Every finding on record at Alameda County Medical Center D/P SNF

Based on observation, interview and record review, the facility failed to ensure 106 of 106 residents had food prepared and stored in a safe and sanitary manner when: 1. frozen raw tilapia and frozen raw shrimp was stored above ready to eat chicken enchiladas and bean and cheese pupusas. 2. a dispensing scoop was stored in panko breadcrumbs. 3. staff did not perform hand hygiene when their hands were contaminated by picking up a clipboard which fell on the floor. These failures placed the facility's 106 residents who received food from the kitchen at risk of foodborne illness. Findings: 1. During a concurrent observation and interview on 8/19/24, at 10:27 a.m., with Director of Food and Nutrition Services (DFNS) and Registered Dietitian 1 (RD 1), the freezer containing protein products was inspected. One opened box of frozen raw tilapia, one opened box of frozen raw shrimp and one closed box of frozen raw shrimp was found on the shelving above an open box of ready-to-eat chicken enchiladas, two unopened boxes of ready-to-eat chicken enchiladas and three closed boxes of ready-to-eat bean and cheese pupusas. RD 1 stated the raw seafood products needed to be stored below the heat to serve food products. During a concurrent observation and interview on 8/19/24, at 10:30 a.m., with DFNS, a chart titled, proper refrigerator and freezer storage, dated 1/2024, was reviewed. DFNS stated the chart indicated the frozen seafood is stored below frozen cooked and ready-to-eat food. A review of the Food and Drug Administration Food Code, dated 2022, indicated food be protected from cross contamination by separating raw animal foods from ready-to-eat foods. 2. During an observation on 8/19/24, at 10:41 a.m., a bin with a removable lid of panko breadcrumbs was inspected. Inside the container was a metal scoop resting in the panko breadcrumbs. During a concurrent observation and interview on 8/19/24, at 10:42 a.m., with DFNS and RD 1, RD 1 stated the scoop resting in bin needed to be stored outside of the bin to prevent food contamination. A review of the FDA Food Code, dated 2022, indicated dispensing utensils used for dry food items are stored with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. 3. During an observation on 8/21/24, at 12:10 p.m., food service worker 1 (FSW 1) was wearing gloves and taking food temperatures at the lunch tray line. While moving from a movable cart to the tray line, a clipboard containing the temperature logs fell on the floor, and FSW 1 picked up the clipboard and placed it back on the cart. Without performing hand hygiene or changing gloves, FSW 1 continued to take food temperatures, such as mashed potatoes, pureed food and food held in a hot holding cart, until completion of the task. During an interview on 8/21/24, at 12:45 p.m., with RD 1, RD 1 stated kitchen staff were expected to change gloves and wash hands with soap and water after contamination by dirty surfaces such as the floor. During a record review of facility Policy and Procedure (P&P) titled, Sanitation and Infection Prevention/Control Hand Hygiene, dated 1/24, the P&P indicated in the food & nutrition services department: all associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: after any other activity that may contaminate the hands. A review of the FDA Food Code, dated 2022, indicated staff wash hands after activity that may contaminate the hands.

