RN 1 stated that the social service department is in charge of completing Advance Directive Acknowledgment forms (ADA-a document provided by the facility that indicates whether a resident has an Advance Directive, would like information regarding creation of an advance directive, or refusal to create an advance directive) for residents upon their admission to the facility. RN 1 stated that the ADA form for Resident 46 was not completed upon her admission to the facility on 9/19/2024. RN 1 stated that if no information is provided to the resident regarding AD, then it is a violation of their right to be informed of the option to formulate an AD.
During a concurrent interview and record review on 1/29/2025 at 1:30 p.m., with Social Worker 1 (SW 1), Resident 46`s medical records were reviewed. SW 1 stated that the ADA form should be completed upon admission. SW1 stated that the ADA form contains information regarding the resident`s right to be informed and to receive information on how to formulate an AD. SW 1 stated that she (SW1) did not complete an ADA form for Resident 46 upon her admission to the facility on 9/19/2024. SW1 stated if the resident was not provided information regarding AD, there is a risk that the resident's wishes may not be honored.
During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 7/2024, the P&P indicated that upon admission the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and formulate an advanced directive if he or she chooses to do so. Information about whether or not the resident has executed an AD shall be displayed prominently in the medical record. If the resident indicates that he or she has not established an AD, the facility staff will offer assistance in establishing an AD.
2. During a review of Resident 35's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 35 on 11/20/2024 and readmitted the resident on 12/3/2024.
During a review of Resident 35's History and Physical (H&P), dated 7/10/2024, the H&P indicated the facility admitted the resident with diagnoses including chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen [odorless and tasteless gas that is essential for life] and carbon dioxide [ a colorless, odorless gas that's naturally produced when we breath] over a prolong time), type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and chronic encephalopathy (the group of condition that cause brain dysfunction[can appear as confusion, memory loss and personality change).
During a review of Resident 35's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/3/2024, the MDS indicated that the resident had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 35 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent interview and record review with Social Worker 1 (SW 1), on 1/28/2025 at 9:43 a.m., Resident 35's clinical records including the Advance Directive acknowledgement form were reviewed. SW1 stated that the resident's Advance Directive acknowledgement form indicated that Resident 35 had an advance directive. SW1 stated that the advance directive was not in the chart. SW1 stated that a copy of Resident 35's advance directive should have been kept in the resident's chart to provide guidance to the facility staff about the resident's wishes.
During an interview with the Director of Staff Development (DSD) on 1/28/2025 at 4:13 p.m., the DSD stated that a copy of Resident 35's advance directive should have been kept in the resident's chart to ensure the resident's wishes would be carried out, and to provide guidance to the facility staff about the resident's wishes.
During a review of the facility's policies and procedures titled Advance Directives, revised 7/2024, indicated that it is the policy of the facility to comply with state law regarding the development and implementation of a resident's advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for three of three sampled residents (Resident 46, Resident 55 and Resident 57) by failing to:
1. Develop and implement a comprehensive person-centered care plan addressing Resident 46`s Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility).
This deficient practice had the potential to result in Resident 46`s inadequate care.
2. Develop and implement a comprehensive person-centered care plan addressing Resident 57 and 55`s antibiotic (drugs that kill bacteria) therapy.
This deficient practice had the potential to result in failure to deliver the necessary care and services.
Findings:
1. During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 46 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.
During a review of Resident 46`s Medication Review Report (physician order) dated 12/26/2024, the report indicated an order for Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility) to provide Passive Range of Motion (PROM-when an outside force such as a therapist exclusively causes movement of a joint) and Active Assistive Range of Motion (AAROM-use of muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) to Resident 46`s Bilateral Upper Extremities (BUE-both arms) and Bilateral Lower Extremities (BLE-both legs) five times a week for 90 days.
During a concurrent interview and record review on 1/30/2025 at 9:37 a.m., with Registered Nurse 2 (RN 2), Resident 46`s physician orders and care plans were reviewed. RN 2 stated Resident 46`s physician ordered for an RNA program five times a week for 90 days on 12/26/2024. However, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s RNA program. RN 2 stated Resident 46 had a stroke and has left sided weakness and a care plan with person-centered intervention is required to monitor the resident's range of motion (ROM- full movement potential of a joint) improvement. RN 2 stated the potential outcome of not developing a person-centered care plan with goals and interventions for a resident who has weakness due to stoke is a lack of care and the inability to implement the specific services and monitoring that the resident requires.
During a review of the facility's policy and procedure (P&P) titled, Care Planning, last revised on 7/2024, the P&P indicated that the purpose of this policy is to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. It is the policy of this facility that within 24 hours of admission, a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. The long-term goal is stated in relation to the expected outcome of the resident's condition and is determined collectively by the health care team as part of the review of the care plan. Reviews will be recorded by date in number sequence. Objectives/goals are expectations, within the resident's abilities, which can be reached realistically. Each problem should have an objective/goal that is simple, specific and measurable within a specified time frame.
2.a. During a review of Resident 57's Patient Information, the Patient Information indicated that the facility admitted the resident on 1/13/2025.
During a review of Resident 57`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 1/22/2025, the H&P indicated that the resident had multiple diagnoses including chronic renal failure (involves a gradual loss of kidney function) and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
During a review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/27/2024, the MDS indicated Resident 57`s cognitive (ability to think, understand and reason) skills for daily decision making was severely impaired and was dependent on staff for activities of daily living (ADLs - activities related to personal care).
During an interview and record review on 1/29/25 at 8:40 a.m., with Registered Nurse 1 (RN 1) reviewed Resident 57`s physician`s order dated 1/21/2025 for Zosyn (used to treat infections caused by bacteria) 3.375 milligram (mg) intravenously (refers to giving medicines or fluids through a needle or tube inserted into a vein) every 8 hours for pneumonia (an infection that inflames the air sacs in one or both lung). RN 1 stated that Resident 57 had pneumonia which was a change in the resident's condition and an antibiotic (Zosyn) was prescribed on 1/21/2025. RN 1 stated any changes in the resident's condition including antibiotic treatment, would require the development of a short-term care plan. RN 1 stated a care plan for antibiotic therapy would include monitoring for any adverse reactions to the antibiotic such as rashes, nausea and vomiting and swelling of the eyes. RN 1 stated that with a care plan in place, the nurses would be able to identify if the resident is having an adverse reaction to the antibiotic and will be able to intervene timely and evaluate if the treatment is effective or not. RN 1 stated that a care plan also serves as communication tool among nurses to ensure continuity of care. RN 1 stated that Resident 57 could have had an adverse reaction from the antibiotic (Zosyn) such as nausea and vomiting which could lead to dehydration.
During a review of the facility`s policy and procedure, titled Care Planning, last reviewed on 7/2024, the policy indicated that a purpose To assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident .
During a review of the facility`s policy and procedure, titled Change in Resident Condition, last reviewed on 7/2024, the policy indicated that All signs and symptoms of the condition change will be communicated to the physician promptly .document resident change of condition and response in Nursing Progress Notes, on a 24-hour report and update resident care plan as indicated .
2.b. During a review of Resident 55's Patient Information, the Patient Information indicated that the facility admitted the resident on 8/22/2024.
During a review of Resident 55`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 10/28/2024, the H&P indicated that the resident had multiple diagnoses including dysphagia (difficulty swallowing) and hypertension (a condition in which the force of the blood against the artery walls is too high).
During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/29/2024, the MDS indicated Resident 55 is in a persistent vegetative state (comatose). The MDS indicated that Resident was totally dependent on staff for activities of daily living (ADLs - activities related to personal care).
During an interview and record review on 1/29/25 at 9:13 a.m., with Registered Nurse 1 (RN1) reviewed Resident 55`s physician`s order dated 10/27/2024 for Zosyn (used to treat infections caused by bacteria) 3.375 milligram (mg) intravenously (refers to giving medicines or fluids through a needle or tube inserted into a vein) every 8 hours for urosepsis (a serious infection that occurs when a urinary tract infection [UTI] spreads to the kidneys). RN 1 stated that Resident 55 had a urosepsis which was a change in the resident's condition and an antibiotic was prescribed (Zosyn) on 10/27/2024. RN 1 stated any changes in the resident's condition including antibiotic treatment, would require the development of a short-term care plan. RN 1 stated a care plan for antibiotic therapy would include monitoring for any adverse reactions to the antibiotic such as rashes, nausea and vomiting and swelling of the eyes. RN 1 stated that with a care plan in place, the nurses would be able to identify if the resident is having an adverse reaction to the antibiotic and will be able to intervene timely and evaluate if the treatment is effective or not. RN1 stated that a care plan also serves a communication tool among nurses to ensure continuity of care. RN 1 stated that Resident 55 could have had an adverse reaction from the antibiotic (Zosyn) such as nausea and vomiting which could lead to dehydration.
During a review of the facility`s policy and procedure, titled Care Planning, last reviewed on 7/2024, the policy indicated that a purpose To assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident .
During a review of the facility`s policy and procedure, titled Change in Resident Condition, last reviewed on 7/2024, the policy indicated that All signs and symptoms of the condition change will be communicated to the physician promptly .document resident change of condition and response in Nursing Progress Notes, on a 24-hour report and update resident care plan as indicated .

2. During a review of Resident 38's History and Physical (H&P) dated 6/25/2024, the H&P indicated that the facility admitted the resident on 5/23/2022, with diagnoses including hemorrhagic stroke (a life-threatening emergency that happens when a blood vessel in your brain breaks and bleeds), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and recurrent Urinary Tract Infection (UTI- an infection in the bladder/urinary tract).
During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2024, the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 38 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 38 had an indwelling catheter.
During a review of Resident 38's care plan for risk for UTI related to use of indwelling catheter initiated on 12/10/2024, the care plan indicated a goal that the resident will show no sign and symptoms of infection during every shift through the next review date. The care plan interventions were to change the indwelling catheter and the bag per facility`s policy, evaluate for pain, encourage fluids, and irrigate (washing out an organ by flushing it with a fluid) the indwelling catheter as ordered.
During a review of Resident 38's Physician Order Summary dated 1/7/2025, the order summary indicated that the resident`s indwelling catheter order for neurogenetic bladder (lack bladder control due to a brain, spinal cord or nerve problem) was discontinued on 1/7/2025 at 3:53 p.m.
During a concurrent interview and record review 1/29/2025 at 10:30 a.m., with MDS Nurse 1 (MDSN 1), Resident 38`s care plans and physician orders were reviewed. MDSN 1 stated Resident 38 `s indwelling catheter order was discontinued on 1/7/2025. However, the care plan for indwelling catheter is still active and was not revise after removal of the indwelling catheter. MDSN 1 stated licensed staff are required to revise a resident`s care plan immediately after removal of the indwelling catheter. MDSN1 stated the potential outcome of not revising the resident's care plan is incorrect medical record and the inability to provide appropriate care and services to the resident.
During an interview on 1/30/2025 at 2:05 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to update/revise a resident`s care plan for indwelling catheter immediately after removal of the catheter. The DON stated the residents` care plans need to reflect the correct condition of the residents with the current services and interventions that are being implemented. The DON stated the potential outcome of not updating/revising a resident`s care plan after removal of an indwelling catheter is the inability to provide appropriate care and services to the resident and incorrect medical records.
During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, last revised on 7/2024, the P&P indicated that the purpose of this policy is to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. It is the policy of this facility that within 24 hours of admission, a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. Reviews will be recorded by date in number sequence. Document resolution of the problem. When a problem is resolved the appropriate date will be indicated on the resident care plan.
Based on interview and record review, the facility failed to:
1. Ensure the Interdisciplinary Team (IDT-a group of experts from various disciplines working together to treat your ailment, injury, or chronic health condition) invite the resident and /or the resident's representative to participate in the IDT Care Conferences for three out of five (R6, 48 and 55) sampled residents.
As a result, the resident and their resident representative were unable to participate in developing the care plan or making decisions about his or her care.
2. Update and revise a resident's care plan (a document outlining a detailed approach to care customized to an individual resident's need) after the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) was removed on 1/7/2025, for one of three (Resident 38) sampled residents reviewed under urinary catheter/ Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) care area.
This deficient practice had the potential to result in Resident 38 receiving inadequate care.
Findings:
1.a. During a review of Resident 6's Patient Information, the Patient Information indicated that the facility admitted the resident on 12/29/2020.
During a review of Resident 6`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 9/06/2024, the H&P indicated that the resident had multiple diagnoses including chronic traumatic encephalopathy (a brain disorder likely caused by repeated head injuries) and seizure disorder (abnormal electrical activity in your brain).
During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/09/2025, the MDS indicated Resident 6 is in a persistent vegetative state (comatose). The MDS indicated that Resident 6 was totally dependent on staff for self-care.
During a record review and interview on 1/30/2025 at 8:11 a.m., with Social Worker 1 (SW 1), reviewed the monthly IDT for Resident 6. SW 1 stated that they conduct monthly and quarterly IDTs. SW 1 stated that during the IDT meetings the team will discuss the resident's plan of care, any changes in the resident`s condition and the objective of the IDT is to come up with a resident-centered care plan. SW 1 stated that it is important to have the resident or the resident's representative to be invited in the IDT meeting to get their input, such as food and activity preferences to ensure the care plan is resident centered. SW 1 stated that it has been a long time since she has read the policy on IDT and from what she can remember the policy states that the resident's family or representative should be involved in the meeting. SW1 stated if the resident's representative does not attend the IDT meeting, the care plan developed may not be resident-centered or able to address the resident's needs. SW1 stated the IDT meeting was held on the following dates and no invitation was extended to Resident 6's representative:
1.01/08/2025
2.11/06/2024
3. 9/04/2024
4. 8/07/2024
During a review of the facility`s policy and procedure, titled Interdisciplinary Team, last reviewed on 7/2024, the policy indicated that Each resident will have an Interdisciplinary Team Conference Meeting held monthly for the Sub-Acute program and weekly for the Transitional Care Program .The Interdisciplinary Team is composed of the Physician, Clinical Manager, MDS Coordinator, Charge Nurse and/or Licensed Nurse who provide care for the resident, a representative from Social Services, Activities, Dietary, Physical, Occupational and Speech Therapies, Respiratory Therapy, Pharmacy, Nursing Assistants, Case Manager(s), Chaplin. The participation of the resident, the resident`s family or resident`s representative is encouraged and welcomed whenever possible .
1.b. During a review of Resident 48's Patient Information, the Patient Information indicated that the facility admitted the resident on 2/16/2024.
During a review of Resident 48`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 2/19/2024, the H&P indicated that the resident had multiple diagnoses including dysphagia (difficulty swallowing) and multiple fractures.
During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/21/2024, the MDS indicated Resident 48 is in a persistent vegetative state (comatose). The MDS indicated that Resident 48 was totally dependent on staff for self-care.
During a concurrent interview and record review on 1/30/2025 at 8:11 a.m., with Social Worker 1 (SW1), reviewed Resident 48's monthly IDT meetings. SW 1 stated that during the IDT meetings the team will discuss the resident's plan of care, any changes in the resident`s condition and the objective of the IDT is to come up with a resident-centered care plan. SW 1 stated that it is important to have the resident`s or the resident's representative to be invited in the IDT meeting to get their input, such as food and activity preferences to ensure the care plan is resident centered. SW 1 stated that it has been a long time since she has read the policy on IDT and from what she can remember the policy states that the resident's family or representative should be involved in the meeting. SW1 stated if the resident's representative does not attend the IDT meeting, the care plan developed may not be resident-centered or able to address the resident's needs. SW1 stated the IDT meeting was held on the following dates and no invitation was extended to Resident 48's representative:
1.01/27/2025
2.10/28/2024
3.08/26/2024
During a review of the facility`s policy and procedure, titled Interdisciplinary Team, last reviewed on 7/2024, the policy indicated that Each resident will have an Interdisciplinary Team Conference Meeting held monthly for the Sub-Acute program and weekly for the Transitional Care Program .The Interdisciplinary Team is composed of the Physician, Clinical Manager, MDS Coordinator, Charge Nurse and/or Licensed Nurse who provide care for the resident, a representative from Social Services, Activities, Dietary, Physical, Occupational and Speech Therapies, Respiratory Therapy, Pharmacy, Nursing Assistants, Case Manager(s), Chaplin. The participation of the resident, the resident`s family or resident`s representative is encouraged and welcomed whenever possible .
