Citations in California E

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.

Plan Of Correction

From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement contact isolation precautions for a resident who developed signs and symptoms consistent with Clostridioides difficile infection (CDI) and was later confirmed positive. The resident was admitted with diagnoses including pulmonary embolism and sepsis and subsequently developed diarrhea meeting the facility’s criteria for suspected CDI on 1/18/2026. A physician ordered a stool test for CDI on that date, but the resident was not placed on contact precautions at the time of suspicion, despite facility policy requiring contact precautions for residents with diarrhea and suspected CDI while awaiting laboratory results. The resident’s change in condition evaluation on 1/20/2026 documented CDI with onset of symptoms on 1/18/2026, and the resident was not placed on contact isolation until 1/20/2026, after the physician ordered contact isolation for a positive CDI result. During this period, the CDI-positive resident continued to share a room with two roommates. One roommate had diffuse large B-cell lymphoma, was actively receiving antineoplastic chemotherapy, and was identified as immunocompromised and at high risk for infection. This roommate’s care plan, initiated later, identified her as at high risk for nosocomial infection and indicated staff should perform hand hygiene and wear gowns and gloves during high-contact activities, but there was no evidence that this high-risk status was used to prevent her from being cohorted with a resident with active CDI. The other roommate had multiple chronic conditions, including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety, and required substantial assistance with ADLs. Both roommates remained in the same room with the CDI-positive resident while an isolation cart and contact precaution sign were posted outside the room. The facility did not complete infection risk assessments for either roommate before or during their cohorting with the resident who had CDI. The DON confirmed there was no documented evidence of infection risk assessments for these roommates between 1/17/2026 and 1/30/2026, and stated that such assessments should have been completed by the Infection Preventionist or a licensed nurse to determine appropriate roommate placement when a resident had an infection. The Infection Preventionist Nurse and DON acknowledged that the immunocompromised roommate should not have been placed with the CDI-positive resident and that the facility failed to follow its own CDI and isolation policies, which required private rooms when possible or cohorting only with low-risk roommates. The facility also failed to inform and educate the two roommates about their potential risk of acquiring CDI and the infection control guidelines they should follow. One roommate reported not understanding why the room was on isolation and stated that staff did not provide any explanation when asked. The other roommate, aware of her compromised immune system and ongoing chemotherapy, stated she was not told why staff were wearing gowns when caring for her roommate and was reassured that it had nothing to do with her, despite her expressed concerns. The Infection Preventionist Nurse confirmed there was no documented evidence that staff notified or educated the roommates about their risk for CDI or appropriate precautions. Additionally, the facility did not monitor the two roommates for signs and symptoms of CDI after their exposure to the infected resident. The Infection Preventionist Nurse stated that no monitoring was conducted for these roommates for CDI-related symptoms such as fever, abdominal pain or spasms, diarrhea, nausea, or vomiting. The Medical Director stated that staff were aware of appropriate infection control measures but failed to implement them, and that staff did not follow facility policy or CDC guidelines regarding cohorting and isolation for CDI. The DON described this as a failure in the facility’s system process, including lack of staff training on isolation precautions and infection risk assessments, which contributed to the deficient practice. The facility’s written policies required that residents with diarrhea and suspected CDI be placed on contact precautions while awaiting lab results, and that residents with diarrhea associated with CDI be placed on contact precautions. The isolation policy further required that residents on contact precautions be placed in a private room if possible, or, if not, that the Infection Preventionist assess risks and cohort only with low-risk roommates. Despite these written requirements, the resident with CDI remained in a shared room with an immunocompromised roommate and another medically complex roommate, without documented risk assessments, without timely initiation of contact precautions at the time of suspicion, without education of roommates about their risk and needed precautions, and without monitoring of the roommates for CDI symptoms. These actions and omissions formed the basis of the cited infection control deficiency under F880.

Removal Plan

• Moved Resident 2 to Room B with no roommates due to immunocompromised condition and initiated RN Supervisor monitoring every shift for 40 days for CDI signs/symptoms.
• Designated Room A as a single isolation room and assigned Resident 1 no roommates.