Based on interview and record review the facility failed to ensure safe use of antibiotic eye medication called erythromycin ophthalmic (eye) ointment (ointment a smooth oily preparation mixed with antibiotic to treat eye infection) for ongoing long-term use in one out of five residents reviewed for unnecessary medication (Resident 36). This unsafe practice could contribute to ineffective use of antibiotic for an unapproved indication and risk of antibiotic becoming ineffective with long term use. Findings: During a record review of Resident 36's electronic medical record, titled MAR Report (MAR stands for Medication Administration Record; a document used by nursing staff to document orders carried out based on doctor's order), dated 8/21/24, the record indicated an order for eye medication called erythromycin as follow: erythromycin (Romycin, another name for antibiotic) 5 mg/gm (0.5%) [mg stands for milligram and gm stands for gram as measure of weight, and % stand for percent as measure of potency] ophthalmic ointment: Freq (Frequency of use) 2 times daily; Route: Both eyes; Start 4/8/24 . End: 4/8/25. The order in the MAR did not have a specific duration of use or an indication for use of antibiotic in the eyes. Review of Resident 36's electronic medical record, signed by Medical Doctor 2 (MD 2), dated 7/29/24, the record by eye specialist indicated resident had previous eye surgeries and was treated with multiple eyes drops for glaucoma (a chronic eye disease that damages the nerves, which connects the eye to the brain) and its complications. The record further indicated Resident 36 had an eye condition called Dry Eye Syndrome (an eye condition that occurs when the eyes didn't produce enough tears, or the tears didn't work properly to provide lubrication for the eyes) and treated by artificial tears (a type of eye drop that mimicked the lubrication of natural tears) and erythromycin eye ointment. Efforts to get a hold of MD 2 via phone was unsuccessful during the Department's survey. During a concurrent record review and interview with Medical Doctor 1 (MD 1), the primary physician caring for Resident 36, on 8/21/24, at 1:21 PM, at facility's nursing station for B1 unit, MD 1 stated the eye specialist ordered resident's eye medicines. MD 1 reviewed the most recent progress note by MD 2 on 7/29/24 and confirmed the antibiotic ointment was used as lubricant. MD 1 could not find an active order for artificial tears as noted in the eye specialists' note. MD 1 stated long term use of eye antibiotic could contribute to resistance (means antibiotic no longer worked on the bugs) not to the extent of an antibiotic given by mouth. MD 1 was not sure why the artificial tears eye lubricant was not listed as an order to be administered to Resident 36. During an interview with facility's Consultant Pharmacist (CP), on 8/22/24, at 11:26 AM, the CP stated she tracked antibiotic use in the facility part of Antibiotic Stewardship Program (or ASP, a set of coordinated approaches to improve how antibiotics were prescribed for the right diagnosis, dose, and duration, and only when needed. This helped minimize the spread of antibiotic resistant). The CP stated she didn't realize how long the eye antibiotics was used when she last reviewed the Resident 36's record. The CP stated the eye specialist and infection disease doctor should have consulted to assess continuation of long-term use of eye antibiotic. The CP stated she could not find a standard of practice or publication that supported long term use of the eye antibiotic as a lubricant. Review of the facility's policy, titled Medication Therapy, dated 4/2007, the policy indicated Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. The policy further indicated . the staff and practitioner (assisted by consultant pharmacist) will review an individual's current medication regimen, to identify whether: a. there is a clear indication for treating that individual with medication; . c. the frequency of administration and duration of use are appropriate . Review of erythromycin ophthalmic ointment via online drug information site called UpToDate LexiDrug, last accessed on 8/27/24, the drug monograph (a scientific document that provides factual information about a drug product) indicated the labeled indication for use was Ocular infections (ocular the eye; infection on the surface of the eye). The drug monograph under Warning/Precautions: Concerns related to adverse Effects indicated Prolonged use may result in fungal or bacterial superinfection (new infection occurring after or on top of an earlier infection with continued use of antibiotic).