1.c. During a review of Resident 55's Patient Information (IP), the Patient Information indicated that the facility admitted the resident on 8/22/2024.
During a review of Resident 55`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 10/28/2024, the H&P indicated that the resident had multiple diagnoses including dysphagia (difficulty swallowing) and hypertension (a condition in which the force of the blood against the artery walls is too high).
During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/29/2024, the MDS indicated Resident 55 is in a persistent vegetative state (comatose). The MDS indicated that Resident was totally dependent on staff for self-care.
During a concurrent interview and record review on 1/30/2025 at 8:11 a.m., with Social Worker 1 (SW1), reviewed Resident 55's monthly IDT meetings. SW 1 stated that during the IDT meetings the team will discuss the resident's plan of care, any changes in the resident`s condition and the objective of the IDT is to come up with a resident-centered care plan. SW 1 stated that it is important to have the resident`s or the resident's representative to be invited in the IDT meeting to get their input, such as food and activity preferences to ensure the care plan is resident centered. SW 1 stated that it has been a long time since she has read the policy on IDT and from what she can remember the policy states that the resident's family or representative should be involved in the meeting. SW1 stated if the resident's representative does not attend the IDT meeting, the care plan developed may not be resident-centered or able to address the resident's needs. SW1 stated the IDT meeting was held on the following dates and no invitation was extended to Resident 55's representative:
1.
01/27/2025
2.
10/28/2024
3.
08/26/2024
During a review of the facility`s policy and procedure, titled Interdisciplinary Team, last reviewed on 7/2024, the policy indicated that Each resident will have an Interdisciplinary Team Conference Meeting held monthly for the Sub-Acute program and weekly for the Transitional Care Program .The Interdisciplinary Team is composed of the Physician, Clinical Manager, MDS Coordinator, Charge Nurse and/or Licensed Nurse who provide care for the resident, a representative from Social Services, Activities, Dietary, Physical, Occupational and Speech Therapies, Respiratory Therapy, Pharmacy, Nursing Assistants, Case Manager(s), Chaplin. The participation of the resident, the resident`s family or resident`s representative is encouraged and welcomed whenever possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to follow the facility's Policy and Procedure (P&P) titled Discharge Planning, for one of two sampled residents (Resident 60) investigated under closed record review by failing to:
1. Develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) addressing Resident 60`s discharge plan.
2. Initiate a discharge planning assessment prior to Resident 60`s discharge.
These deficient practices placed Resident 60 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.
Findings:
During a review of Resident 60's Patient Information Form (face sheet), the patient information form indicated that the facility admitted the resident on 11/9/2023, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 60 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.
During a review of Resident 60`s Intradisciplinary Team (IDT- a group of healthcare workers from different health care disciplines to help people receive the care they need) Conference notes dated 10/28/2024, the IDT notes indicated no entries or documentations for psychosocial and discharge planning sections.
During a review of Resident 60`s assessments, there was no discharge planning assessment conducted for the resident prior to his discharge on [DATE].
During a review of Resident 60's Order Summary Report (physician order) dated 12/22/2024, the order indicated to discharge the resident home with his medications on 12/22/2024.
During a review of Resident 60`s Nursing Progress Notes dated 12/22/2024 at 3:57 p.m., the progress notes indicated that Resident 60 was discharged home with Family Member 1 (FM1) and the discharge instructions were provided to FM 1.
During a concurrent interview and record review on 1/30/2025 at 8:51 a.m., with Social Worker 1 (SW 1), Resident 60`s social service notes, assessments, IDT notes, and care plans were reviewed. SW 1 stated the last IDT conference held for Resident 60 was on 10/28/2024. However, there is no documentations regarding Resident 60`s discharge planning. SW1 stated that she (SW 1) was on medical leave at that time and unable to attend the meeting. SW 1 stated that there was no IDT meeting held addressing Resident 60`s discharge and discharge planning after 10/28/2024. SW 1 stated social service department is involved with the residents` discharge and any coordination required prior to their discharge from the facility. SW 1 stated she was involved with Resident 60`s discharge process. However, she did not document any notes regarding the resident`s discharge planning and all coordination completed prior to the resident`s discharge home. SW 1 stated she did not develop a care plan addressing Resident 60`s discharge plan. SW 1 stated there should be a care plan developed for the resident`s discharge upon admission and the care plan should be updated as needed. SW 1 stated it the facility policy for social workers to initiate a discharge planning assessment when the resident has a planned discharge. However, she (SW 1) did not initiate a discharge planning assessment for Resident 60. SW 1 stated it is important to comply with the facility`s discharge policy and procedure by documenting all the necessary discharge information and conducting required assessments prior to the resident`s discharge for a safe and effective discharge.
During an interview on 1/30/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated staff are required to follow the facility`s discharge planning policy and procedure. The DON stated Resident 60`s discharge planning was incomplete. The DON stated staff did not develop a care plan addressing Resident 60`s discharge needs. The DON stated there was no IDT conference held by the facility staff prior to the resident`s discharge home to discuss the resident`s discharge needs. The DON further stated that staff did not initiate and complete a discharge planning assessment prior to Resident 60`s discharge. The DON stated the potential outcome of an incomplete discharge planning is the lack of provision of the necessary discharge care and services to the resident.
During a review of facility`s Policy and Procedure (P&P) titled Discharge Planning, last reviewed 7/2024, the P&P indicated that The IDT and discharge planner (social worker) are actively involved in planning for the residents who are about to be discharged . The social worker will document in the resident care plan section for discharge planning the level of care required for the resident. The level of care shall be documented within seven days of admit and updated as needed, quarterly and upon change of condition. The social worker shall initiate the discharge planning assessment when it is known that a resident anticipates being discharged . This may be on admission or any time a discharge to home, another facility, lower level of care, nursing facilities indicated. This form should be completed within seven days notice of the discharge. Once the need for discharge planning has been determined, the social worker is responsible for coordination with the resident/responsible party and appropriate disciplines/services the team`s development and completion of the post discharge plan of care summary. Upon discharge the completed discharge forms will be maintained in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the physician's order by failing to check a resident's orthostatic hypotension (a condition where blood pressure drops significantly upon standing or sitting up from a lying position) on 10/23/2024 and 11/27/2024 for one of one (Resident 33) sampled resident.
This deficient practice had the potential for Resident 33 to experience dizziness, lightheadedness, or even fainting when standing up, which can lead to falls and injury.
Findings:
During a review of Resident 33's Patient Information, the Patient Information indicated that the facility admitted the resident on 8/17/2021.
During a review of Resident 33`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 1/20/2024, the H&P indicated that the resident had the following diagnoses, including:
a. Dysphagia (difficulty swallowing)
b. bipolar disorder (a mental health condition where you have extreme mood changes)
c. Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
During a review of Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/25/2024, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS indicated that the resident required supervision during shower, upper body and lower body dressing, putting on/taking off footwear and dependent on staff for toileting hygiene.
During a review of Resident 33`s Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated that the resident is high risk for fall.
During a review of Resident 33`s Physician`s Order (PO) dated 2/3/2023, the Physician's Order indicated that the resident will be monitored for side effects of Zoloft every shift and monitor for orthostatic hypotension on 7:00 a.m. to 7:00 p.m. shift for 14 days then weekly.
During a review of Resident 33`s Physician`s Order dated 1/3/2025, the Physician's Order indicated a renewed order for Zoloft Oral Tablet 50 milligram (mg) one tablet by mouth in the morning for depression manifested by verbalization of sad feelings.
During a review of Resident 33`s Medication Administration Records (MAR- used to document medications taken by each individual) for the month of October 2024 and November 2024, the MAR indicated that a section/column that indicated 2/2/23 Monitor for orthostatic hypotension from 7a-7p sitting/lying position weekly on Wednesday. The MAR for the month October 2024 was blank on the week of 10/21/2024 (Monday) to 10/27/2024 (Sunday) and November 2024 week of 11/25/2024 (Monday) to 11/30/2024 (Sunday).
During a concurrent interview and record review on 1/29/2025 at 10:34 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 33`s physician`s order for Zoloft, the order to monitor for orthostatic hypotension and the MAR for October 2024 and November 2024. RN 1 stated monitoring for orthostatic hypotension is done for residents on certain medications, including Zoloft. RN 1 stated that monitoring for orthostatic hypotension is important to prevent a fall incident, potentially resulting in injuries if the resident`s blood pressure drops, or the resident becomes hypotensive (low blood pressure) due to the medication. RN 1 stated that licensed nurses should have checked the resident for orthostatic hypotension and document in the MAR on 10/23/2024 and 11/27/2024 to ensure Resident 33's blood pressure was not low.
During a review of the facility`s policy and procedure, titled Pharmaceutical Services Policy and Procedure Manual, last reviewed on 7/2024, the policy indicated that residents who receives antidepressant, hypnotic, antianxiety, or antipsychotic medications shall be monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with minimum untoward effects . physician, nurse, or other health professional documentation that the resident is being monitored for adverse consequences of therapy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1. Check the gastrostomy tube (G-tube, a tube inserted through the abdomen] to deliver nutrition and medications directly to the stomach]) residual volume (the amount of fluid in the stomach after a feeding) before administering a medication to one of five residents (Resident 7) observed during medication administration
This deficient practice had the potential to place Resident 7 at increased risk for aspiration pneumonia (a type of lung infection that occurs when food, saliva, or other substances are inhaled into the lungs, which occurs when medication is accidentally delivered into the lungs instead of the stomach because an improperly placed tube could be in the esophagus or trachea, allowing medication to enter the airway).
2. Ensure the G-tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding bottle was labeled with the date and time the feeding was started for one of 41 residents (Resident 48) prescribed with G-tube feeding.
This deficient practice placed Resident 48 at risk for infection from spoiled G-tube feeding formula since it was unknown when the G-tube feeding bottle was changed or started.
3. Failed to label the feeding syringe (a medication device that helps deliver nutrients, medications, or fluid directly into a patient's digestive system through a feeding tube) with the resident's name and the date it was last changed for one of four of four sampled residents (Residents 52) reviewed under tube feeding (feeding delivered through a medical device bypassing oral intake)
This deficient practice had the potential to increase the risk of healthcare acquired infection to Resident 52.
4. Implement their enteral tube feeding (a method of supplying nutrition directly into the stomach) policy by failing to ensure that one of three sampled resident's (Resident 19) gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding formula was labeled with the time, date, and initials of the licensed nurse who initiated the feeding formula.
This deficient practice had the potential to result in the feeding formula exceeding its hang-time (the amount of time a prepared tube feeding formula can safely remain at room temperature before it needs to be discarded) and may have the potential to cause adverse reactions (an undesired effect of a treatment) such as upset stomach and/or diarrhea (loose stool).
Findings:
1. During a review of Resident 7's Patient Information, the Patient Information indicated the facility originally admitted the resident on 1/21/2024 and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period) and persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness).
During a review of Resident 7`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/13/2024, the MDS indicated Resident 7's is in a persistent vegetative state (comatose). The MDS indicated that Resident 7 was totally dependent on staff for self-care.
During a review of Resident 7`s Physician`s order dated 2/27/2024, it indicated an order for Tramadol HCL Tablet 50 milligram (mg), give 1 tablet via G-Tube every 6 hours as needed for moderate to severe pain.
During a medication observation and concurrent interview on 1/28/25 at 4:18 p.m., observed Licensed Vocational Nurse 1 (LVN1) prepared Tramadol 50 mg for Resident 7. Observed LVN 1 enter the resident`s room, greeted the resident, introduced himself, checked the resident`s ankle band and explained to the resident that he (LVN 1) administer Tramadol 50 mg. LVN 1 washed his hands after he placed the resident in semi-Fowler_position. LVN 1 flushed Resident 7's G-tube with water and gave the medication through the medication syringe attach to the G-Tube port. After giving the resident the medication, LVN 1, stated that he should have verified the G-tube placement by aspirating for gastric contents and withheld the medication if the gastric residual (the volume of fluid remaining in the stomach after a meal or during enteral feeding) exceeded 100 milliliters (ml.-unit of measurement). LVN1 stated that it is important to check for gastric residual to confirm the G-Tube's placement and prevent aspiration pneumonia.
During a review of the facility`s policy and procedure titled Medication Administration, last reviewed on 11/2022, the policy indicated in the procedure that for tube administration, check for proper placement of tube by aspirating gastric contents; flush the tube with approximately 30 ml of water; draw the liquefied medications into the feeding syringe or pour into connected feeding syringe by gravity; and allow medications to flow by gravity through the enteral tube .
2. During a review of Resident 48's Patient Information, the Patient Information indicated that the facility admitted the resident on 2/16/2024.
During a review of Resident 48`s History and Physical (H&P- the most formal and complete assessment of the patient and the problem) dated 2/19/2024, the H&P indicated that the resident had multiple diagnoses including dysphagia (difficulty swallowing) and multiple fracture.
During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/21/2024, the MDS indicated Resident 48 is in a persistent vegetative state (comatose). The MDS indicated that Resident 48 was totally dependent on staff for self-care.
During a review of Resident 48`s Physician`s Order (PO) dated 8/26/2024, the PO indicated an order for G-Tube feeding of Glucerna 1.2 at 75 milliliter (ml) per hour via enteral pump (enteral pumps are used when a tube feeding needs to be administered slowly over an extended period of time).
During a concurrent observation and interview on 01/27/25 11:34 a.m., with Licensed Vocational Nurse 2 (LVN2), observed Resident 48`s G-Tube feeding formula bottle without date and time it was started. LVN 2 stated the formula should have a label indicating the rate of infusion, room number, and the date and time the feeding formula was hung and started. LVN 2 stated that it is important to label the formula with the date and time because the formula should only be used for 24 hours. LVN 2 stated that if the feeding formula has been hung for more than 24 hours, there is a risk that the resident may receive spoiled formula, potentially causing stomach illnesses to Resident 48.
During an interview with Registered Nurse 1(RN 1) on 01/28/25 11:11 a.m., RN 1 stated that if the feeding formula is not labeled with the time it was hung, they will not be able to determine if the feeding formula has been in use for more than 24 hours. RN 1 stated the feeding formula must be discarded after 24 hours for infection control and to prevent foodborne illnesses
During a review of the facility`s policy and procedure, titled Enteral Feeding via G-Tube, last reviewed on 11/2024, the policy indicated to Fill and connect bag and tubing. DO NOT fill with more formula than will be administered in four hours. If using closed system, formula may hang for 24 hours. Label bag with date and time hung.
4. During a review of Resident 19's History and Physical (H&P) dated 7/1/2024, the H&P indicated that the facility admitted the resident on 2/18/2022, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 11/22/2024, the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 19 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, and personal hygiene. The MDS further indicated that Resident 19 was receiving nutrition via gastrostomy tube.
During a review of Resident 19`s Medication Review Report (physician order) dated 11/25/2024, the medication review report indicated an order for Glucerna 1.2 (type of enteral feeding) at 50 ml (milliliter- unit of measurement)/hr. (hour) for eighteen hours via enteral pump.
During a concurrent observation and interview on 1/27/2025 at 9:36 a.m., with Licensed Vocational Nurse 5 (LVN 5), inside Resident 19's room, LVN 5 stated that Resident 19`s GT formula and water bags did not have a label with the date and time the feeding was started nor the initials of the nurse who started the feeding. LVN 5 stated when licensed nurses start a new feeding bag, they are required to label the feeding bag with the date and time the feeding was started and mark their initials on the label. LVN 5 stated this is to ensure that the formula is safe for the resident.
During an interview on 1/30/2025 at 2:24 p.m., with the Director of Nursing (DON), the DON stated that all feeding bags and bottles should be labeled with the resident's name, type of feeding, rate, date and time and initial of the licensed nurse who hung the feeding. The DON stated the date and time are important to be labeled because feeding bags and tubing must be changed and discarded every 24 hours per facility`s policy. The DON stated the potential outcome of not properly labeling a tube feeding bag is the inability to know the date and time the feeding was started.