• Reviewed and revised Resident 2’s care plan to reflect immunocompromised status and that Resident 2 should not share a room with a resident who has an active infection.
• Conducted in-service training for all nursing staff on Infection Control policy, with written quizzes to validate understanding; provided phone/follow-up training for staff not present prior to next shift; removed from schedule any staff who did not complete training until completed.
• Provided one-on-one in-service to the Administrator and DON on the admission process for residents requiring isolation precautions and appropriate cohorting.
• Provided one-on-one in-service training to the Infection Preventionist Nurse on infection control practices, including proper PPE use and appropriate cohorting.
• Conducted record review of all residents with changes in condition to identify residents with signs/symptoms consistent with CDI; found no other affected residents.
• Assessed all residents for CDI signs/symptoms; found no additional affected residents.
• Implemented process for DON and Infection Preventionist Nurse to review all incoming admissions to determine need for isolation/precautions and arrange appropriate room placement/cohorting.
• Implemented Infection Preventionist Nurse tracking log for all residents with active infections, including CDI, to prevent spread.
• Established monthly infection control meetings led by Administrator and IDT to ensure adherence to infection control and PPE policies and to promptly identify/address room placement and cohorting issues.
• Developed a QAPI plan for Infection Control practices including root cause analysis to be reviewed and updated during monthly QAPI meetings for three months to ensure corrective actions are effective and sustained.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of misappropriation of resident property to the State Survey Agency (SSA) as required by regulation and facility policy. A resident admitted with muscle weakness and sepsis had documentation in the History and Physical and Minimum Data Set indicating intact cognitive function and capacity to understand and make decisions. During an interview, the resident reported that a family member visitor took his wallet, left the facility, charged $500 to his credit card, and then returned the wallet and card. The resident stated he had informed the Social Worker of this incident, though he could not recall the exact date and time of either the event or the report. The Social Worker confirmed that the resident had reported that the family member took the wallet and charged $500 to the resident’s credit card, without specifying the date and time. The Administrator acknowledged that the resident had informed the Social Worker of the allegation and that she did not report this allegation of misappropriation of property to the SSA. The facility’s abuse, neglect, exploitation, and misappropriation reporting policy, last reviewed on 8/15/2025, states that all reports of theft or misappropriation of resident property must be reported to local, state, and federal agencies as required, and that suspected misappropriation must be reported immediately to the Administrator and to the state licensing/certification agency, with “immediately” defined as within two hours for allegations involving abuse or misappropriation. Despite this policy, the allegation was not reported to the SSA.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident who was immunocompromised and at high risk for infection. The resident’s face sheet showed an original admission with a readmission date and diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney. The resident’s MDS indicated intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Despite these documented conditions and functional needs, there was no care plan addressing the resident’s immunocompromised status. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator did not initiate a care plan upon admission to address the resident’s immunocompromised condition related to diffuse large B-cell lymphoma. The DON acknowledged that the care plan should have included interventions such as not cohorting the resident with others who had active infections and that the existing care plan was not comprehensive or person-centered. Review of the facility’s policy on comprehensive, person-centered care plans showed that care plans were required to include measurable objectives and timetables, be derived from a thorough assessment, describe needed services, and reflect recognized standards of practice, which was not done for this resident’s immunocompromised status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans for two residents after they were cohorted with another resident who had a suspected and later confirmed Clostridium difficile (CDI) infection. Resident 1 was admitted with diagnoses including pulmonary embolism and sepsis, and later developed enterocolitis due to CDI, with symptom onset identified as occurring on 1/18/2026. A physician ordered stool collection for CDI testing on 1/18/2026, and a Change in Condition evaluation completed on 1/20/2026 documented CDI, diarrhea meeting CDI criteria, and placement of Resident 1 on contact isolation. Despite these developments and the infection-control implications, the care plans for the cohorted residents were not updated. Resident 2 had a history of diffuse large B-cell lymphoma, chemotherapy, and acquired absence of a kidney, with an MDS indicating intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Resident 3 had diagnoses including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety disorders, with an MDS showing moderately impaired cognition and a need for substantial/maximal assistance with toileting hygiene, lower body dressing, and footwear. Both residents were cohorted with Resident 1 when CDI was suspected and then confirmed, but their care plans were not revised to reflect this change in condition and exposure risk. During an interview and concurrent record review with the DON on 1/30/2026, it was confirmed that staff did not update the care plans for Residents 2 and 3 when they were cohorted with the CDI-positive resident. The DON stated that licensed staff and the MDS Coordinator were responsible for updating care plans and acknowledged that the existing care plans for these residents were not comprehensive or person-centered in light of the new circumstances. The facility’s own policy on comprehensive, person-centered care plans requires that care plans be derived from thorough assessment, describe services to meet residents’ highest practicable well-being, reflect current standards of practice, and be revised as residents’ conditions change. The failure to revise the care plans after the cohorting event constituted the cited deficiency.