Based on observation, interview, and record review the facility failed to ensure safe practices on storage and handling of the hazardous medications (or HD, Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in three out of six medication carts with resident census of 106 based on CDC's (Centers for Disease Control and Prevention, a federal agency leading the science-based, data-driven, service organization that protects the public's health) National Institute for Occupational Safety and Health (NIOSH a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines. The unsafe storage and handling of hazardous medications could pose health risk to staff and residents. Findings: 1. During a concurrent observation and interview with Licensed Nurse 2 (LN 2), on 8/19/24, at 10:40 AM, in the facility's B2 unit, the Medication Cart 2 stored multiple medications labeled by pharmacy as Hazardous Material with a black and white strip as part of prescription label. Further observation indicated a bottle of drug called megestrol tablet (or Megace, a type of hormone used to treat cancer or stimulate appetite) was stored inside an individual zip lock plastic bag with a large yellow [NAME] to handle safely Observe safety precautions for handling and administration. The medication cart additionally stored other labeled hazardous material drugs including finasteride (a hormone used to treat enlarged prostate) and tofacitinib (a drug belong to class of drugs called tumor necrosis factor blockers, suppressed immune system, and used to treat sever arthritis) that were not contained inside a zip lock bag to prevent the accidental exposure during medication storage and handling. LN 2 stated she was not sure why some bottles were in a hazard bag, and some were not. 2. During a concurrent observation and interview with Licensed Nurse 3 (LN 3), on 8/19/24, at 11 AM, in facility's B2 unit, the Medication Cart 1 stored multiple medications labeled by pharmacy as Hazardous Material on the body of the prescription label. Further observation indicated a bottle of drug called methotrexate in tablet form (a drug used to treat cancer and severe arthritis) was stored inside an individual zip lock plastic bag with a large yellow warning to handle safely Observe safety precautions for handling and administration. The medication cart additionally stored other labeled hazardous material drugs including colchicine tablet (drug used to treat pain associated with [NAME] arthritis), Dilantin (or Phenytoin, used to treat or prevent seizure in the brain; Seizure a disease that caused temporary burst of uncontrolled electrical activity in the brain leading to loss of conscious and body movement) in capsule form, and Liquid bottles of megestrol. LN 3 stated the yellow hazard bag alerted the nurse to use gloves when handling the drug. 3. During an inspection of the facility's Medication Cart 2, at Unit B3, on 8/19/23, at 2:54 PM, accompanied by Licensed Nurse 7 (LN 7), the cart stored a bottle of drug called megestrol tablet stored inside an individual zip lock plastic bag with a large yellow warning to handle safely Observe safety precautions for handling and administration. Further observation indicated storage of hazardous drugs without protective covering including oxcarbazepine bottle of pills (drug used to treat Seizure), Divalproex bottle of pills (or Depakote, a seizure drug also used for treating mood swings) which was not labeled as Hazardous in the body of the label, and Dilantin (or phenytoin drug used to treat seizure) liquid bottles with yellow color spills on the outer surface of the bottle. In an interview with Director of Nursing (DON), on 8/22/24, at 12:49PM, the DON stated the inconsistent storage of hazardous drugs for safe handling could be pose safety to staff who used the medication cart every day. The DON stated the facility relied on pharmacy to provide consistent method of highlighting the risks and safe containment. The DON stated pharmacy should put all of the hazardous drugs in a protective bag for safe use and handling. The DON stated the nurses should use gloves and whatever needed per policy. The DON stated having hazardous med in the hazard bag helped the nurses to recognize them for safer handling in addition to use of protective gloves. Review of facility's undated policy, titled Policies and Procedures for Safe handling of Hazardous Drugs, the policy under purpose indicated The policies and procedures within this document are designed to establish safe handling of hazardous drugs (HD's) for the healthcare worker at this facility and to provide guidance to create a safe, consistent method for receipt, storage, preparation, administration and disposal of hazardous drug. The policy on objective section indicated To ensure that the staff at this LTC (Long Term Care) nursing facility handle all hazardous drug according to procedures in this document or to state or federal regulation, whichever is stricter. The policy on receiving section indicated Yellow HD Caution: Hazardous Drug auxiliary labels should be affixed by pharmacy personnel receiving medication to manufacturers packaging prior to transportation to storage. The policy on storage section indicated HDs shall be stored in a manner that prevents spillage . Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, last accessed on 8/27/24 via https://www.cdc.gov/niosh/docs/2023-130/default.html, the document indicated Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Review of the clinical guidelines from American Society of Health-System Pharmacists (ASHP serves as a collective voice on issues related to medication use and public health), titled ASHP Guidelines on Handling Hazardous Drugs, last accessed on 8/24/24 via https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/handling-hazardous-drugs.ashx , the guideline indicated Drugs that have been identified as requiring safe handling precautions should be clearly labeled at all times during their transport, storage, and use . The document indicated NIOSH categorized hazard level to three groups: Group 1 hazard level included antineoplastic drugs (cancer drugs) and Group 2, and Group 3 were non-antineoplastic hazardous drugs including reproductive risks (ability to have healthy children). Review of the facility provided NIOSH list of hazardous drug, and comparative review of the drug information website called UpToDate Lexidrug, last accessed on 8/27/24, the documents indicated Megace (or megestrol) was on Group 1 of hazardous drugs while tofacitinib, Dilantin, and oxcarbazepine were listed in the Group 2 of hazardous drugs and finasteride and colchicine were listed in the Table 3 of the NIOSH hazardous drug with recommendation Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal.