During a review of the facility`s Policy and Procedure (P&P) titled Enteral Feeding Via G-Tube) last reviewed 11/2024, the P&P indicated that enteral feeding will be administered by a continuous method via pump as ordered by the physician, and per facility`s standard. Change feeding bag and tubing every 24 hours.
3. During a review of Resident 52's Inpatient Registration Form, the Inpatient Registration Form indicated that the facility admitted Resident 52 on 10/9/2024 and readmitted the resident on 10/15/2024.
During a review of Resident 52's History and Physical (H&P), dated 10/16/2024, the H&P indicated the resident was admitted with diagnoses including hypertension (a condition in which blood pressure is higher than normal), chronic respiratory failure status post tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and dysphagia (difficulty swallowing). The H&P indicated that Resident 52 did not have a capacity to make decisions.
During a review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/26/2024, the MDS indicated that the resident had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 52 was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During the review of Resident 52's Order Summary Report, the Order Summary Report indicated an order dated 10/15/2024 for Jevity 1.2 ( feeding formula) at 50 cc/hours (rate of infusion of feeding formula) for 22 hours to provide 1320 cc/day (number of calories for 24 hours) via G-Tube.
During the review of Resident 52's care plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) regarding gastrostomy status revised on 1/28/2025 the care plan indicated that goal of care plan was to minimize risk of infection at G-Tube site.
During an observation on 1/27/2025 at 12:15 p.m. in Resident 52's room, observed a feeding syringe in an open package and did not have a label indicating the resident's name and the date it was last changed.
During an interview on 1/27/2025 at 12:16 p.m., Registered Nurse 3 (RN 3) confirmed that Resident's 52 feeding syringe was not labeled with a name and the date it was changed. RN 3 stated the feeding syringe should be labeled with the resident's name and the date it was last changed to prevent cross contamination and decrease risk of healthcare acquired infection to Resident 52.
During an interview on 1/28/2025 at 4:13 p.m. with the (DSD), the DSD stated that the feeding syringe should be labeled with the resident's name and the date it was last changed to prevent microbial growths and cross contamination. The DSD stated that this deficient practice had the potential for increased risk of infection to Resident 52.
During an interview on 1/30/2025 at 7:43 a.m. with the Infection Preventionist (IP), the IP stated that the feeding syringe has to be changed every 24 hours and labeled with the date it was changed and the resident's name to prevent microbial growths and cross contamination. The IP stated that this deficient practice has the potential for increased risk of healthcare acquired infection to Resident 52.
During a review of the facility policy named Enteral Feeding via G-tube or G-Tube (continuous) pump, last reviewed on 11/2024, the policy stated: Enteral feeding will be administered by a continues method via pump as ordered by the physician, and per facility standards .Change feeding bag and tubing every 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pain was assessed before and after administration of pain medication for two of two sampled residents (Resident 6 and Resident 42).
This deficient practice resulted in Resident 6 and Resident 42's pain not being assessed and placed the residents at risk for having unmanaged pain that may diminish the residents' quality of life.
Cross reference F755
Findings:
a. During a review of Resident 6's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 6' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/09/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
During a review of Resident 6's Physician's Orders, the documents indicated the following orders:
-
Hydrocodone acetaminophen tablet (brand name is Norco, a narcotic pain medication) 10-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-Tube, a plastic tube inserted into the stomach to give medications for those with difficulty swallowing) every four hours as needed (PRN, or pro re nata, Latin for as needed) for severe pain 7-10, (numeric pain scale in which a resident's pain is indicated with zero being no pain and 10 for the worst pain imaginable), dated 7/24/2024.
During a review of Resident 6's CDR, the document indicated the medication Norco was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic bubbles [or blisters] that is punched out to administer to a resident) on the following dates:
1/28/2025 at 4:20 a.m.
1/26/2025 at 6 a.m.
1/24/2025 at 6 a.m.
1/23/2025 at 11 p.m.
During a review of Resident 6's MAR for the month of 1/2025, the MAR did not indicate Resident 6 was given Norco on the above dates. The MAR did not indicate any documentation that Resident 6's pain was assessed for these dates.
b. During a review of Resident 42's Patient Information Form, the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a serious condition that occurs when the lungs are unable to exchange oxygen and carbon dioxide [a by-product of respiration] efficiently with the blood).
During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 42 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 42 had a diagnosis of pain.
During a review of Resident 42's Physician's Orders, the documents indicated the following orders:
-Norco 5-325 mg, give one tablet by mouth every eight hours as needed for severe pain 7-10, dated 5/19/2023.
During a review of Resident 42's CDR, the CDR indicated the medication Norco was removed from the blister pack on 1/24/2025 at 9 p.m. The MAR did not indicate any documentation that Resident 6's pain was assessed for these dates.
During a review of Resident 42's MAR for the month of 1/2025, the MAR did not indicate Resident 42 was given Norco on 1/24/2025 at 9 p.m. The MAR did not indicate any documentation that Resident 6's pain was assessed for these dates.
During a medication cart observation and concurrent record review with Registered Nurse 1 (RN 1) on 1/28/2025 at 9:08 a.m., observed the contents of Subacute 2 Medication cart 3. Reviewed Resident 6's CDR for Norco which indicated Norco was signed out to be given to Resident 6 on 1/28/2025 at 4:20 a.m., 1/26/2025 at 6 a.m., 1/24/2025 at 6 a.m., and 1/23/2025 at 11 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. RN 1 stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. RN 1 stated the licensed nurse should have signed the MAR after giving the medication. RN 1 stated this process is important so that a resident's physician knows how much medication is being given and will indicate whether a resident's pain relief is achieved. Also in Subacute 2 Medication Cart 3, reviewed Resident 42's CDR for Norco which indicated Norco was signed out to be given to Resident 42 on 1/24/2025 at 9 p.m. However, there was no corresponding entry in Resident 42's 1/2025 MAR.
During an interview with the Director of Staff Development (DSD) on 1/29/2025 2:45 p.m., they stated the licensed nurse who signed the CDR but not the MAR for Resident 6 and Resident 42 worked the 7 p.m. to 7 a.m. shift. Asked for name and contact information for the licensed nurse but did not receive during the recertification survey.
During an interview with the DSD on 1/30/2025 at 12:20 p.m., they stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DSD stated this was important to know if the pain medication was effective, and if not affective to notify the doctor to receive an order to modify the dosage.
During an interview and concurrent record review with the Director of Nurses (DON) on 1/30/2025 at 2:14 p.m., they stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated they thought the pain medications removed for Resident 6 and Resident 42 and were documented on the CDRs were given to them. The DON stated they did not think there was an issue of drug diversion. The DON stated it is important to sign the MAR because for pain medication there is a pain level documented and if not signed in the MAR, then no assessment or reassessment of the effectiveness of the pain medication. The DON stated this had the potential to result in a resident's pain will not be relieved. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those times.
During a review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, last reviewed 7/2024, the policy and procedure indicated when a medication is removed from stock, the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication.
During a review of the facility's policy and procedure titled, Controlled Medications, last reviewed 7/2024, the policy and procedure indicated the following:
When a controlled medication is administered, the licensed nurse administering the medication shall immediately enter the following information on the accountability record:
1)
Date and time of administration
2)
Amount administered
3)
Signature of the nurse administering the dose, completed after the medication is actually administered
Note: Entering information on the accountability record does not replace recording medication administration on the MAR.
During a review of the facility's policy and procedure titled, Medication Administration, reviewed 7/2024, the policy and procedure indicated the following:
The individual who administers the medication dose shall record the administration of the resident's MAR directly after the medication is given.
When PRN medications are administered, the following documentation shall be provided:
1)
Date and time of administration, dose, route of administration (if other than oral).
2)
Complaints or symptoms for which the medication was given.
3)
Results achieved from giving the dose and the time results were noted.
4)
Signature of initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician sign and date all orders in the physical or electronic record, during visits of three out of 23 sampled residents (Resident 4, Resident 13, and Resident 51).
This deficient practice had the potential to cause a delay in a resident's plan of care.
Findings:
a. During a review of Resident 4's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 4' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/18/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 4's paper Physician's Orders, the documents indicated the following telephone orders that were not signed by a physician, nor was there a date or time indicated:
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Physical therapy/Occupational evaluation (evaluating use of arms and legs).
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Recommend Restorative Nursing Assistant Program (RNA, a nurse who helps in moving a resident's arms and legs to maintain a resident's functioning) for bilateral (both) upper extremity (arms) maintenance.
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RNA to perform Passive Range of Motion Exercises (PROM, when a nurse moves a resident's arms and legs for those who cannot move them) exercises to bilateral upper extremities and bilateral lower extremities as tolerated five times a week for 90 days.
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RNA/Nursing to apply right elbow splint (a device that holds the elbow in place) per protocol.
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RNA/Nursing to apply bilateral ankle foot orthosis (a brace worn to provide support) AFO's per protocol.
b. During a review of Resident 13's Patient Information Form, the document indicated Resident 13 was admitted to the facility on [DATE]. No diagnoses were indicated on the Face Sheet.
During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 13 was independent (resident completes the activity by themselves with no assistance from a helper) with eating and oral hygiene. The MDS indicated Resident 13 had a diagnoses of diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells)
During a review of Resident 13's paper Physician's Orders, the documents indicated the following orders without a date or time on them:
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Zepbound (a medication to help one to lose weight) 7.5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) once a week for four weeks, followed by Zepbound 10 mg once a week for four weeks followed by Zepbound 12 mg once a week for four weeks followed by Zepbound 15 mg once a week as maintenance dosage (medication required to maintain a desired steady-state drug concentration in the body).
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Laboratory values hemoglobin A1C (Hgb A1C, a blood test that measures the average blood sugar [glucose] level over the past 2-3 months)
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Loratadine (medication to treat allergy to pollen or dust) 10 mg daily.
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Discontinue Flonase (treats allergy symptoms).
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Debrox (medication for ear wax removal) 4 drops twice a day for four days, manual ear flushing.
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Laboratory values: uric acid, CBC, BMP
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Venous ultrasound to rule out deep vein thrombosis (DVT, a blood clot that forms in the deep veins such as the legs that can travel to the lungs and stop breathing) ankle brachial index (ABI, ultrasound device to measure blood pressure in the ankle to see if there is any blood vessel blockage) bilateral lower extremities (both legs).
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X-ray left lower leg.
c. During a review of Resident 51's Face Sheet, the face sheet indicated Resident 51 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 51 was dependent on staff with oral hygiene, dressing, toileting, and personal hygiene.
During a review of Resident 51's paper Physician's Orders, the document indicated an order to draw labs for iron (a mineral that the body needs to produce hemoglobin [a protein in red blood cells that carries oxygen]) and ferritin (a protein in the blood that stores iron) without a date or time on them.
During a concurrent interview and record review with the Director of Staff Development (DSD) on 1/30/2025 at 12:20 p.m., reviewed Physician's Orders for Resident 4, Resident 13, and Resident 51. The DSD confirmed that none of the orders were dated or timed. The DSD confirmed that Resident 4's Physician Orders were not signed by the resident's physician. The DSD stated the process is for a resident's physician signs, dates, and times the physical order record or if the order is a telephone order, the nurse dates and times the order and the doctor comes to the nurse's station to sign the physical telephone order. The DSD stated after that, the licensed nurse enters the order into the electronic health record in the computer. The DSD stated this is important to ensure that a resident's orders are current, medications have the correct dosages and helping in tracking orders to see if they are completed. Reviewed Resident 4's Physician's Orders for RNA and the electronic order for RNA. The DSD confirmed, according to the RNA electronic order, the RNA orders were carried out 8/01/2024. Reviewed Resident 51's Laboratory Values for iron and ferritin, dated 12/18/2024. The DSD stated 12/18/2024 was the date the physical order for Resident 51 was written for the order of iron and ferritin.
During an interview with the Director of Nurses (DON), on 1/30/2025 at 2:14 p.m., he stated a resident's physical orders need to be dated and timed by the resident's physician. The DON stated this is important, so the licensed nurses know when the order was written. The DON stated if the order is not entered directly into the electronic health record system the day the order was taken, there could be a delay in care for a resident.
During a review of the facility's policy and procedure titled, Prescriber Medication Orders, last reviewed 7/2024, the policy and procedure indicated the following:
Medications shall be administered only upon the clear, complete, and signed order of a licensed physician lawfully authorized to prescribe medications. Telephone orders are received only by licensed nurses or pharmacists and countersigned by the prescriber within the time prescribed by facility policy but in any even no later than 5 (five) days following generation of the telephone order. Each medication order shall be written in the resident's medical record with the date, time, and signature of the person writing or receiving the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure titled, Patient Care Services-Assessment, for one of two sampled residents (Resident 46) by failing to conduct a social service assessment within 48 hours of the resident`s admission to the facility.
This deficient practice placed the residents at risk of not receiving sufficient and appropriate social services to meet the resident's needs.
Findings:
During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 46 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.
During an interview on 1/29/2025 at 1:00 p.m., inside Resident 46`s room, Resident 46 stated that she was admitted to the facility on [DATE]. However, she (Resident 46) has not seen a social worker in the facility since her admission. Resident 46 stated that she did not have any social services needs to be addressed but she (Resident 46) is aware that the social worker is required to visit her (Resident 46) upon her admission to the facility.
During a concurrent interview and record review on 1/29/2025 at 1:35 p.m., with Social Worker 1 (SW 1), Resident 46`s assessments were reviewed. SW 1 stated that Resident 46 was admitted to the facility on [DATE]. However, she (SW 1) did not conduct any social service assessments for the resident since her admission. SW 1 stated the social workers are required to meet with the residents or their families within 24 hours of their admission and gather information necessary to conduct an initial assessment within 48 hours of the resident`s admission. SW1 stated that this assessment includes psychosocial history, physical, cultural and spiritual factors having impact on the resident`s adjustment and wellbeing in the facility, and the determination of anticipated discharge planning. SW 1 stated that the reason she did not conduct a social service assessment for Resident 46 was because she was backed up with assignments for other residents. SW1 stated that the potential outcome of not timely assessing a resident is the delay in addressing their psychosocial issues and assisting the residents with their adjustment period in the facility.
During an interview on 1/30/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated the social worker should visit the residents within 24 hours of their admission into the facility and shall conduct a social service assessment within 48 hours of the admission. The DON stated SW 1 did not conduct any social service assessments for Resident 46 and the potential outcome is inability to address psychosocial concerns, prevent psychosocial issues, provide safe discharge, and assist residents with their adjustment period in the facility.
During review of the facility's Policy and Procedure (P&P) titled, Patient Care Services-Assessments, last reviewed on 7/2024, the P&P indicated that a social service assessment will be conducted within 24 hours of the resident`s admission with written assessment/documentation completed within 48 hours of the admission to the unit. Psychosocial information should be gathered that is pertinent to successful medical treatment, significant personal and social problems, emotional well-being and the resident`s ability for successful utilization of facility services. The purpose of the social service assessment shall be to understand those factors in the resident`s history, family situation and illness that affect the resident and his family in accepting and adjusting to the resident`s current situation and his need for placement on the subacute unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) affecting Resident 6 and Resident 42 in one of three inspected medication carts (subacute unit two medication cart 3).
This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).
2. Ensure that the refrigerator emergency kit (e-Kit, a collection of medications that can help people survive or respond to an emergency) in two of two medication storage rooms investigated (subacute unit two and subacute unit three medication rooms), were replaced within 72 hours after removing three residents' medications (Resident 4, Resident 27, Resident 14)
This deficient practice had the potential to delay the necessary pharmaceutical services to the residents in the subacute unit two and subacute unit three.
Findings:
1 a. During a review of Resident 6's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 6' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/09/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
During a review of Resident 6's Physician's Orders, the documents indicated the following orders:
- Hydrocodone acetaminophen tablet (brand name is Norco, a narcotic pain medication) 10-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-Tube, a plastic tube inserted into the stomach to give medications for those with difficulty swallowing) every four hours as needed (PRN, or pro re nata, Latin for as needed) for severe pain 7-10, (numeric pain scale in which a resident's pain is indicated with zero being no pain and 10 for the worst pain imaginable), dated 7/24/2024.