Penalty

Fine: $414,390

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for residents at risk of elopement, particularly two residents with known risk factors, and the failure to complete required elopement risk assessments for nearly all residents. One resident with alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy was cognitively intact per BIMS and independent in transfers and walking, and he frequently went to the facility’s garden. Staff reported that he had previously left the facility in the morning and returned intoxicated in the evening, and that this incident should have been reported to management. Despite a physician’s order for an Elopement Evaluation and an order that he could only leave the SNF/hospital property with a responsible party, no Elopement Evaluation Assessment was completed upon admission, and staff confirmed there was no tool in use to assess elopement risk. The nurse manager stated the assessment was not done because the resident was alert, oriented, and independent. The same resident’s preference for frequent independent garden time was documented in his activity preferences, but the activity staff did not develop a comprehensive activity care plan that included objectives, interventions, supervision requirements, or monitoring of his whereabouts during garden time. The activities coordinator and nursing staff acknowledged that the existing documentation did not constitute a true care plan and that there was no constant monitoring of the resident while he was in the garden. In addition, the facility did not follow its Leave of Absence (LOA) policy requiring a complete mental, physical, and functional assessment within 30 minutes before leaving and upon return, documented in the nursing progress notes. Multiple LOA forms for this resident showed times out with no times in, missing nurse initials, and incomplete destination information, and the nurse manager confirmed that nurses did not complete or document required assessments on numerous dates. Staff interviews revealed that nurses and CNAs did not routinely check on residents in the garden, did not sign the resident back in when he returned for medications, and believed that the resident’s signature on the LOA form released the facility from responsibility. On the day of the fatal incident, the resident signed out in the morning to go to the garden, was seen on surveillance video leaving and re-entering the building, and later left again in the early afternoon without signing out. He took his medication early that afternoon, but staff did not verify his whereabouts afterward. Surveillance footage reviewed by the director of quality showed the resident exiting through the lobby doors and heading toward a nearby street, after which he was no longer visible until a truck stopped in front of the hospital later that evening, coinciding with the time of a motor vehicle accident in which he was struck as a pedestrian. He was subsequently admitted to the acute hospital as a trauma patient with extensive injuries and an elevated blood alcohol level and later died; the hospital death summary listed multiple traumatic injuries and alcohol intoxication among the diagnoses and contributing conditions. A second resident, with diagnoses including alcoholism, diabetes mellitus, hemiplegia due to prior stroke, hypercholesterolemia, hypertension, and wheelchair dependence, had a BIMS score indicating severe cognitive impairment. No Elopement Evaluation Assessment was completed upon his admission. The nurse manager stated that such assessments were only done when residents were “triggered” by an elopement incident or a change in condition, rather than upon admission. This resident routinely signed LOA forms and left the facility or went to the garden unassisted, propelling his wheelchair using his left arm and leg, often in the early morning hours. CNA staff reported that he preferred to go out alone to stores to purchase lottery scratcher tickets and that staff did not take his vital signs each time he returned from LOA. Review of his LOA forms showed numerous entries with times out but no times in, missing nurse initials, missing destinations, and lack of documentation of assessments before leaving or upon return, contrary to facility policy. Beyond these two residents, the facility failed to complete Elopement Evaluation Assessments upon admission for 39 of 40 residents reviewed. The report states that this failure could result in not identifying residents’ elopement risk levels and not implementing resident-centered plans of care, with the potential to result in harm, injury, or death for residents at high risk of elopement. The cumulative failures to assess elopement risk, to develop and implement individualized care plans for residents with known preferences for independent outdoor time, and to follow the LOA policy for assessment and documentation led to an immediate jeopardy situation, as the noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents, exemplified by the elopement and subsequent fatal motor vehicle accident