Based on observation, interview, and record review the facility failed to ensure safe storage practices for medications and medical supplies stored in medication carts, treatment cart and refrigerators with census of 106 when: 1. Medication Cart 2 in Unit B2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems) and opened packets of a skin patch called lidocaine topical system (or Ztlido, a numbing agent used to treat pain). 2. Medication refrigerator in Unit B2 medication room stored unlabeled prescription medication called CathFlo (or alteplase, medication used to unclog Intravenous (IV, into the Vein) line by dissolving the blood clots) and two boxes of suppositories (drug inserted in rectum) called bisacodyl (a bowel laxative) and acetaminophen (pain drug) that did not require refrigeration based on manufacturer recommendation. 3. Treatment Cart in Unit B4 stored unlabeled prescription drugs called Santyl (a topical product used to remove dead tissue from wounds so they can start to heal), tubes of Triamcinolone 0.1% cream (%, or percent and measure of potency), opened wound care supplies and expired bleach product in active storage areas. 4. Medication refrigerator in Unit B3 was unlocked and stored outdated medications including Flu vaccine, an antibiotic liquid medication called vancomycin (used to treat stomach infection) and undated antibiotic liquid bottle called Cephalexin (or Keflex- used to treat infection). These failed practices could contribute to unsafe and spoiled medication use in the facility. Findings: 1. During a concurrent observation and interview with Licensed Nurse 2 (LN 2), on [DATE], at 10:40 AM, in the facility's B2 unit, the Medication Cart 2 stored an inhalation medication called DuoNeb out of its foiled wrap. The product label on the foil box indicated Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week. The Medication Cart 2 contained two opened packets of a topical drug called lidocaine in the active storage areas. The packets did not have resident name, date, and time it was opened. LN 2 acknowledged the findings and stated the patch was refused by resident. 2. During a concurrent observation and interview with Registered Nurse 1 (RN 1), on [DATE], at 12:18 PM, in facility's medication room at unit B2, the refrigerator inside the medication room stored one vial of CathFlo with no label or resident's name on it. Further inspection indicated bisacodyl and acetaminophen suppository boxes were stored in the refrigerator door. The label on bisacodyl product box indicated to Store at 20 to 25 degrees Celsius (,d+[DATE]-degree Fahrenheit) (Celsius and Fahrenheit are temperature scales) and the label on acetaminophen indicated store at ,d+[DATE] degree Celsius (,d+[DATE] degrees Fahrenheit) or in a cool place. RN 1 acknowledged the findings. 3. During a concurrent observation and interview with Licensed Nurse 5 (LN 5), on [DATE], at 2:48 PM, in facility's B4 unit, the Treatment Cart stored unlabeled and used prescription medications and expired supply for wound care in the active storage areas as follow: a. One Santyl ointment 30 gm tube (gm is gram, a measure of weight) with no resident label and partially used. b. Two Triamcinolone 0.1% cream 80 gm tubes marked Rx Only (means prescription drug), with no resident label and partially used. c. Opened and unwrapped packet of a wound care supply called Hydrogel colloidal Sheet with Leptospermum Honey; MEDIHONEY; the packet was marked Do not re-use and indicated a sterile product. d. An opened bottle of a liquid product called Sodium Hypochorite (same as bleach) had manufacturer expiration date on the bottle for ,d+[DATE]. LN 5 acknowledged the findings. 4. During a concurrent observation and interview with Licensed Nurse 6 (LN 6), in the facility's B3 medication room, the medication refrigerator was placed on the ground floor and unlocked. Further observation indicated storage of outdated flu vaccine and undated antibiotic as follow: a. One box of influenza Vaccine (or Flu vaccine) had expiration date of [DATE]. b. One amber color bottle of vancomycin oral solution (antibiotic to treat gut infection) marked as expired on [DATE]. c. Two bottles of liquid antibiotic called cephalexin 250mg/5mL (antibiotic used to treat various infections; the powder product mixed with water prior to dispensing; mg is milligram and mL is milliliter, a measure of dosage and volume) did not have date of reconstitution (date that powder mixed with water). The label on the bottle indicated discard after 14 days. LN 6 acknowledged the findings. In an interview with Pharmacy Supervisor (RX-S), on [DATE], at 11:15 AM, in the B3 hallway, the RX-S stated the pharmacy conducted floor inspection (checking medication storage areas in the facility) on monthly basis and report given to nursing leadership for review. In an interview with Director of Nursing (DON), on [DATE], at 9 AM, the DON stated the medication storage areas were regularly checked for outdates by pharmacy. Review of facility's policy, titled Labeling of Medication Container, dated ,d+[DATE], the policy indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . Labels for individual containers shall include all necessary information, such as the resident's name, . The expiration date when applicable . The facility did not provide medication storage policy.