-Lorazepam (brand name Ativan, a medication given to treat anxiety [feelings of uneasiness]) 0.5 mg, give 0.25 mg via G-Tube every eight hours as needed for anxiety, manifested by pulling out tubes and crying, dated 1/01/2025.
During a review of Resident 6's CDR, the document indicated the medication Norco was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic bubbles [or blisters] that is punched out to administer to a resident) on the following dates:
1/28/2025 at 4:20 a.m.
1/26/2025 at 6 a.m.
1/24/2025 at 6 a.m.
1/23/2025 at 11 p.m.
During a review of Resident 6's CDR, the document indicated the medication lorazepam was removed from the blister pack on the following dates:
1/24/2025 at 3 a.m.
1/23/2025 at 9 p.m.
During a review of Resident 6's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 1/2025, the MAR did not indicate Resident 6 was given Norco or lorazepam on the above dates.
1 b. During a review of Resident 42's Patient Information Form, the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a serious condition that occurs when the lungs are unable to exchange oxygen and carbon dioxide [a by-product of respiration] efficiently with the blood).
During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 42 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 42 had a diagnosis of pain.
During a review of Resident 42's Physician's Orders, the documents indicated the following orders:
- Norco 5-325 mg, give one tablet by mouth every eight hours as needed for severe pain 7-10, dated 5/19/2023.
During a review of Resident 42's CDR, the CDR indicated the medication Norco was removed from the blister pack on 1/24/2025 at 9 p.m.During a review of Resident 42's MAR for the month of 1/2025, the MAR did not indicate Resident 42 was given Norco on 1/24/2025 at 9 p.m.
During a medication cart observation and concurrent record review with Registered Nurse 1 (RN 1) on 1/28/2025 at 9:08 a.m., observed the contents of Subacute 2 Medication cart 3. Reviewed Resident 6's CDR for Norco which indicated Norco was signed out to be given to Resident 6 on 1/28/2025 at 4:20 a.m., 1/26/2025 at 6 a.m., 1/24/2025 at 6 a.m., and 1/23/2025 at 11 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. RN 1 stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. RN 1 stated the licensed nurse should have signed the MAR after giving the medication. RN 1 stated this process is important so that a resident's physician knows how much medication is being given and will indicate whether a resident's pain relief is achieved. Reviewed Resident 6's CDR for Ativan which indicated Ativan was signed out to be given to Resident 6 on 1/24/2025 at 3 a.m. and 1/23/2025 at 9 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. Reviewed Resident 42's CDR for Norco which indicated Norco was signed out to be given to Resident 42 on 1/24/2025 at 9 p.m. However, there was no corresponding entry in Resident 42's 1/2025 MAR.
During an interview with the Director of Staff Development (DSD) on 1/29/2025 2:45 p.m., the DSD stated the licensed nurse who signed the CDR but not the MAR for Resident 6 and Resident 42 worked the 7 p.m. to 7 a.m. shift. Asked for name and contact information for the licensed nurse but did not receive during the recertification survey.
During an interview with the DSD on 1/30/2025 at 12:20 p.m., the DSD stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DSD stated this was important to know if the pain medication was effective, and if not affective to notify the doctor to receive an order to modify the dosage.
During an interview and concurrent record review with the Director of Nursing (DON) on 1/30/2025 at 2:14 p.m., the DON stated that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those times. The DON stated she (DON) did not think there was an issue of drug diversion. The DON stated it is important to sign the MAR because for pain medication there is a pain level documented and if not signed on the MAR, then no assessment or reassessment of the effectiveness of the pain medication and a resident's pain relief will not be relieved.
During a review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, reviewed 7/2024, the policy and procedure indicated when a medication is removed from stock, the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication.
During a review of the facility's policy and procedure titled, Controlled Medications, last reviewed 7/2024, the policy and procedure indicated the following:
When a controlled medication is administered, the licensed nurse administering the medication shall immediately enter the following information on the accountability record:
1)
Date and time of administration
2)
Amount administered
3)
Signature of the nurse administering the dose, completed after the medication is actually administered
Note: Entering information on the accountability record does not replace recording medication administration on the MAR.
During a review of the facility's policy and procedure titled, Medication Administration, reviewed 7/2024, the policy and procedure indicated the following:
The individual who administers the medication dose shall record the administration of the resident's MAR directly after the medication is given.
When PRN medications are administered, the following documentation shall be provided:
1)
Date and time of administration, dose, route of administration (if other than oral).
2)
Complaints or symptoms for which the medication was given.
3)
Results achieved from giving the dose and the time results were noted.
4)
Signature of initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.
2 a. During a review of Resident 4's Patient Information Form (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 4' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/18/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 4's Physician's Orders, the documents indicated an order for Ativan injection solution (a medication given to treat seizures) 2 milligrams/milliliter (mg/ml, metric unit of measurement, used for medication dosage and/or amount), inject 1 ml intramuscularly (administered into the muscle through a needle) every six hours as needed for seizures, dated 1/14/2025.
During a review of Resident 4's Nursing Progress Notes, dated 1/14/2025, indicated Ativan 1 mg was given for a seizure episode.
During a review of Resident 4's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 1/2025 indicated Resident 4 received Ativan 1 mg intramuscularly for one dose on 1/14/2025.
2 b. During a review of Resident 27's Patient Information Form, the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 27' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/16/2024, the MDS indicated Resident 27 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 27 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure.
During a review of Resident 27's Physician's Orders, the documents indicated an order for Ativan injection solution 1 mg, give intramuscularly for one dose for seizures, dated 12/24/2025.
During a review of Resident 27's Nursing Progress Notes, dated 12/24/2024, indicated Ativan 1 mg was given for a seizure episode.
During a review of Resident 27's MAR for 12/2024 indicated Resident 27 received Ativan 1 mg intramuscularly for one dose on 12/24/2024.
During a concurrent record review and medication storage observation for the Subacute 2 Medication Room, with Registered Nurse 1 (RN 1) observed the e-Kit stored in the refrigerator, that contained one vial (a small container, typically cylindrical and made of glass, used for holding liquid medicine) of Ativan. Observed two emergency drug [NAME] Forms, one for Resident 4, dated 1/14/2025 and another for Resident 27, dated 12/24/2024. RN 1 stated these forms were filled out when medication was removed from the e-kit. Reviewed the e-Kit Content List indicated the e-Kit was originally stocked with three Ativan 2mg/ml vials. RN 1 stated the e-Kit was opened on 12/24/2024 and 1/14/2025 and that a vial of Ativan was removed each time. When asked when the pharmacy should be notified so that the e-Kit can be replaced, RN 1 stated that is to be conducted immediately right after removing the medication from the e-Kit. RN 1 stated this was important to ensure medications are replaced so there will be available for other residents who need the medications. RN 1 stated Licensed Vocational Nurse 3 (LVN 3) was the licensed nurse who removed both vials of Ativan on 12/24/2024 and 1/14/2025.
During an interview with RN 1 on 1/29/2025 at 10 a.m., RN 1 stated the licensed nurse peels off a sticker when removing the medication from the e-Kit and faxes and then calls the pharmacy to come replace the e-Kit.
During an interview with the Director of Staff Development (DSD) on 1/30/25 at 12:20 p.m., the DSD stated the importance of replacing the e-Kit within 72 hours is to ensure a medication is available in case of emergency. The DSD stated the process to follow is once a medication is removed from the e-Kit, the licensed nurse is to call the pharmacy to replace the e-Kit and fax the sticker to the pharmacy. After that, the pharmacy has the responsibility to replace the e-Kit. The DSD stated they were not sure what part of the process was not followed.
During an interview with the Director of Nurse (DON) on 1/30/25 at 2:14 p.m. the DON stated it is important to replace an e-Kit within 72 hours, is to ensure needed medications will be available to residents that need them.
During a review of the facility's policy and procedure titled, Emergency Pharmacy Services/Emergency Kits, last reviewed 7/2024, indicated the following: When an emergency or starter dose (first dose) of a medication is needed, the nurse shall break the container seal and remove the required medication. As soon as possible, the nurse records the medication use on the medication order form and calls the pharmacy for replacement of the kit. When the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy. All kits must be replaced within 72 hours of opening.
2 c. During a review of Resident 14's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 14 on 4/20/2024 and readmitted the resident on 1/15/2025.
During a review of Resident 14's care plan dated 12/11/2025, the care plan indicated the resident was admitted with diagnoses including seizures disorder (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements) and cerebral anoxia (a condition that affects muscle coordination and can cause clumsy movements). The care plan indicated that Resident 14 was Ativan (medication to treat seizure disorder) PRN (as needed).
During a review of Resident 14 physician order dated 4/30/2024, the physician order indicated an order for Ativan 2 mg intramuscularly every 6 hours as needed for seizures.
During a review of Resident 14's MDS, dated [DATE], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 14 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview on 1/28/2025 at 03:53 p.m., the surveyor observed the contents of third floor medication refrigerator with Registered Nurse 2 (RN 2). The refrigerator e-Kit was open and was missing one vial of Ativan 2 mg /ml. RN 2 confirmed that emergency kit was open and missing medication. RN 2 stated that by facility policy the nurse who used medication in emergency kit has to immediately call the pharmacy and request a new emergency medication kit. RN 2 called the pharmacy and ordered the new emergency kit. RN 2 was unable to find the log for usage of emergency medication and was not sure what date it was used and for which resident.
During a concurrent interview and record review on 1/29/2025 at 12p.m. with Director of Staff Development (DSD), the DSD reviewed emergency drug billing form dated 1/10/2025 and stated that Ativan 2 mg /ml was used on 1/10/2025 for Resident 14 for seizure activities. The DSD stated that that emergency kit should be replaced with 72 hours of opening. The DSD stated it is the charge nurse responsibility before reporting of duty, the charge nurse should indicate the open status of the emergency kit at the shift change if the supply has not yet been replaced by the pharmacy. The potential of this deficient practice can delay pharmaceutical services to the residents.
During a review of facility policy called Emergency pharmacy services /emergency kit, last reviewed 7/2024, the policy indicated:' An emergency supply of medications, including emergency drugs, antibiotics, controlled substances, and infusion products shall be supplied by Alliance Pharmacy, Inc in limited quantities in portable, sealed containers, in compliance with all applicable state regulations .All kits must be replaced within 72 hours of opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for two of five sampled residents (Resident 17 and 35) by:
1. Failing to act upon the facility consultant pharmacist's recommendation to assess the need for the medication, FeroSul (also known as ferrous sulfate, medication given for those with an iron [a mineral that the body needs for growth, development, and transporting oxygen] deficiency) for Resident 17.
2. Failing to act upon the facility consultant pharmacist's recommendation to order blood testing for the medication, levetiracetam solution (Keppra [brand name], medication that treats seizures) for Resident 35.
These deficient practices placed the residents at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug).
Findings:
a. During a review of Resident 17's Patient Information Form, the Patient Information Form indicated the facility admitted the resident on 4/3/2021, with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).
During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 11/7/2024, the MDS indicated Resident 17 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 17 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
During a review of Resident 17's physician's orders, the physician's orders indicated an order for Ferosul give 325 milligrams (mg, a unit of measurement) by mouth two times a day for supplement, dated 4/3/2021.
During a review of Resident 17's MRR, dated 10/13/2024, the MRR indicated the following: Resident 17 has been receiving Ferosul tablet since 4/2021. Please consider reassessing the need for this therapy currently. There was no indication Resident 17's physician had addressed the concern on the MRR.
During a concurrent interview and record review on 1/29/2025 at 3:44 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's MRR dated 10/13/2024. RN 1 was unable to find documentation that the physician had been contacted to see if the physician wanted to continue the medication.
During an interview on 1/30/2025 at 12:20 p.m., with the Director of Staff Development (DSD), the DSD stated the process is the consultant pharmacist sends a monthly report, and it is given to the licensed nurses to call a resident's physician. The DSD stated the licensed nurses are calling to see if the physician wants to continue, discontinue, or change a medication's dosage. The DSD stated he did not see documentation that Resident 17's use of Ferosul had been brought to the physician's attention. The DSD stated Resident 17's physician will be contacted to see if the physician wants to continue the medication, Ferosul. The DSD stated there is no policy for the nursing process of addressing the monthly MRR or the time frame required in which to address issues brought up in the report. The DSD stated it is important to address all issues reported in the MRR to ensure there is no endangerment to a resident by continuing an unnecessary medication.
During an interview on 1/30/2025 at 2:14 p.m., with the Director of Nursing (DON), the DON stated the importance of addressing concerns brought up in the MRR is to ensure the necessity of a medication. The DON stated he was not sure why Resident 17's Ferosul was not addressed. The DON stated the issue should have been brought to Resident 17's physician's attention.
b. During a review of Resident 35's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 35 on 7/8/2024 and readmitted the resident on 12/3/2024.
During a review of Resident 35's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 7/10/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and chronic encephalopathy (condition that affects the brain's function).
During a review of Resident 35's MDS dated [DATE], the MDS indicated that the resident had severely impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 35 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).
During a review of Resident 35' care plan (a document that summarizes a resident's needs, goals, and care/treatment) for risk of seizures (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements) dated 7/23/2024, the care plan indicated Resident 35 was taking levetiracetam solution. The interventions included were to monitor for toxicity (the extent to which something is poisonous or harmful) and adverse consequences.
During a review of Resident 35's physician order dated 7/8/2024, the physician order indicated an order for levetiracetam 1000 mg via gastrostomy (g-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) every 12 hours for seizures disorder.
During a review of Resident 35's MRR, created between 9/1/2025 and 9/10/2025, the MRR indicated that Resident 35 was on levetiracetam, please consider ordering Keppra panel (measures the amount of levetiracetam in the blood) for clinical monitoring.
During a concurrent interview and record review on 1/30/2025 at 3:07 p.m., with Registered Nurse 5 (RN 5), reviewed Resident's 35 lab results from 9/1/2024 to 1/30/2025. RN 5 stated that a Keppra level test was never done for Resident 35. RN 5 stated the facility should follow the consultant pharmacist's recommendation in 30 days after recommendation was made. RN 5 stated that this deficient practice increases risk for medication side effects for Resident 35.
During an interview on 1/30/2025 at 4:07 p.m., with the DON, the DON stated that facility has to follow the consultant pharmacist's recommendation about Keppra blood work to monitor Resident 35's Keppra level is in safe range. The DON stated that this deficient practice increases the risk of receiving medication that was not optimal for Resident 35's medical condition and increases the risk of adverse consequences.
During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed 7/2024, the policy indicated the following: Medications shall be administered in accordance with written orders of the attending physician. If a dose seems excessive with respect to the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse shall call the facility's pharmacy for clarification prior to the administration of the medication. If necessary, the facility's pharmacy shall contact the physician for clarification. This interaction with the pharmacy and the resulting order clarification shall be documented in the nursing notes and elsewhere in the medical records as appropriate.
During a review of the facility's policy and procedure titled, Pharmaceutical Services Policy Procedure Manual, reviewed 11/2021, indicated, Medication orders from physician assistants, nurse practitioners, clinical nurse specialists shall be acceptable if they comply with all the requirements listed below, are in accordance the state law, and comply with applicable prescribing protocols that have been approved by the facility.

Based on interview and record review, the facility failed to monitor a resident for side effects for the use of Cymbalta (medication used for depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 11) investigated under the care area of unnecessary medications.
This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).
Findings:
During a review of Resident 11's Inpatient Registration Form, the Inpatient Registration Form indicated the facility admitted Resident 11 on 5/4/2015 and the facility readmitted Resident 11 on 5/9/2017.
During a review of Resident 11's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 7/1/2024, the H&P indicated Resident 11 was admitted with diagnosis included Guillain-Barre (GBS- a condition in which the immune system attacks the nerves), diabetes mellitus type two (2) (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). The H&P indicated Resident 11 had the capacity to understand and make decisions.
During a review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/11/2024, the document indicated the Resident 11 had an intact cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 11 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).
During a review of Resident 11's physician's orders dated 11/21/2022, the physician's orders indicated an order for Cymbalta capsule delayed release 60 milligrams (mg- unit of measurement), give one (1) capsule by mouth.