involving the first resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from sexual abuse by a staff member. The resident, who had Parkinson's disease with dyskinesia, dysphonia, muscle weakness, and intact cognition per a recent MDS (BIMS score 13), was dependent on staff for care and had contracted limbs. On one occasion, a licensed nurse entered the resident's room and observed an unlicensed staff member standing beside the resident, with his pants pulled down in the front, holding his exposed penis in his hand. The nurse saw his penis pressed against the resident’s left buttock at the gluteal fold while his other hand was on the resident’s left buttock. The resident was lying on her bed with her legs contracted, positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed where the unlicensed staff member was standing. Following this event, the business office manager was informed and interviewed both the licensed nurse and the unlicensed staff member. The unlicensed staff member did not deny having his penis exposed in the resident’s room and responded, "I don't know" and "whatever she said" when asked about the allegation. The resident later reported that the unlicensed staff member had been inappropriate with her, that he did things she did not want him to do, and confirmed that he had inserted two to three fingers into her vagina when cleaning her and had put his penis in her vagina more than once, despite her saying no. A charge nurse reported that the resident stated "boundaries were crossed" during personal care, that the staff member sometimes pushed his fingers on her anus, was rough, and lingered too long in her room. A police detective stated that the resident reported multiple instances of the staff member touching her with his penis and inserting his penis and fingers into her vagina, and that the staff member admitted to touching the resident inappropriately with his penis and fingers on multiple occasions. This conduct occurred despite a facility policy stating a zero-tolerance stance toward any form of resident abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure safe care and adequate supervision during in‑bed care for a resident, resulting in a fall and fracture. The resident was admitted in 2025 with multiple orthopedic and musculoskeletal conditions, including intervertebral disc degeneration of the lumbar region, a closed right patella fracture, an infection of an internal fixator in the right ankle, and a history of an unspecified fall. A Fall Risk Assessment dated 10/18/25 scored the resident at 25, categorized as a moderate fall risk. The resident’s MDS Section GG, dated 9/22/25, documented a need for substantial/maximum assistance with toileting and hygiene, meaning staff performed more than half the effort and held or lifted the trunk and limbs. On the morning of 1/23/26, CNA 2 provided incontinence care after finding the resident incontinent of stool in bed. CNA 2 rolled the soiled linens and tucked them under the resident while the resident was on her side. CNA 2 reported that she had one hand on the resident to steady her and one hand on the tucked linen, and then attempted to pull the soiled linen out with one hand but was unable to do so. CNA 2 stated she instructed the resident to hold onto the cabinet or bed frame so that CNA 2 could use both hands to pull the linens. CNA 2 then removed the hand that had been supporting the resident in order to use both hands on the linens. According to CNA 2, the resident indicated it was acceptable for her to let go, and CNA 2 proceeded to pull the linens; at that point, the resident fell from the bed onto the floor on her right side. The resident later reported that she had been holding the privacy curtain when she fell. At the time of the fall, there were no side rails on the bed and no fall mats on either side of the bed. Following the fall, the resident complained of right arm pain, with documentation of pain at level 7 and painful, limited ROM in the upper extremity. An x‑ray obtained that day showed a horizontal distal humerus fracture without displacement of the right elbow. The IDT Falls Progress Note dated 1/25/26 documented that the resident fell when CNA 2 was turning her and that, per the resident’s statement, she was holding onto the side of the mattress and leaning too much, resulting in loss of balance and a fall. Predisposing factors listed included a history of falls, muscle weakness, gait/balance deficit, poor safety awareness, and overestimation of limits. The same IDT note listed preventive measures such as a low, locked bed and a landing mat on the floor to reduce impact and injury of falls, but the DON later confirmed that a fall mat was not actually in place at the time of the fall and was only placed days later. The DON also confirmed that a physician’s order for quarter side rails for mobility and positioning was dated 1/26/26, with a bed rail assessment and resident consent completed that same day, but the rails were not installed until 1/28/26. The DON acknowledged that once the resident fell, a