Based on observation, interview, and record review, the facility failed to ensure staff followed policies and procedures designed to prevent infection in two out of 12 residents observed for medication administration observation and blood sugar testing (Resident 81 and Resident 407) when: 1. For one of 12 residents (Resident 81), Licensed Nurse 1 (LN 1) failed to clean the pill cutter (an instrument used to cut pills to provide an accurate dose) before and after use or practice hand hygiene. 2. For two of 12 residents (Resident 81 and Resident 407), Licensed Nurse 1 (LN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use based on standards of practice and facility's policy. These failures had the potential to cause infection or spread infection in the facility. Findings: 1. During an observation on 8/20/24, at 11:30 AM, Resident 81 required a pain medication called hydromorphone (or Dilaudid, an opioid pain medication) in 2mg dosage in pill form (mg is milligram, a unit of measure). LN 1 retrieved a 4 mg pill from narcotic storage in the med medication room. LN 1 removed the pill from the packaging without hand hygiene and placed the pill in the pill cutter. The pill cutter was observed to have residue/powder present before the current med medication administration. LN 1 placed one half pill in a medication cup and the other half pill in another cup inside the medication cart drawer. LN 1 did not clean the pill cutter after use. 2. During an observation on 8/20/24, at 11:40 AM, Resident 81 required blood sugar testing by finger stick before lunch. After retrieving the glucometer from the medication cart drawer, LN 1 scanned the blood sugar test strip package. LN 1, without hand hygiene, took the pain medication, test strip, and blood sugar monitor (glucometer) to the room marked as Enhanced Barrier Precaution (means it required special prevention means before performing certain type of physical bodily care). LN 1 did not clean the blood sugar machine (glucometer) before entering Resident 81's room. LN 1 placed the glucometer on Resident 81's bedside table and administered the pain medication. LN 1 then performed finger stick with poking the Resident 81's index finger with a lancet (a thick and long needle used to puncture the fingertip to get blood drop) to get blood drop for the test. LN 1 completed the blood sugar check and left the room. LN 1 using the same glove wiped the glucometer's outer surface quickly for less than 10 seconds with one Sani-Cloth wipe (facility's sanitization choice for killing germs on the resident care devices). LN 1 then walked to the nursing station to put the glucometer in its docking station to transmit the information into the computer. LN 1 then proceeded to next Resident 407 for blood sugar measurement using the same glucometer. LN 1 with gloved hand added the test strip to the glucometer and went into the room with lancet (a sharp point or needle that used to poke finger to get drops of blood), alcohol wipes and Sani-Cloth wipe. LN 1 poked the left middle finger and squeezed it to get blood to soaking the test strip. LN 1 placed the glucometer on top of bedside table while poking the finger for blood drop. LN 1 soaked the test strip with blood to get the blood sugar number. LN 1 used the same glove to quickly clean the outer surface of the glucometer with one Sani-Cloth wipe for less than 10 seconds. In an interview with Director of Nursing (DON), on 8/20/24, at 2:31 PM, the DON stated she expected nursing staff to clean the shared glucometer before and after each resident use. The DON stated the nursing staff should wipe all external surfaces of glucometer for one minute to keep the surface wet according to required contact time of the 2 minutes. Review of the facility's preferred sanitization wipe called Sani-Cloth (a germicidal disposable wipe), reviewed on 8/20/24, the product information on its packet indicated Cleaning Procedure: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by germicidal wipe. Open, unfold and use first germicidal wipe to remove visible soil . The second germicidal wipe to thoroughly wet