During a review of Resident 11's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for Cymbalta initiated on 1/10/2025 , the care plan interventions indicated to monitor for adverse side effects every shift, tally with hashmark, monitor for tardive dyskinesia (involuntary movements of the tongue, jaw, face, mouth), monitor for cognitive impairment, monitor for akathisia (a movement disorder that cause a person to feel restless and have an uncontrollable urge to move), facial expression, drooling, rigidity (stiffness), monitor for orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting).
During a concurrent interview and record review on 1/29/2025 at 10:22 a.m., with Registered Nurse 4 (RN 4), reviewed Resident 11's Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional) dated 1/2025. RN 4 stated Resident 11 received Cymbalta 60 mg by mouth on the following dates and times:
1.1/17/2025 at 9 a.m.
2.1/18/2025 at 9 a.m.
3.1/19/2025 at 9 a.m.
4.1/20/2025 at 9 a.m.
5.1/21/2025 at 9 a.m.
6.1/22/2025 at 9 a.m.
7. 1/23/2025 at 9 a.m.
8. 1/24/2025 at 9 a.m.
9. 1/25/2025 at 9 a.m.
10.1/26/2025 at 9 a.m.
11 1/27/2025 at 9 a.m.
When asked to provide documentation that the licensed nurses were monitoring for side effects, RN 4 stated she could not find any documentation indicating that the nurses were monitoring for side effects.
During an interview on 1/29/2025 at 12 p.m., with the Director of Staff Development (DSD), the DSD stated nurses needed to monitor for adverse side effects so it could be reported to the physician and necessary changes could be made to the dosage. The DSD stated if the nurses did not monitor for side effects then the resident may possibly be receiving an unnecessary medication.
During a review of the facility's policy and procedure titled, Psychoactive Drug Monitoring, last reviewed and revised on 3/2024, the policy indicated physician, nurse, or other health professional documentation that the resident is being monitored for adverse consequences or complications of therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services in accordance with professional standards by failing to:
1. Ensure an open (in-use) potassium chloride (supplement used for treatment of hypokalemia [lower than normal potassium level]) solution was labeled with an open date to readily identify the beyond use date for one of one sampled resident (Resident 44).
2. Discard an open and discontinued chlorhexidine 0.12% (antiseptic [slows or stops growth of microorganisms] used to treat skin infection), solution stored in the medication cart for one of one sampled resident (Resident 54).
3. Ensure a container of Vitamin A and Vitamin D (a medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations, known simply as A & D Ointment) Skin Ointment was labeled upon opening for one of four medication carts (Medication Cart B) investigated for medication storage.
These deficient practices had the potential for the unintentional administration of possibly expired or discontinued medications.
Findings:
1. During a review of Resident 44's Inpatient Registration Form, the Inpatient Registration Form indicated that the facility admitted Resident 44 on [DATE] and readmitted the resident on [DATE].
During a review of Resident 44's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated [DATE], the H&P indicated the resident was admitted with diagnoses including intraparenchymal hematoma of brain (bleeding within the brain tissue) and dysphagia (difficulty swallowing).
During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 44 had severely impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 44 was totally dependent on staff with all activities of daily living (ADLs - activities related to personal care).
During a review of Resident 44's physician's orders, the physician's orders indicated an order for potassium chloride oral solution 10% (unit of measurement of concentration) give 15 milliliters (ml- unit of measurement) via gastrostomy (g-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) in the morning for supplement dilute with 20 ml of water, dated [DATE].
During a concurrent observation and interview on [DATE] at 3:53 p.m., with Registered Nurse 2 (RN 2), observed the contents of Medication Cart A. Observed an opened potassium chloride oral solution 10% with no open date and no beyond used date. RN 2 confirmed by stating that the potassium chloride oral solution 10% did not have the date when it was opened. RN 2 stated that the potassium chloride oral solution 10% should have the date when it was opened to readily identify its beyond use date.
2. During a review of Resident 54's Inpatient Registration Form, the Inpatient Registration Form indicated that the facility admitted Resident 54 on [DATE] and readmitted the resident on [DATE].
During a review of Resident 54's H&P dated [DATE], the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and dysphagia.
During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 4 had severely impaired cognition. The MDS further indicated that Resident 44 was totally dependent on staff with all ADLS.
During a review of Resident 54's physician's orders, the physician's orders indicated there was no order for chlorohexidine oral solution 0.12%.
During a review of Resident 54's Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional), dated 1/2025, the MAR indicated that Resident 54 did not receive chlorohexidine oral solution.
During a concurrent observation and interview on [DATE] at 3:53 p.m., with RN 2, observed the contents of Medication Cart A. Observed an open chlorohexidine oral solution 0.12% with no open date and no beyond used date for Resident 54. RN 2 confirmed by stating that chlorohexidine oral solution 0.12% did not have the date when it was opened. RN 2 stated that the chlorohexidine oral solution 0.12% should be discarded because there was no physician order for this medication for 1/2025 and Resident 54 was not taking it.
During an interview on [DATE] at 4:13 p.m., with the Director of Staff Development (DSD), the DSD stated medications with no order should be removed from the medication cart. The DSD stated the staff are to call the pharmacy to come and take the medication from the medication cart. The DSD stated this should be done the day the medication was discontinued or by the next day if the pharmacy is not available the day of the order discontinuation. The DSD stated this was important to avoid possible medication error such as a resident accidentally receiving the unordered medication. The DSD stated it is important for medications to be labeled with open date because there was a potential for a resident to receive an ineffective medication.
During a review of the facility's policy and procedure titled, Storage of Medication last reviewed and revised on 11/2021, the policy and procedure indicated, Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures shall be immediately removed from stock, disposed of according to procedures for medication disposal.
3. During a concurrent observation and interview on [DATE] at 9:50 a.m. with Registered Nurse 1 (RN 1), observed Medication Cart B. Observed an open, undated Vitamin A and Vitamin D Skin Ointment in the bottom drawer. RN 1 stated all medications that are opened must have an open date on it so that the licensed nurses will know how long it has been opened to not keep the medication for too long of a time.
During an interview on [DATE] at 12:20 p.m., with the DSD, the DSD stated medications in the medication carts need to be dated with the date it was first opened. The DSD stated A & D Ointment is considered a medication and was unsure of the shelf life (the length of time for which an item remains usable) after opening of the container.
During a review of the facility's policy and procedure titled, House-Supplied Floor Stock (bulk medications placed in the drug room or medication cart of the nursing unit enabling licensed nurses to access the medicines faster without going through an in-patient pharmacy) Medications, last reviewed 7/2024, the policy indicated the following: Floor stock may not be maintained on the nursing unit beyond the manufacturer's expiration date. Once the medication has expired or has been opened for more than 180 days, it must be removed and sequestered from all other floor stock until it can be destroyed).

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's freezers were labeled with the date they were placed in the freezer.
This deficient practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
During a concurrent observation and interview on 1/27/2025 at 8:10 a.m., in the facility's kitchen with Registered Dietician 1 (RD 1), observed an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1. RD 1 stated all food items in the freezer are required to be labeled with the date they were placed in the freezer.
During a concurrent observation and interview on 1/27/2025 at 8:13 a.m., in the facility's kitchen with RD 1, observed an unlabeled bag of frozen fish sticks in Freezer 2. RD 1 stated all food items in the freezer are required to be labeled with the date they were placed in the freezer.
During an interview on 1/27/2025 at 2:45 p.m., with the Dietary Supervisor (DS), the DS stated all food in the freezer needs to be labeled with the date they were placed in the freezer.
During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, last reviewed 3/2021, the P&P indicated that frozen foods will be wrapped or containerized in a manner that prevents oxidation (freezer-burn). Single or separate food items taken out of the original container will be labeled with the name of the item and date of delivery for easy identification.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers of Medicare and Medicaid Services [CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to millions of Americans]) for two of four fiscal quarters (3rd quarter [April 1 to June 30, 2024] and 4th quarter of 2024 [July1- September 30, 2024].
The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.
Findings:
During a concurrent interview and record review on 1/30/2025 at 11:25 a.m., with the Director of Staff Development (DSD), reviewed the Payroll-Based Journal Staffing Data Report (PBJ-SDR) for 3rd and 4th quarter of 2024. The DSD stated that the person in-charge now of submitting the PBJ-SDR is on medical leave and he has no idea if she had submitted the data for these particular reporting period on or before the due date. The DSD also stated that the previous facility Administrator and the Director of Nursing (DON) were the ones who have access to the PBJ-SDR reporting portal and are no longer employed by the facility and that could be the reason that there was no submission for the reporting periods for the 3rd and 4th quarter of 2024.
During a review of the facility-provided policy titled, PBJ Data Submission Specifications, dated 4/16/2020, the policy indicated that staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Staffing information is collected daily and for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:
Fiscal Quarter 1: October 1- December 31. Submission deadline: February 14
Fiscal Quarter 2: January 1-March 31. Submission deadline: May 15
Fiscal Quarter 3: April 1- June 30. Submission deadline: August 14
Fiscal Quarter 4: July 1- September 30. Submission deadline: November 14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 8's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 8 on 1/25/2013.
During a review of Resident 8's H&P dated 3/15/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying), and hemiplegia and hemiparesis (weakness or paralysis of one side of the body).
During a review of Resident 8's MDS dated [DATE], the MDS indicated that the resident had moderately impaired cognition (thought processes). The MDS further indicated that Resident 8 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).
During a review of Resident 8's Order Summary Report, the Order Summary Report indicated an order dated 4/21/2020 for enteral feed every four (4) hours of bolus (administration of a discrete amount of medication, drug, or other compound within a specific time) of Jevity 1.2 calories (feeding formula) of six (6) cans a day.
During a review of Resident 8's care plan (a document that summarizes a resident's needs, goals, and care/treatment), dated 1/29/2025 regarding EBP, an intervention included for staff to wear gloves and gown during high-contact care activities.
During a medication administration observation on 1/29/2025 at 8:12 a.m. in Resident 8's room, observed Resident 8's wall had signage which indicated that the resident was on EBP, which required to don a gown and gloves when performing high contact activity and use of feeding tube. Observed LVN 6 administering enteral feeding bolus of two (2) cans of Jevity 1.2 calories and medications via g-tube without wearing a gown.
During an interview on 1/29/2025 at 8:25 a.m., with LVN 6, LVN 6 stated that she (LVN 6) did not wear a gown during Resident 8's enteral feeding administration of Jevity 1.2 calories. LVN 6 stated that she was not aware that she has to wear a gown when using a g-tube to administer bolus feeding or medication to Resident 8 to prevent possible infection spread.
During an interview on 1/29/2025 at 12 p.m., with the Director of Staff Development (DSD), the DSD stated that residents placed on EBP include residents at increased risk of developing an infection because they have a g-tube. The DSD stated when a resident is on EBP, all staff are required to don gowns and gloves when performing high contact resident care activities (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated) such as administering bolus feeding and medication via g-tube.
During an interview on 1/30/2025 at 7:43 a.m., with the Infection Preventionist (IP), the IP stated that according to the facility's policies regarding EBP, LVN 6 should have donned a gown prior to administering bolus feeding and medication via g-Tube to Resident 8.
During a review of the facility's P&P titled, Isolation Precautions, last reviewed on 11/2023, the P&P indicated in the implementation of Enhanced Standard Precaution to perform hand hygiene and don PPE, gloves to protect hands, gown to protect body and clothes .
Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to:
1. Ensure Housekeeping 1 (HK 1) donned (to wear) a gown before entering a room under contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) and performed hand hygiene after exiting the resident's room for one of one sampled resident (Resident 38).
2. Ensure Licensed Vocational Nurse 1 (LVN 1) donned a protective gown while administering medication via gastrostomy tube (G- Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach) to a resident on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of five sampled residents (Resident 7).
3. Ensure Licensed Vocational Nurse 6 (LVN 6) donned a gown during bolus feeding (a method of administering liquid nutrition) and medication administration via g-tube to a resident on EBP for one of five sampled residents (Resident 8).
This deficient practice had the potential to result in the spread and development of infection through possible cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another).
Findings:
1. During a review of Resident 38's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 6/25/2024, the H&P indicated that the facility originally admitted the resident on 5/23/2022 and readmitted the resident on 6/25/2024, with diagnoses including hemorrhagic stroke (a life-threatening emergency that happens when a blood vessel in your brain breaks and bleeds), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and recurrent urinary tract infection (UTI- an infection in the bladder/urinary tract).
During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2024, the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 2 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 38 had an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine).
During a review of Resident 38's Medication Review Report (physician order) dated 12/23/2024, the Medication Review Report indicated to place the resident on contact isolation for Carbapenem-resistant Enterobacterales (CRE-a type of bacteria that can cause serious infections and can be hard to treat)/Extended-Spectrum Beta-Lactamases (ESBL- enzymes [proteins that help speed up metabolism] produced by some bacteria that may make them resistant to some antibiotics) of urine.
During a concurrent observation and interview on 1/27/2025 at 9:42 a.m., with Licensed Vocational Nurse 4 (LVN 4), Housekeeper 1 (HK 1) was observed entering Resident 38's room, which had a contact isolation sign posted on the door, without wearing a gown. HK 1 collected the trash, exited Resident 38's room, took off his (HK 1) gloves, and placed the trash bag inside the trash bin and left without performing hand hygiene. LVN 4 stated all staff entering Resident 38's room are required to wear gloves and gown, because Resident 38 is on contact isolation. LVN 4 stated HK 1 could potentially spread the infection when entering other residents' rooms. LVN 4 stated HK 1 exited Resident 38's room and removed his gloves without performing hand hygiene. LVN 4 stated staff are required to wash their hands or use alcohol-based hand sanitizer (ABHS) after exiting each resident's rooms. LVN 4 stated the potential outcome of not performing hand hygiene after exiting a resident room and in between residents is spreading infection to other residents and staff members.
During an interview on 1/28/2025 at 8:41 a.m., with the Housekeeping Lead (HKL), the HKL stated the facility's Infection Preventionist (IP) gives in-services regarding infection control to all housekeeping staff. The HKL stated staff are required to wear a gown when entering a resident's room that has a contact precaution sign posted. The HKL stated staff are required to perform hand hygiene after exiting each resident's room, especially a resident under contact precaution. The HKL stated the potential outcome of not donning a gown when entering a resident's room with contact isolation and not performing hang hygiene after exiting, is the spread of infection to other residents and facility staff.
During a review of the facility's policy and procedure (P&P) titled, Isolation Precautions-Contact Precautions, last reviewed 11/2023, the P&P indicated in addition to wearing gloves as outlined under standard precautions, wear a gown when entering the room if you anticipate that your clothing with have substantial contact with the patient, environment surfaces, or items in the patient's room. After gown removal ensure that clothing does not contact potentially contaminated environment surfaces to avoid transfer of microorganisms to other patients or the environment.
During a review of the facility's P&P titled Isolation Precautions-Standard Precautions, last reviewed 11/2023, the P&P indicated to wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or the environment.
2. During a review of Resident 7's Patient Information, the Patient Information indicated the facility originally admitted the resident on 1/21/2024 and readmitted the resident on 1/29/2024, with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and persistent vegetative state.
During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 is in a persistent vegetative state. The MDS indicated that Resident 7 was totally dependent on staff for self-care.
During a review of the facility's posted signage in Resident 7's room, the signage indicated the following, Enhance Barrier Precautions: Everyone must, clean their hands, including before entering and leaving the room. Provider and Staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities .Device care or use: central line (long, thin, flexible tube that's inserted into a large vein near the heart), urinary catheter, feeding tube, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe) .
During a concurrent medication observation and interview on 1/28/2025 at 4:18 p.m., observed Licensed Vocational Nurse 1 (LVN 1) administer tramadol (medication used for moderate to severe pain) 50 milligrams (mg- unit of measurement) to Resident 7 via g-tube. During the entire process of administering the medication, LVN 1 was not wearing a protective gown. After the medication administration, LVN 1 stated that he should have worn a protective gown when administering medication to a resident on enhance barrier precaution for infection control. LVN 1 stated that wearing a protective gown can prevent Resident 7 from acquiring infection due to cross contamination, as staff's clothing can be contaminated when taking care of multiple residents which can result to Resident 7 becoming ill.