fall mat should have been placed immediately and that the resident’s injury was preventable. The resident’s treating physician stated he was not aware that only one CNA had provided incontinence care at the time of the fall and stated that there should have been two CNAs providing that care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to prevent unnecessary chemical restraint and to adequately monitor and obtain informed consent for the use of the antipsychotic medication quetiapine for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical dated 12/19/2025 documented that the resident did not have the capacity to understand and make decisions, while a subsequent MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and that the resident was receiving an antipsychotic. On 12/22/2025, the physician ordered quetiapine 100 mg by mouth at bedtime for psychosis manifested by delusions. The facility failed to follow physician orders for monitoring orthostatic blood pressure related to quetiapine use. An order dated 1/15/2026 required orthostatic blood pressure checks (lying and then sitting within three minutes) every Sunday, with instructions to call the physician if the systolic blood pressure changed by more than 20 mmHg or the diastolic by more than 10 mmHg. Review of the January 2026 MAR showed that on 1/18/2026 and 1/25/2026, the assigned LVN documented orthostatic blood pressure as “not applicable” for both lying and sitting positions, meaning the ordered monitoring was not performed. The ADON and DON both stated that quetiapine can cause orthostatic hypotension, that the order required weekly orthostatic blood pressure monitoring, and that failure to complete and document these assessments could delay physician notification and delay care. Facility policies on Adverse Consequences and Medication Errors and on Psychotropic Medication Use required monitoring residents for adverse consequences and documenting responses to psychotropic medications. The facility also failed to obtain appropriate informed consent for the initiation and subsequent dose increase of quetiapine. An informed consent form dated 12/19/2025 documented that the resident verbally consented to quetiapine 50 mg twice a day for agitation and aggression, verified by an RN. However, the H&P from the same date indicated the resident lacked capacity to understand and make decisions. The ADON stated the facility should have followed the H&P and clarified with the physician and informed the responsible party. On 12/22/2025, the order was clarified to quetiapine 100 mg at bedtime, and on 12/28/2025, an additional order for quetiapine 50 mg in the evening was added, resulting in a total daily dose of 150 mg from 12/28/2025 to 1/4/2026. The ADON and DON stated that when the dose of a psychotropic medication is increased, a new informed consent is required, and acknowledged that no new consent was obtained when the dose was increased to a total of 150 mg. The DON further stated that, because the resident did not have capacity, the responsible party should have provided consent, and that without valid informed consent, the responsible party’s rights were violated. Review of the facility’s Psychotropic Medication Use and Antipsychotic Medication Use policies showed requirements to inform residents or representatives of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic use and to obtain documented consent prior to initiating or increasing psychotropic medications, which the DON stated were not followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to administer pain medication according to physician orders for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 indicated the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 documented intact cognitive skills for daily decisions, a need for supervision with hygiene, toileting, and showering, and occasionally moderate pain. Physician orders dated 1/15/2026 directed that hydrocodone-acetaminophen 5-325 mg be given every four hours as needed for moderate pain rated 4–6, and oxycodone-acetaminophen 7.5-300 mg be given every six hours as needed for severe pain rated 7–10. Review of the MAR for January 2026 showed that LVN 2, LVN 3, and LVN 4 administered hydrocodone instead of the ordered oxycodone when the resident’s pain was documented at levels 7 or 8 on four separate occasions (1/21/2026 at 2:27 a.m., 1/25/2026 at 6:28 a.m., 1/26/2026 at 1:10 a.m., and 1/29/2026 at 3:10 a.m.). During interviews, the ADON confirmed that the physician’s order specified hydrocodone for pain levels 4–6 and oxycodone for pain levels 7–10, and acknowledged that the nurses should have administered oxycodone instead of hydrocodone on those dates. The DON also stated that nurses are expected to follow physician orders and that the resident’s pain could not be completely relieved because the orders were not followed. Review of facility policies on Pain Assessment and Management and Administering Medications showed that medications are to be implemented and administered as ordered, including required time frames.