surfaces. Allow surface to remain wet for two (2) minutes. Let air dry. During a review of the facility policy and procedure titled, Cleaning and Disinfecting Non-Critical Resident Care Items, dated June 2011, the policy indicated Reusable items are cleaned and disinfected or sterilized between residents. During a review of the facility policy and procedure titled, Point of Care Blood Glucose (sugar) Testing, dated April 2023, the policy indicated glucometers were to be cleaned after every patient use, when soiled and at least once per day routinely. A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, dated August 2015, indicated that hand hygiene should be performed before and after direct contact with residents, before preparing or handling medications, after contact with resident intact skin or blood, and after contact with medical equipment. During an interview on 8/22/24, at 12:30 PM, with Registered Nurse/Clinical Instructor (RN/CI), the RN/CI stated annual skills competency evaluation had to be completed every year on the same month of original hire date. RN/CI stated the annual skills competency evaluation for infection control practices had not started for this year yet. During a review of the facility's RN/LVN Annual Skills Competency Checklist, the following skills were indicated as being included in the annual competency checklist: B. Safety/Infection Control: Universal Precaution, Enhanced Standard Precautions, Transmission-based Precautions, Hand Hygiene guidelines, Donning & Doffing of PPE .

Based on observation, interview and document review, the facility failed to ensure the facility had a medication error rate of less than 5 percent when nursing staff failed to follow physician orders for administration of medication for two of eight sampled residents (Resident 89 and Resident 231) during medication pass: Resident 89 did not receive an ordered blood test before meals and Resident 231 did not receive the correct dosage of medication during medication pass. The failure to follow medication administration instructions during two of 28 opportunities of medication administration resulted in an error rate of 7.1 percent. Findings: 1. During a review of Resident 89's Minimum Data Set (MDS-an assessment tool to direct care), dated 7/24/23, the MDS indicated Resident 89 had a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). The MDS also indicated Resident 89 received an injection of insulin on seven of seven days in the assessment look-back period. During a review of Resident 89's July physician orders, the physician order start date 5/15/23, indicated the following sliding scale (dosage to vary by level of blood glucose) dosage of seven units of insulin for a blood glucose reading of 201-250 was to be administered by injection before the meal. The physician order indicated Resident 89 was to have a blood glucose test before each meal. During an observation on 7/26/23 at 12:51 p.m., Licensed Vocational Nurse 1 (LVN 1) took a blood glucose sample for Resident 89 as he began to eat his lunch. LVN 1 stated Resident 89's blood glucose reading was 201. LVN 1 stated Resident 89 was on a sliding scale for insulin administration. LVN 1 stated she did not want to bother the resident with an injection in the middle of his meal and would give his insulin later. 2. During a review of Resident 231's MDS dated [DATE], the MDS indicated Resident 231 had a diagnosis of seizure disorder. (Seizures are the result of abnormal electrical impulses in the brain, and can result in sudden, violent, irregular movements of a limb or the body.) During a review of Resident 231's July physician orders, start date 7/21/23, indicated an order for 1000 milligrams (mg) of oral Keppra (an anti-seizure medication) twice a day. During a medication pass observation and concurrent interview on 7/26/23 at 8:51 a.m., LVN 1 poured five milliliters (mLs) of liquid Keppra into a medication cup for Resident 231 and Resident 89 drank the medication. LVN 1 stated the label on the Keppra bottle indicated a concentration of 500 mg of Keppra for each 5 mLs of liquid. LVN 1 stated the Keppra was to prevent seizures. During a follow-up interview on 7/26/23 at 1:00 p.m., LVN 1 stated she had administered 5 ml of Keppra to Resident 231, which was only a 500 mg dose. LVN 1 stated Resident 231 should have received a 1000 mg dose. During a concurrent interview and observation of Resident 231's physician orders and Keppra bottle label on 7/26/23 at 1:04 p.m., with the Infection Preventionist (IP), the IP stated Resident 231's Keppra medication label indicated a concentration of 500 mg per 5 mLs of liquid. The IP stated Resident 231's order was for 1000 mg of Keppra, which would be 10 mLs of liquid.