During a review of the facility's P&P titled, Isolation Precautions, last reviewed on 11/2023, the P&P indicated in the implementation of Enhanced Standard Precaution to perform hand hygiene and don PPE, gloves to protect hands, gown to protect body and clothes .

Based on observation, interview, and record review, the facility failed to:
1. Maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (°F, unit of temperature) for 51 of 51 residents (Resident 1 to Resident 51) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit.
2. Maintain the chiller (a cooling water circulation device that is connected to the air conditioning [A/C] system) for two of two chillers in working condition.
3. Monitor and record room temperatures in accordance with facility's policy and procedures, titled Daily Maintenance Log and Out of Range Temperatures, and Temperature Monitoring of Patient Room.
4. Ensure the rental chillers, which were used temporarily to replace the broken chillers of the air conditioner, were working properly.
These deficient practices placed the 51 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures).
On 6/15/2024 at 7:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death of a resident) situation for the facility's failure to provide a safe environment to the residents by failing to maintain an acceptable residents' rooms temperature range of 71 to 81 degrees Fahrenheit in the presence of the Chief Nursing Officer (CNO) 1.
On 6/16/2024 at 2:16 p.m. and 3:45 p.m., the facility submitted an IJ Removal Plan (immediate action that includes all actions the entity has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), which was not accepted.
On 6/16/2024 at 4:12 p.m., the survey team conducted an exit conference with CNO 1 and exited the facility, with the IJ situation not removed.
6/18/2024 at 2:46 p.m., the facility submitted an IJ Removal Plan, which was not accepted.
Findings:
During an interview on 6/15/2024, at 2:11 p.m., with CNO 1, CNO 1 stated the chillers for the hospital went out yesterday on 6/14/2024 with no time identified. The hospital had vendors come and installed 2 rental chillers to use. The staff engineer checked the rental chillers after installation and the staff engineer stated everything was to be ok. The staff engineer did not check the temperature of the residents' rooms to confirm the temperature range was safe for patient care.
During an interview on 6/15/2024, at 2:30 p.m., with House Supervisor (HS) 1, HS 1 stated, It feels very hot in the hospital. The engineer staff have been working on it today.
During an interview on 6/15/2024, at 2:39 p.m., with Engineer Staff (ES) 1, ES 1 stated he was on duty today and the vendors were checking on the two rental chillers. The two rental chillers were running fine when ES 1 left the hospital at 1:15 pm today. ES 1 stated he told staff if they had issues with the temperature to call the on-call engineer staff. ES 1 stated 68 to 74 degrees Fahrenheit was a normal comfortable temperature range for the Sub Acute Unit. ES 1 did not know at this time if the two rental chillers were down. ES 1 stated it is important to keep the residents' rooms in running cool temperature. ES 1 stated he did not do a temperature log for today. ES 1 stated he did not have time to do the temperature log.
During an interview on 6/15/2024, at 2:39 p.m., with Director of Operations (DO) 1, DO 1 stated the following: two rental chillers were installed at 4 am this morning and at 9 am, both rental chillers were running fine. DO 1 stated the engineer staff should be checking the chillers and temperature of the Sub Acute Unit daily. DO 1 stated the engineer staff should be checking and monitoring the temperature of the Sub Acute Unit after installation of the rental chillers.
During an observation on 6/15/2024, at 3:34 p.m., on Sub Acute Unit on the 3rd Floor, rooms 340 to 344 were noted to have a hot temperature.
During an interview on 6/15/2024, at 3:36 p.m., with Registered Nurse (RN) 2, RN 2 stated, Yesterday, called engineering department because temperature was hot, and they came. Today I called engineering department for the temperature, and they did not come. It has been hot today on the Sub Acute Unit. Did not provide cooling measures to the residents today. Not safe for residents to be in high temperature condition, they can have serious complications.
During an observation on 6/15/2024, at 4:03 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on the 3rd Floor, ES 1 used a handheld thermometer (a non-contact thermometer temperature-sensing instrument) to obtain the temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer.
During an observation on 6/15/2024, at 4:46 p.m., with Engineer Staff (ES) 1 on the Sub Acute Unit 2nd Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer.
During an observation on 6/15/2024, at 5:50 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on 3rd Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer.
During an interview on 6/15/2024, at 5:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Today at 11 a.m., it started to be hot. The temperature feels hot. It is important for the temperature to be cool for residents, they can have problems if the rooms are very hot.
During an interview on 6/15/2024, at 6:01 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Nursing station temperature is really bad and felt really hot the whole start of my shift. The hospital air conditioning has always been a problem, we alerted the engineering department about the AC problem, but I think there are limited staff to get it done. Today is obvious hot on this Sub Acute Unit floor. It is not safe for residents to be in this hot air condition, they can have problems.
During an interview on 6/15/2024, at 6:19 p.m., with CNO 1 and Engineer Staff (ES) 1, CNO 1 and ES 1 stated, The reason why the facility had problems with the two rental chillers because the vendor installed it incorrectly. Informed by the current vendor onsite who does not want to touch the work of another vendor. The water hoses of the rental chillers (was) installed incorrectly by the vendor. There is no estimated time for the vendor, who installed the chillers incorrectly, will be here. They are on their way as soon as possible to fix the issue.
During a review of the facility's census dated 6/15/2024, the census indicated that there were 51 sub-acute residents in the facility.
During a review of the facility's policy and procedure (P&P) titled, Contingency Plan for Failure of Air Conditioning System, revised on 2/2024, the P&P indicated, The Engineering Department shall have a contingency plan in place in the event of failure of the air-conditioning system.
During a review of the facility's P&P titled, HVAC System, revised on 2/2024, the P&P indicated, Engineering Department personnel shall be trained in the preventative maintenance, location and safe operation of the HVAC system.
During a review of the facility's P&P titled, Daily Maintenance Log and Out of Range Temperatures, revised on 2/2024, the P&P indicated, Engineering Department personnel will conduct daily rounds and monitor patient room temperatures that drop below or exceed above normal comfortable room temperature ranges. The facility was unable to provide records of residents' rooms temperature monitoring for the sub-acute.
During a review of the facility's P&P titled, Temperature Monitoring of Patient Room, dated 10/2023, the P&P indicated, Purpose: This policy is to provide instructions on how to monitor and document temperatures that are required for assuring optimal conditions for patient rooms. Frequency: Temperatures of room air are monitored and documented each day manually by the Engineering Department. Acceptable Temperature Room Ranges 71 to 81 degrees

Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure two transparent plastic bins containing poultry meat (chicken) in one of two facility refrigerators (Refrigerator 1) were labeled and dated while being thawed.
This deficient practice had the potential to place 14 of 59 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Findings:
During an observation of the facility's kitchen and concurrent interview on 2/6/2024 at 8:26 a.m., with Catering Manager 1 (CM 1), observed two transparent plastic container bins containing cut up chicken legs and thighs. Upon closer inspection, the container bins did not have a date as to when the chicken legs and thighs were placed in Refrigerator 1 for thawing. CM 1 stated that he thinks the poultry meat were thawed two days ago and the person in charge called in sick, which is why it was not labeled and dated.
During an interview on 2/8/2024 at 3:04 p.m., with the Director of Food Service (DFS), the DFS stated that upon receipt of frozen meat, the meat is placed in the freezer, or the refrigerator if it will be used within three days. The DFS stated any meat placed in the refrigerator for thawing are dated with a cut off date, which is the last day wherein the meat can still be used. The DFS stated that dating is important to provide the staff information on when food should be used. According to the DFS, if any meat are used after the cut off date, it increases the risk of foodborne illnesses to the residents if the meat were consumed. The DFS stated that if there is no date indicated for a meat that is being thawed, it should be discarded because they cannot determine if it is still safe for consumption.
A review of the facility's policy and procedure titled, Food and Nutrition Services, last reviewed on 11/16/23, indicated, All frozen items taken out of the freezer which are placed in the walk-in refrigerator for thawing process shall be labeled with the current date removed from the freezer and given a three day used by date by designated Food Delivery Staff Member .thawing and freezing damages food quality and is more likely to have been exposed to conditions that support bacterial growth .

Based on interview and record review, the facility failed to ensure two of five residents (Resident 19 and 22), who were reviewed for psychotropic medication (medications that affect mental processes, resulting in temporary changes in perception, mood, consciousness, and behavior) use, were free from unnecessary medications by failing to:
1. Ensure Resident 19's physician order for Ativan (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed had a duration and documented evidence that the physician indicated the clinical rationale why the medication is being used longer than 14 days.
2. Provide Resident 22 with non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering lorazepam (Ativan [brand name]) as needed.
These deficient practices had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the residents' mental or physical condition.
Findings:
a. A review of Resident 19's admission Record indicated the facility admitted the resident on 4/22/2022, with diagnoses that included congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood).
A review of Resident 19's History and Physical (H&P - a formal assessment of a patient and their problem) dated 1/31/2024, indicated that the resident is in a vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness).
A review of Resident 19's physician's orders dated 4/21/2023 included an order for Ativan 0.5 milligram (mg- a unit of measurement) one (1) tablet by mouth every six hours as needed for anxiety manifested by restlessness and hyperventilation (rapid or deep breathing) leading to shortness of breath.
During a concurrent interview and record review on 2/8/2024 at 3:30 p.m., with the Director of Staff Development (DSD), reviewed Resident 19's physician's progress notes dated from 4/21/2023 to 2/8/2024. The DSD stated that there was no documented evidence that the physician had evaluated and documented the rationale of extending the use of Ativan beyond 14 days. The DSD stated that a review of the resident's use of psychotropic medication is necessary to determine if the resident would benefit from the use of the medication because a resident should not be receiving a medication that they do not need, otherwise it may lead to drug dependence (occurs when you need one or more drugs to function).
A review of the facility's policy and procedure titled, Psychotropic Medication for Residents with a Diagnosis of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), last reviewed on 11/16/2023, indicated the purpose of the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
During an interview on 2/8/2024 at 4:39 p.m., with the Director of Nursing (DON), the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but there was no policy for psychotropic use for non-dementia residents.
b. A review of Resident 22's admission Record indicated the facility admitted the resident on 5/15/2017 with diagnoses including chronic respiratory failure.
A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for bed mobility and transfers.
During a concurrent interview and record review on 2/7/2024 at 4:22 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 22's physician's orders and 2/2024 Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional). MDS Nurse 1 stated Resident 22 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) by mouth every 24 hours as needed for restlessness leading to shortness of breath, ordered on 1/17/2024 with an end date of 2/15/2024. Upon review of Resident 22's 2/2024 MAR, MDS Nurse 1 stated Resident 22 received lorazepam daily from 2/1/2024 to 2/6/2024. MDS Nurse 1 stated she could not find anywhere in Resident 22's progress notes dated 2/1/2024 to 2/6/2024 that indicated the nurses provided non-pharmacological interventions to the resident prior to administering lorazepam.
During an interview on 2/8/2024 at 9:56 a.m., with the DON, the DON stated that non-pharmacological interventions were important because the resident can either become dependent on the medication or experience side effects or an adverse reaction to the medication. The DON stated the resident could potentially become dependent on the medication, or the medication can depress (to lessen the activity or strength of) the resident's breathing, especially since their respiratory status was already compromised.
A review of the facility's policy and procedure titled, Psychotropic Medication for Residents with a Diagnosis of Dementia, last reviewed on 11/16/2023, indicated the purpose of the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Charge Nurse will initiate a behavior sheet with the specific behavior(s) for which the antipsychotic medication was prescribed, in accordance with the physicians' wishes when he/she reviews the medication orders. The behavior sheet will include resident specific non-pharmacological interventions for the resident.
During an interview on 2/8/2024 at 4:39 p.m., with the Director of Nursing (DON), the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but there was no policy for psychotropic use for non-dementia residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensuring the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a record of all medications taken by a resident on a day-to-day basis) for four of six sampled residents (Resident 2, Resident 15, Resident 26, and Resident 209).
This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).
2. Ensure midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) greater than (>) 120 millimeters of mercury (mmHg, a unit of measure for blood pressure) for one of 11 sampled residents (Resident 6).
This deficient practice had the potential to cause complications such as high blood pressure.
3. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave medications unattended and out of eyesight at a resident's bedside for one of five (5) sampled residents (Resident 7).
This deficient practice had the potential to increase the risk of other residents having access to the medications.
Findings:
1.a. A review of Resident 2's admission Record indicated the facility admitted the resident on 2/8/2021 with diagnoses that included chronic hypoxemic respiratory failure (happens when you don't have enough oxygen in your blood).
A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/7/2023 indicated Resident 2 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 2 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
A review of Resident 2's physician's orders indicated an order for hydrocodone-acetaminophen tablet (Norco [brand name], medication used for moderate to severe pain) 5-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) every six hours as needed for severe pain 7-10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), dated 11/4/2021.
A review of Resident 2's CDR indicated Norco 5-325 mg was removed from the bubble pack (a package that contains multiple sealed compartments with medication/s) on 2/2/2024 and 2/3/2024.
A review of Resident 2's MAR for the month of 2/2024 indicated Resident 2 was not administered Norco 5-325 mg on 2/2/2024 and 2/3/2024.
During a concurrent interview and record review on 2/8/20024 at 10:15 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 2's CDR for Norco 5-325 mg. RN 1 stated Norco 5-325 mg was removed from Resident 2's Norco 5-325 mg bubble pack on 2/2/2024 and 2/3/2024 but was not documented on Resident 2's 2/2024 MAR. RN 1 stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to document on the CDR, give the medication to the resident, and then document on the MAR. RN 1 stated the licensed nurse should have documented on the MAR on 2/2/2024 and 2/3/2024.
During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the Director of Nursing (DON), reviewed Resident 2's CDR for Norco 5-325 mg and Resident 2's 2/2024 MAR. The DON verified by stating there was a discrepancy between the CDR and MAR because the entries made on the CDR on 2/2/2024 and 2/3/2024 were not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to document on the CDR, give the medication to the resident, and then document on the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR.
1.b. A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses that included hypertensive heart and renal disease (when the blood flow is less to the kidneys due to high blood pressure which impairs kidney function).
A review of Resident 15's MDS dated [DATE], indicated Resident 15 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 15 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
A review of Resident 15's physician's orders indicated an order for Norco 5-325 mg, give one tablet by G-tube every six hours as needed for pain management, dated 8/27/2023.
A review of Resident 15's Care Plan for Pain, initiated 7/24/2023, indicated a goal that the resident will display a decrease in behaviors of inadequate pain control. The care plan indicated an intervention to administer pain medication as ordered.
A review of Resident 15's CDR indicated Norco 5-325 mg was removed from the bubble pack on 2/1/2024, 2/2/2024, and 2/3/2024.
A review of Resident 15's MAR for the month of 2/2024 indicated Norco 5-325 mg was not administered on 2/1/2024, 2/2/2024, and 2/3/2024.
During a concurrent interview and record review on 2/8/20024 at 10:45 a.m., with RN 1, reviewed Resident 15's CDR for Norco 5-325 mg. RN 1 stated Norco 5-325 mg was removed from Resident 15's Norco 5-325 mg bubble pack on 2/1/2024, 2/2/2024, and 2/3/2024 but was not documented on Resident 15's 2/2024 MAR. RN 1 stated the licensed nurse should have documented on the MAR on 2/1/2024, 2/2/2024, and 2/3/2024.
During a concurrent interview and record review on 2/8/2024 at 11:10 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 15's CDR for Norco 5-325 mg and 2/2024 MAR. LVN 4 stated she gave Resident 15 Norco 5-325 mg at 9:30 a.m. earlier on 2/8/2024 but did not document on the CDR or the MAR. LVN 4 stated she should have documented on both the CDR and the MAR. LVN 4 stated it was important so that licensed nurses would know that Norco was given and to not give the medication twice.
During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 15's 2/2024 MAR and CDR for Norco 5-325 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entries made on the CDR on 2/1/2024, 2/2/2024, and 2/3/2024 were not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR.
1.c. A review of Resident 209's admission Record indicated the facility admitted the resident on 1/23/2024 with diagnoses that included chronic hypoxemic respiratory failure.
A review of Resident 209's MDS dated [DATE], indicated Resident 209 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 209 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
A review of Resident 209's physician's orders indicated an order for oxycodone with acetaminophen (Percocet [brand name], medication used for moderate to severe pain) 5-325 mg, give one tablet by G-tube every six hours as needed for severe pain 7-10, dated 1/23/2024.
A review of Resident 209's Care Plan for Pain, initiated 1/25/2024 indicated a goal that the resident will report satisfactory pain control every shift for 90 days. The care plan indicated an order to administer pain medications per order.
A review of Resident 209's CDR indicated Percocet 5-325 mg was removed from the bubble pack on 1/27/2024.
A review of Resident 209's MAR for the month of 1/2024 indicated Percocet 5-325 mg was not administered on 1/27/2024.
During a concurrent interview and record review on 2/8/20024 at 10:50 a.m., with RN 1, reviewed Resident 209's CDR for Percocet 5-325 mg and 1/2024 MAR. RN 1 stated Percocet 5-325 mg was removed Resident 209's Percocet 5-325 mg bubble pack on 1/27/2024 but was not documented on Resident 209's 1/2024 MAR. RN 1 stated the licensed nurse should have signed the MAR on 1/27/2024.
During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 209's 1/2024 MAR and Resident 209's CDR for Percocet 5-325 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entry made on the CDR on 1/27/2024 was not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR.
1.d. A review of Resident 26's admission Record indicated the facility admitted the resident on 12/05/2023 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood).
A review of Resident 26's MDS dated [DATE], indicated Resident 26 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 26 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
A review of Resident 26's physician's orders indicated an order for lorazepam (Ativan [brand name], medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) 0.5 mg tablet, give one tablet by G-tube every six hours as needed for seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), dated 1/19/2024.
A review of Resident 26's CDR indicated Ativan 0.5 mg was removed from the bubble pack on 2/7/2024 at 10 a.m.
A review of Resident 26's MAR for the month of 2/2024 indicated Ativan 0.5 mg was not administered on 2/7/2024.
During a concurrent interview and record review on 2/8/20024 at 11:28 a.m., with LVN 5, reviewed Resident 26's CDR for Ativan 0.5 mg and 2/2024 MAR. LVN 5 stated Ativan 0.5 mg was removed from Resident 26's Ativan 0.5 mg bubble pack on 2/7/2024 but was not documented on Resident 26's 2/2024 MAR. LVN 5 stated the licensed nurse should have signed the MAR on 2/7/2024.
During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 26's 2/2024 MAR and CDR for Ativan 0.5 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entry made on the CDR on 2/7/2024 was not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR.
A review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, reviewed 11/16/2023, indicated when a medication is removed from stock, the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication.
A review of the facility's policy and procedure titled, Medication Administration, reviewed 11/16/2023, indicated medications shall be charted immediately after being administered.
2. A review of Resident 6's admission Record indicated the facility admitted the resident on 12/29/2020 with diagnoses that included respiratory failure (serious condition that makes it difficult to breathe on your own).
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/9/2024, indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.
A review of Resident 6's physician's orders indicated an order for midodrine tablet five milligrams (mg, a unit of measurement), give five mg via gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) three times a day for hypotension (low blood pressure), hold if SBP is > 120 mmHg, dated 12/29/2020.
A review of Resident 6's Medication Administration Record (MAR, a report detailing the drugs administered to a resident by a licensed nurse) for the month of 10/2023 indicated on 10/24/2023 at 6 a.m., Resident 6 was given midodrine when their SBP was 127.
During a concurrent interview and record review on 2/8/2024 at 8:44 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 6's 10/2023 MAR. RN 1 stated midodrine was given to Resident 6 on 10/24/2023 at 6 a.m. even though the resident's SBP was above 120. RN 1 stated the licensed nurse should have held the medication. RN 1 stated Resident 6 could have been at risk for increased blood pressure as a result.
During a concurrent interview and record review on 2/8/2024 at 4:26 p.m., with the Director of Nursing (DON), reviewed Resident 6's 10/2023 MAR. The DON verified by stating midodrine was given on 10/24/2023 at 6 a.m. even though the resident's SBP was above 120. The DON stated the licensed nurse should have held the medication since Resident 6's blood pressure was outside of the medication's parameters (limit or range). The DON stated Resident 6 could have been at risk for increased blood pressure as a result.
A review of the facility's policy and procedure titled, Medication Administration, reviewed 11/16/2023, indicated these policies and procedures are established to assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner.
3. A review of Resident 7's admission Record indicated the facility admitted the resident on 1/25/2013 with diagnoses including intracranial hemorrhage (bleeding inside the skull) and respiratory failure.
A review of Resident 7'sMDS dated [DATE], indicated the resident had moderately impaired cognition and was dependent on staff for eating, dressing, and toileting hygiene.
A review of Resident 7's physician's order summary indicated the following:
Loratadine (medication that helps with the symptoms of allergies) 10 milligrams (mg - unit of measurement), ordered 1/31/2024.
Doxycycline (medication used to treat infections) 100 mg ordered 1/31/2024.
Baclofen (medication that treats muscle spasms [cramps]) 10 mg, ordered 3/17/2021.
Levetiracetam (medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) 100 mg per milliliter (ml-unit of measurement), ordered 1/24/2020.
Multivitamin (supplement of vitamin, minerals, and other nutritional elements) five (5) ml ordered 6/12/2023.
Senna (medication to treat constipation [inability to have a bowel movement]) 8.6
mg two tablets, ordered 2/1/2020.
On 2/7/2024 at 8:19 a.m., during a concurrent medication administration observation and interview with Licensed Vocational Nurse 2 (LVN 2), observed LVN 2 prepare the following medications for Resident 7:
Loratadine 10 mg
Doxycycline 100 mg
Baclofen 10 mg
Levetiracetam 100 mg per ml
Multivitamin 5 ml
Senna 8.6 mg two tablets
Observed LVN 2 leave the medications unattended and out of eyesight at Resident 7's bedside while she washed her hands at the sink. Observed LVN 2 once again leave the medications unattended and out of eyesight at Resident 7's bedside when LVN 2 left Resident 7's room. At the conclusion of the medication administration observation, during an interview, LVN 2 stated that she left Resident 7's medications unattended at the resident's bedside. LVN 2 stated she should not leave medications unattended.
On 2/8/2024 at 9:50 a.m., during an interview, the Director of Nursing (DON) stated that medications should never be left unattended at a resident's bedside and out of eyesight because then anyone walking by can take the medications. The DON stated that another resident could possibly take the unattended medications, which could then potentially cause other residents to have an adverse health reaction to medications not intended for them.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 11/16/2023, indicated that the nurse shall maintain the security of the medications during the preparation of doses and while medications are being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Provide range of motion (ROM - exercises that improve the movement of a joint) exercises as prescribed by the physician for two of seven sampled residents (Residents 1 and 34) investigated for position and mobility.
2. Ensure one of seven sampled residents (Resident 42) received their prescribed Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) order for bilateral (both sides) hand rolls (used to prevent contractures [permanently shortened muscles that resist stretching] of the fingers) as ordered by the physician.
These deficient practices had the potential to decrease the residents' range of motion and mobility which could affect their overall function.
Findings:
1.a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/7/2022 with diagnoses including cardiovascular respiratory distress (a term related to breathing problems).
A review of Resident 1's History and Physical (H&P - a formal assessment of a patient and their problem) dated 6/5/2023, indicated the resident is in a chronic vegetive state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2023, indicated the resident was dependent on staff for personal hygiene and bed mobility.
During a concurrent interview and record review on 2/7/2024 at 3:10 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 1's physician's orders and Treatment Records for 1/2024 and 2/2024. MDS Nurse 1 stated Resident 1 had a physician's order for RNA/Nursing program for passive range of motion (PROM - ROM that is achieved when an outside force exclusively causes movement of a joint) exercises to bilateral (both sides) lower extremities (BLE), order revised on 9/22/2023. MDS Nurse 1 stated that Resident 1's Treatment Records indicated there was no documentation on 1/26/2024, 1/30/2024, and 2/2/2024, and PROM exercises were not done on those days. MDS Nurse 1 stated she also could not find documentation anywhere else in the resident's medical record to indicate that the PROM exercises were provided. MDS Nurse 1 stated it was important for the resident to receive RNA exercises, as prescribed, in order to prevent a decrease in mobility and to ensure that the resident is at his highest functional level. MDS Nurse 1 stated the resident could have a potential decline in mobility if he missed RNA exercises.
During an interview on 2/8/2024 at 9:53 a.m., with the Director of Nursing (DON), the DON stated it was important for residents to receive their prescribed RNA exercises because, if they didn't, then their range of motion could potentially deteriorate. The DON stated if the RNA did not sign on the Treatment Record, it meant that the service was not provided.
A review of the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated it was the facility's policy that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. Restorative and supportive care shall include providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. Restorative and supportive nursing care services when provided to the resident will be documented on the treatment flowsheets.
1.b. A review of Resident 34's admission Record indicated the facility admitted the resident on 12/31/2021 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own).
A review of Resident 34's History and Physical (H&P - a formal assessment of a patient and their problem), dated 6/9/2023, indicated the resident was unable to make decisions.
A review of Resident 34's MDS, dated [DATE], indicated the resident was dependent on staff for toileting hygiene, personal hygiene, and bed mobility.
During a concurrent interview and record review on 2/7/2024 at 4:03 p.m., with MDS Nurse 1, reviewed Resident 34's physician's orders and Treatment Records for 1/2024 and 2/2024. MDS Nurse 1 stated Resident 34 had a physician's order for RNA/Nursing program for PROM exercises to all extremities five times a week for 90 days, order revised on 6/19/2023. MDS Nurse 1 stated that Resident 34's Treatment Records indicated there was no documentation on 1/31/2024, 2/1/2024, and 2/2/2024, and PROM exercises were not done on those days. MDS Nurse 1 stated she also could not find documentation anywhere else in the resident's medical record to indicate that the exercises were provided. MDS Nurse 1 stated it was important for the resident to receive RNA exercises, as prescribed, in order to prevent a decrease in mobility and to ensure that the resident is at his highest functional level. MDS Nurse 1 stated the resident could have a potential decline in mobility if he missed RNA exercises.
During an interview on 2/8/2024 at 9:53 a.m., with the DON, the DON stated it was important for residents to receive their prescribed RNA exercises because, if they didn't, then their range of motion could potentially deteriorate. The DON stated if the RNA did not sign on the Treatment Record, it meant that the service was not provided.
A review of the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated it was the facility's policy that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. Restorative and supportive care shall include providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. Restorative and supportive nursing care services when provided to the resident will be documented on the treatment flowsheets.
2. A review of Resident 42's admission Record indicated the facility originally admitted the resident on 7/14/2022 and readmitted the resident on 6/24/2023 with diagnoses that included gastro-esophageal reflux disease (GERD-when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and chronic respiratory failure (when the respiratory system cannot adequately provide oxygen to the body).
A review of Resident 42's MDS dated [DATE], indicated that Resident 42 was in a persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness). The MDS further indicated that Resident 42 was totally dependent on staff for activities of daily living. The MDS also indicated that Resident 42's upper extremities (arms) were impaired on both sides.
A review of Resident 42's physician's orders dated 1/25/2024 included an order for RNA for application of bilateral hand rolls as tolerated.
During an interview and record review on 2/7/24 at 7:44 a.m., with the Director of Staff Development (DSD), reviewed Resident 42's Treatment Record from 2/1/2024 to 2/6/2024. The DSD stated that there was no documented evidence that Resident 42 was provided with bilateral hand rolls from 2/1/2024 to 2/6/2024. The DSD stated that the application of bilateral hand rolls to Resident 42 is for the management of contractures. The DSD stated that if Resident 42 was not applied bilateral handrolls, the resident would be at increased risk for contractures.
A review of the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated, Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning . prevent contractures or prevent further deterioration and complications of limited range of motion .

Based on observation, interview, and record review, the facility failed to ensure that the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) for a resident at high risk for developing a pressure ulcer (a wound that develops when skin is damaged by constant pressure or fiction) was set correctly according to the resident's weight for one of five sampled residents (Resident 43) investigated for pressure ulcer/injury.
This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.
Findings:
A review of Resident 43's admission Record indicated the facility admitted the resident on 4/14/2022 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own).
A review of Resident 43's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/15/2023, indicated the resident was unable to make decisions.
A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/19/2024, indicated the resident was dependent on staff for dressing, personal hygiene, and bed mobility.
During an observation on 2/6/2024 at 10:07 a.m., observed Resident 43 awake in bed with their LAL mattress on and set to 260 pounds (lbs. - unit of measurement).
During a concurrent observation and interview on 2/6/2024 at 10:16 a.m., with Licensed Vocational 3 (LVN 3), LVN 3 verified by observing and stating that Resident 43's LAL mattress was set to 260 lbs.
During a concurrent interview and record review on 2/7/2024 at 2:31 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 43's Braden Scale Assessment (a standardized assessment tool used to identify patients at risk of developing pressure sores), dated 10/13/2023 and Weights and Vitals Summary. MDS Nurse 1 stated that Resident 43 was at high risk of developing a pressure ulcer. Upon review of Resident 43's Weights and Vitals Summary, MDS Nurse 1 stated that Resident 43's current weight was 160 lbs. MDS Nurse 1 stated that the LAL mattress should have been set according to Resident 43's weight.
During an interview on 2/8/2024 at 9:49 a.m., with the Director of Nursing (DON), the DON stated that the LAL mattress should be set according to the resident's weight. The DON stated that, if not set correctly, then the resident's existing wound can worsen, or the resident can develop a new wound.
A review of the Drive DeVilbiss Healthcare Simple Air Mattress (LAL mattress brand) User Manual, undated, indicated that the mattress is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. The manual indicated that eight comfort levels are available for a variety of patient weights. Use these buttons to adjust weight settings accordingly.
A review of the facility's policy and procedure titled, Pressure Sore Treatment Protocol, last reviewed on 11/16/2023, indicated it was the facility's policy to reduce the stages of pressure sores of residents being treated at the facility. The policy indicated to use preventive equipment, such as a pressure relief device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet professional standards of practice by failing to label the gastrostomy tubes (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) feeding bottle for three (3) of 15 residents sampled residents (Resident 9, Resident 39, Resident 41).
This deficient practice had the potential to result in nosocomial infections (infections that develop while a person is receiving medical attention) for Resident 9, Resident 39, and Resident 41.
Findings:
a. A review of Resident 9's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia (lung infection).
A review of Resident 9' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/17/2024 indicated Resident 9 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 9 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 9 required G-Tube feeding for nutrition.
A review of Resident 9's Physician's Orders indicated an order for enteral (tube) feed every shift for Glucerna 1.2 formula (a type of tube feeding formula) to be given at 60 milliliters per hour (ml/hr., ml being a unit of measure for liquids and hr. indicating time measured) for 18 hours a day, dated 9/28/2023.
During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 9 was observed to be on tube feeding formula with Registered Nurse 1 (RN 1). RN 1 stated that there was no start date (the date the feeding formula was first used) and no start time (the time the feeding formula was first put into use) written on Resident 9's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection.
b. A review of Resident 39's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition when the respiratory system fails to deliver oxygen to the rest of the body).
A review of Resident 39's MDS dated [DATE], indicated Resident 39 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 39 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 39 required G-Tube feeding for nutrition.
A review of Resident 39's Physician's Orders indicated an order for enteral feed every shift with Glucerna 1.5 formula (a type of feeding formula) to be given at 55 ml/hr for 18 hours a day, dated 9/28/2023.
During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 39 was observed to be on tube feeding formula with RN 1. RN 1 stated that there was no start date and no start time written on Resident 39's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection.
c. A review of Resident 41's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure.
A review of Resident 41' s MDS, dated [DATE], indicated Resident 41 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 41 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 41 required G-Tube feeding for nutrition.
During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 41 was observed to be on tube feeding formula with RN 1. RN 1 stated that there was no start date and no start time written on Resident 41's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection.