Based on observations, interviews, and document reviews, the facility failed to ensure staff followed policies and procedures designed to prevent infection and spread of infection when: 1. For two of five unsampled residents (Resident 105, Resident 229), a Licensed Vocational Nurse (LVN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use. 2. For one of four sampled residents (Resident 83) with wound care issues, LVN 1 stored clean wound care supplies in a resident room and failed to discard a bottle of normal saline (NS, salt-water solution) used for wound irrigation opened inside the resident room. These failures had the potential to cause infection or spread infection for Residents 105, 229, and 83. Findings: 1. During an observation and concurrent interview on 7/26/23 at 12:37 P.M., with LVN 1, LVN 1 brought the blood glucometer to Resident 105's bedside. LVN 1 placed the blood glucometer on Resident 105's bed sheet as she collected a blood sample onto a test strip, placed the test strip sample in the blood glucometer, and discarded the test strip sample after obtaining the blood glucose value. LVN 1 picked up the blood glucometer using gloved hands, walked to the exit door, removed her gloves, placed the glucometer in her armpit, sanitized her hands, then carried the glucometer out of the room and placed it on top of the nursing medication cart. After collecting supplies, LVN 1 donned gloves, carried the glucometer, without intervening cleaning of the glucometer, toward Resident 229's room. When asked when the glucometer needed to be cleaned, LVN 1 stated the glucometer needed to be cleaned when it had visible blood on it. LVN 1 stated she did not see visible blood on the blood glucometer now. LVN 1 entered Resident 229's room and placed the glucometer on Resident 229's overbed table, collected a blood sample on the test strip, placed the sample test strip in the glucometer, read the result, picked up and carried the glucometer to a counter by the exit, and directly placed the glucometer on the counter. LVN 1 doffed her gloves, sanitized her hands, donned gloves, and cleaned the glucometer without sanitizing the counter or Resident 229's overbed table. During an interview on 7/26/23 at 1:04 P.M., the Infection Prevention (IP) nurse stated the blood glucose machine should be cleaned before and after each resident's use. During a review of the facility's policy and procedure (PNP) titled, Obtaining a Fingerstick Glucose Level, revised date October 2011, the PNP indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 36087 2. A review of Resident 83's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/15/23, indicated Resident 83 had a diagnosis of dementia (memory loss). A review of Resident 83's Physician Order, dated 7/13/23, indicated, Cleanse Sacral (the spinal area between the lower back and tailbone) wound with normal saline (NS, used to clean wounds), pat dry .Pack loosely with plain packing strip (thin strips of material used to fill deep pockets in wounds), adding wound gel (ointment for the wound). Cover with Mepilex (bordered foam dressing that is moisture-proof and bacteria-proof) dressing . During a concurrent observation and interview on 7/27/23, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 83's room, LVN 1 completed Resident 83's wound care. LVN 1 opened Resident 83's bedside nightstand bottom drawer and placed the newly sanitized scissors inside the drawer. The bottom drawer also contained a box with several sealed gauze dressings, an opened bottle of plain packing strips, and a roll of paper tape. LVN 1 stated she stored Resident 83's wound care supplies, including the sanitized scissors, dated opened bottles of NS, bottle of plain packing strip, and paper tape inside Resident 83's nightstand bottom drawer between treatments. During an interview on 7/28/23, at 9:20 a.m., with the Infection Preventionist (IP), the IP stated wound care treatment supplies were stored in the treatment cart and clean supply room. The IP stated Licensed nurses (LN) were expected to gather sufficient supplies for each individual resident treatment to the resident bedside, and not store supplies inside the resident room due to safety and infection control concerns. The IP stated open bottles of NS brought into a resident's room should be discarded after opening due to risk of infection. A review of the facility's policy and procedure (P&P) titled, Wound Care, revised October 2020, the P&P indicated, .Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening .Wipe reusable supplies with alcohol as indicated .Return reusable supplies to resident's drawer in treatment cart. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart . A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Implementing interventions to reduce accident risks and hazards shall include the following .safety items and approaches for sharp items .