During an interview with the Director of Nurses (DON) on 2/06/2024 at 2:14 p.m., DON stated that it is the practice of the facility that a G-tube formula feeding bottle is to be discarded 24 hours after it was first opened for use. The DON stated that if licensed nurses do not write the start date (the date the feeding formula was first used) and time (the time the feeding formula was first put into use) on the bottle, there would not be a way for facility staff to know when the feeding formula needed to be discarded. The DON stated that by not documenting a start time and date on a tube feeding formula bottle, it places the residents at risk for infection.
A review of the facility's policy and procedure titled, Enteral Feeding via G-Tube, reviewed 11/16/2023, indicated a feeding bag and tubing should be changed every 24 hours.

Based on interview and record review, the facility failed to renew and revised the resident's comprehensive Care Plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for Range of Motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) for one of three sampled residents (Resident 44) investigated under Care Planning.
This deficient practice resulted to the resident not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent further decline in range of motion.
Findings:
A review of Resident 44's admission Record indicated the facility
admitted the resident on 10/24/2023 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain).
A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/1/2023, indicated that the resident's cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was impaired. The MDS indicated Resident 44 required extensive assistance from staff for dressing, toilet use, bathing; and limited assistance from staff for eating and personal hygiene.
During a concurrent interview and record review on 2/8/2024 at 10:19 a.m., with the Director of Staff Development (DSD), reviewed Resident 44's Care Plan for Range of Motion dated 10/20/2023. The DSD stated that care plans are evaluated quarterly (four times a year, at intervals of three months) and as needed to ensure that each resident's current plan is pertinent to the current health concerns, to determine if the care plan goals have been met, and to determine if any care plan interventions are no longer needed for the resident's current health status. The DSD stated it is important to revise Resident 44's care plan so that staff may monitor the resident's progress on specific issues such as limited range of motion. The DSD stated that Resident 44's Care Plan for Range of Motion should have been reviewed and revised for evaluation on 1/30/2023. The DSD stated that as of 2/8/2024, Resident 44's Care Plan for Range of Motion had not been revised since 10/30/2023. The DSD stated that a review and revision for the care plan is past due.
A review of the facility's policy and procedures titled, Care Planning, last reviewed on 11/16/2023, indicated, Evaluating and reassessing the plan of care for the resident, the following shall be considered: Are the resident's problem still current? Are there new problems?; Are the actions and approaches appropriate and effective?; Are objectives being met within the designated time frames .

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for a resident's use of lorazepam (Ativan [brand name]- medication used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) by failing to include non-pharmacological interventions (therapies that do not involve drugs or medicine) in the care plan for one of five sampled residents (Resident 22) investigated for unnecessary medications.
This deficient practice had the potential to result in failure to deliver necessary care and services.
Findings:
A review of Resident 22's admission Record indicated the facility admitted the resident on 5/15/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood).
A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for bed mobility and transfers.
During a concurrent interview and record review on 2/7/2024 at 4:22 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 22's physician's orders and care plan for Ativan. MDS Nurse 1 stated Resident 22 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) by mouth every 24 hours as needed for restlessness leading to shortness of breath, ordered on 1/17/2024 with an end date of 2/15/2024. Upon review of Resident 22's care plan for Ativan, MDS Nurse 1 stated there were no non-pharmacological interventions included in the care plan.
During an interview on 2/8/2024 at 9:56 a.m., with the Director of Nursing (DON), the DON stated that non-pharmacological interventions were important because the resident can either become dependent on the medication or experience side effects or an adverse reaction (undesired harmful effect resulting from a medication or other intervention) to the medication. The DON stated Resident 22's care plan for Ativan should have included non-pharmacological interventions so that nurses were on the same page about what non-pharmacological interventions were effective for the resident. The DON stated if no non-pharmacological interventions were included in the care plan, then the nurses will just tend to administer the Ativan without attempting non-pharmacological interventions first.
A review of the facility's policy and procedure titled, Psychotropic Medication (medications capable of affecting the mind, emotions, and behavior) for Residents with a Diagnosis of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), last reviewed on 11/16/2023, indicated the purpose of the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Charge Nurse will initiate a behavior sheet with the specific behavior(s) for which the antipsychotic medication (medication used to treat psychosis [severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality]) was prescribed, in accordance with the physicians' wishes when he/she reviews the medication orders. The behavior sheet will include resident specific non-pharmacological interventions for the resident.
During an interview on 2/8/2024 at 4:39 p.m., with the DON, the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but no policy for psychotropic use for non-dementia residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 2/6/2024 at 11:23 a.m., with the Infection Preventionist (IP), observed in Room A, rolled-up bed linen, a blanket, and a towel placed on top of a red biohazard container bin. The IP stated that the used linens, blankets, and towels must not be placed on top of a red biohazard container bin and should not be left open to air because it can contaminate the resident's environment and can potentially spread infection to visitors and staff. The IP stated that the used linens, blankets, and towels must be placed in the designated hamper for laundry.
A review of the facility's policy and procedure titled, Linen Handling, last reviewed on 11/16/2023, indicated, It is the policy of the facility to provide procedures for the proper handling of clean and soiled linens and to ensure procedures are followed .to protect against the transmission of organisms from one location to another through the use of proper linen handling techniques . soiled linens shall be placed immediately into a soiled linen hamper .
Based on observation, interview, and record review, the facility failed to:
1. Ensure staff labeled a wash basin found on the sink countertop of a shared resident bathroom with a resident identifier for three of eight sampled residents (Residents 25, 54, and 15) investigated for infection control.
2. Ensure soiled linens, soiled blankets, and soiled towels were placed in the soiled linen hamper and not on top of the red biohazard waste container bin (used for the disposal of waste that may be contaminated with pathogens [any organism or agent that can produce disease] that present a danger to people and the environment) for one of four contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) rooms (Room A).
These deficient practices had the potential to result in contamination of the resident's environment and risk of transmission of bacteria that can lead to infection.
Findings:
1. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/1/2023 with diagnoses including chronic respiratory failure with hypoxia (condition in which not enough oxygen passes from your lungs into your blood and reaching the body's tissues).
A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/8/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff for personal hygiene and dressing.
A review of Resident 25's admission Record indicated the facility admitted the resident on 7/18/2017 with diagnoses including chronic respiratory failure with hypoxemia (abnormally low concentration of oxygen in the blood).
A review of Resident 25's History and Physical (H&P - a medical examination that involves a physician gathering a patient's medical history, performing a physical exam, and documenting their findings), dated 1/20/2023, indicated the resident was unable to make decisions.
A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses including chronic respiratory failure.
A review of Resident 15's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff for personal hygiene, dressing, and bed mobility.
During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed an unlabeled wash basin on top of the sink countertop in the residents' shared bathroom. LVN 1 stated that the wash basin should have been labeled with the name of the resident to whom it belonged. LVN 1 stated she did not know to whom it belonged.
During an interview on 2/8/2024 at 9:43 a.m., with the Director of Nursing (DON), the DON stated that resident wash basins should be labeled with the resident's last name for infection control purposes. The DON stated there was a potential for infection to be transmitted among residents if the wash basin is not labeled because staff might use it for the wrong resident.
A review of the facility's policy and procedure titled, Labeling and Storing Patient Care Equipment, last reviewed on 11/16/2024, indicated the facility was dedicated to minimizing the risk of healthcare associated infections (HAI- infections people get while they are receiving health care for another condition). Individual urinal, bedpan, and/or plastic basin is labeled with a permanent marker with the patient's name.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three residents' call lights (a device used by patients in hospitals, nursing homes, and other healthcare facilities to request assistance from staff) were within reach while the residents were in bed for three of three sampled residents (Residents 54, 25, and 15) investigated for accommodation of needs.
This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.
Findings:
a. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/1/2023 with diagnoses including chronic respiratory failure with hypoxia (condition in which not enough oxygen passes from your lungs into your blood and reaching the body's tissues).
A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/8/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff for personal hygiene and dressing.
A review of Resident 54's care plan (a written document that summarizes a patient's needs, goals, and care) for risk for falls, initiated on 11/2/2023, indicated to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 54 needs prompt response to all requests for assistance.
During an observation on 2/6/2024 at 10:36 a.m., observed Resident 54 in bed with their call light on the floor.
During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 54's call light on the floor and not within reach. LVN 1 stated the Resident 54's call light should have been within reach.
During an interview on 2/8/2024 at 9:43 a.m., with the Director of Nursing (DON), the DON stated she provided in-services (designating or of training, as in special courses, workshops, etc., given to employees in connection with their work to help them develop skills, etc.) regarding call lights. The DON stated she teaches her staff to respond to call lights promptly and make sure call lights are within residents' reach. The DON stated it was important to make sure that call lights were within residents' reach so that, if they needed anything, they could call staff for assistance. The DON stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach.
A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times.
b. A review of Resident 25's admission Record indicated the facility admitted the resident on 7/18/2017 with diagnoses including chronic respiratory failure with hypoxemia (abnormally low concentration of oxygen in the blood).
A review of Resident 25's History and Physical (H&P - a medical examination that involves a physician gathering a patient's medical history, performing a physical exam, and documenting their findings), dated 1/20/2023, indicated the resident was unable to make decisions.
A review of Resident 25's MDS, dated [DATE], indicated the resident was dependent on staff for dressing, personal hygiene, and chair/bed-to-chair transfer.
A review of Resident 25's care plan for impaired communication, initiated on 10/14/2023, indicated a goal that the resident's needs will be met and anticipated by staff every shift. An intervention included was to ensure/provide a safe environment - have call light within reach.
A review of Resident 25's care plan for alteration in musculoskeletal status, initiated on 1/3/2024, indicated a goal that the resident will remain free of injuries or complications related to muscle spasm. An intervention included was to ensure call light is within reach and respond promptly to all requests for assistance.
During an observation on 2/6/2024 at 10:36 a.m., observed Resident 25's call light not within reach and on the resident's overhead lamp.
During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with LVN 1, observed Resident 25's call light not within reach. LVN 1 stated Resident 25's call light should have been within reach. In addition, LVN 1 stated Resident 25 could not press his call light and needed a pad call light he could turn on by pressing his head against it.
During an interview on 2/8/2024 at 9:43 a.m., with the DON, the DON stated she provided in-services regarding call lights. The DON stated she teaches her staff to respond to call lights promptly and make sure call lights are within residents' reach. The DON stated it was important to make sure that call lights were within residents' reach so that, if they needed anything, they could call staff for assistance. The DON stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach. The DON stated it was also important to give residents a call light that they were able to use. The DON stated, for instance, if a resident was only able to use his/her head, then they would provide him/her with a touch pad call light, instead of the call button. The DON stated it was important to provide them with the correct type of call light because, if they were given one they could not use, then they would not be able to call for help when needed to.
A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times.
c. A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses including chronic respiratory failure.
A review of Resident 15's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff for personal hygiene, dressing, and bed mobility.
A review of Resident 15's care plan for impaired communication, initiated on 7/24/2023, indicated a goal that the resident's needs will be met and anticipated by staff every shift. An intervention included was to ensure/provide a safe environment - keep call light within reach.
A review of Resident 15's care plan for risk for falls, initiated on 7/25/2023, indicated a goal that the resident will be free of falls every shift. An intervention included was to ensure the call light was available to the resident.
A review of Resident 15's care plan for alteration in musculoskeletal status, initiated on 11/20/2023, indicated a goal that the resident will remain free of injuries or complications related to muscle spasm. An intervention included was to ensure the call light was within reach and respond promptly to all requests for assistance.
During an observation on 2/6/2024 at 10:36 a.m., observed Resident 15 awake in bed. Observed that Resident 15 was able to nod or shake his head in response to questions. Observed Resident 15's call light not within reach but on top of his overhead lamp.
During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with LVN 1, observed Resident 15's call light not within reach. LVN 1 stated Resident 15's call light should have been within reach. In addition, LVN 1 stated Resident 15 could not press his call light and needed a pad call light he could turn on by pressing his head against it.
During an interview on 2/8/2024 at 9:43 a.m., with the DON, the DON stated she provided in-services regarding call lights. The DON stated she teaches her staff to respond to call lights promptly and make sure call lights are within residents' reach. The DON stated it was important to make sure that call lights were within residents' reach so that, if they needed anything, they could call staff for assistance. The DON stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach. The DON stated it was also important to give residents a call light that they were able to use. The DON stated, for instance, if a resident was only able to use his/her head, then they would provide him/her with a touch pad call light, instead of the call button. The DON stated it was important to provide them with the correct type of call light because, if they were given one they could not use, then they would not be able to call for help when needed to.
A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times.

Based on observation, interview, and record review, that facility failed to maintain the Heating, Ventilation, and Air Conditioning (HVAC) system in a fully operable condition.
This deficiency has the potential for the air temperature in patient care areas such as resident sleeping rooms and shared recreation rooms to become too hot, directly affecting the safety and health of 16 out of 16 residents.
Findings:
During an interview on 7/13/2023, at 2:38 p.m., with the Director of Engineering (DOE), the DOE stated that the chiller system (the part of the air condition unit that cools the air) was inoperable. The DOE stated that the chiller has not worked for over two years and that attempts to repair the chiller had failed and that the unit would require a replacement. The DOE stated that there was no documentation of any attempts to replace the exiting chiller and that he was unaware if a permit to Department of Healthcare Access and Information (HCAI - the State agency having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) had been submitted for the replacement of the chiller.
During a concurrent observation and interview on 7/13/2023, at p.m., with the DOE, in the Chiller Room, the chiller was observed to be partially taken apart and not operable. A chiller rented from a vendor was observed outside of the Chiller Room. The DOE stated that an attempt to repair the chiller in the Chiller Room was made and that the repair couldn't be completed and that it would be replaced at some point.
During a review of the Projects at Open, Projects In Review, Projects with Approval, and Projects in Construction report exported from the HCAI Report Center (an online portal for HCAI projects), it was indicated that no open/reviewed/approved/construction project permit was available for this facility to replace the existing chiller.
During a review of record titled Total Environmental Management. Inc. - Invoice dated 6/13/2023, the invoice indicated that the facility had rented a 200 ton chiller.

Based on observation, interview, and record review, the facility staff failed to follow facility reporting guidelines for allegation of abuse for 1 (one) of 1 (one) sampled resident (Resident 1). This deficient practice had the potential for delay in investigation and delay in intervention after notification of the allegation of abuse.
Findings:
During an interview on 11/18/2021, at 1:50 p.m., with the Sub Acute Administrator (SAA), SAA stated, the facility failed to follow abuse reporting policy for Resident 1 and Resident 2 alteration on 11/13/2021. SAA stated, on 11/13/2021, Resident 2 kicked Resident 1 at his right leg when both were in the activity room. SAA stated, the charge nurse who knew about the incident failed to fill out the abuse report form because she could not find it. SAA stated, incident was not reported to the health services until the following Monday (11/15/2021) meeting and that's when the social worker reported it. SAA stated, there should have been a phone call within 2 hours once the charge nurse found out about it.
During an interview on 11/18/2021, at 2:30 p.m., with Charge Nurse (CN), CN stated she overheard about the incident regarding Resident 1 and Resident 2. CN stated, stated for any situation regarding physical abuse, it must be reported immediately depending on the situation it could be within 2 hours or 24 hours. CN stated, reporting requirements was not followed for this incident.
During an interview on 11/18/2021, at 2:39 p.m., with Resident 1, Resident 1 stated and nodded yes he was kicked on his right leg by Resident 2 and would like pain medication for it.
During an observation on 11/18/2021, at 2:42 p.m., observed Resident 1 point and rubbed his right leg where he was kicked by Resident 2.
A review of the Progress Notes of Resident 1 on 11/13/2021 10:00am, indicated Resident 2 hit Resident 1 on his right leg and knee.
A review of the facility policy titled: Abuse, Elder and Dependent Adult, Revised 02/2020, indicated: [facility] is also required to report all incidents of alleged abuse or suspected abuse to the Department of Health Services within 24 hours. This includes all unexplained skin alterations and any skin alterations and injuries of unknown sources.