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 72) was treated with dignity and respect when a Certified Nursing Assistant 1 (CNA 1) failed to provide visual privacy during provision of care for ADLs (activities of daily living such as personal hygiene, bathing, dressing, toileting). The failure to fully enclose Resident 72's bed by use of the privacy curtain had the potential to result in public exposure of Resident 72's body during provision of care and cause emotional distress. Findings: A review of Resident 72's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/9/23, the MDS indicated Resident 72 was totally dependent on the assistance of one staff person for ADLs. The MDS indicated Resident 72's vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects), was sometimes able to make himself understood, and sometimes able to understand others. During a concurrent observation and interview on 7/24/23, at 10:50 a.m., with Certified Nursing Assistant 1 (CNA 1), in the doorway outside Resident 72's room, Resident 72's bed was in a fully occupied four-bed room with Resident 72's bed on the side of the room nearer to the hallway and door. Resident 72's left side was visible from the hallway through a two-foot gap created when the privacy curtain was not pulled to the wall for complete enclosure at the foot of the bed. Resident 72 lay flat in bed with no clothing on above the hips while CNA 1 assisted Resident 72 with a bed bath. When asked about the privacy curtain gap, CNA 1 stated the privacy curtain should enclose the bedside to provide visual privacy. During an interview on 7/26/23, at 1:01 p.m., with the Director of Nursing (DON), the DON stated nursing staff should provide resident's privacy during ADL care, either by pulling the cubicle curtain completely around the resident bed or by closing the door in a room occupied by one resident. A review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, revised August 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .Resident shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised May 2022, the P&P indicated, Privacy will be provided using items such as cubicle curtains and closing room doors if needed .

Based on observation, interview, and record review, the facility failed to protect three of three (Resident 1, Resident 2, Resident 3) sampled residents when the facility failed to provide adequate supervision for Resident 2 and to implement the intervention of closing resident room doors to prevent altercations resulting from Resident 2 ' s behaviors of threatening others and wandering. This failure resulted in Resident 2 entering the shared room of Resident 1 and Resident 3 through an open door, yelling at both residents causing psychological distress, and hitting Resident 1 in the face, causing a painful, swollen facial bruise which lasted several days. This also had the potential to result in injury to Resident 2, whose wandering behaviors placed him at risk of altercations with other residents. Findings: A review of Resident 1's face sheet dated 10/5/22, indicated Resident 1 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 8/9/22, indicated Resident 1 had a Brief Interview for Mental Status score of 15. (BIMS, a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 1 needed extensive to total assistance from one person for bed mobility, and transfer between surfaces. A review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 had been in the facility for more than five years with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 3 had a BIMS score of 15. The MDS indicated Resident 3 required extensive assistance from one person for bed mobility, and total assistance from at least two people to transfer between surfaces. The MDS indicated Resident 3 used a wheelchair for locomotion. A review of Resident 2's face sheet dated 10/5/22, indicated Resident 2 was admitted in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 was unable to complete a BIMS exam due to severe memory and attention deficits. The MDS indicated Resident 2 had behavioral problems of daily wandering that significantly intruded on the privacy and activity of others, exhibited verbal, and other symptoms towards others such as threatening, screaming, cursing at others, throwing food and bodily wastes. The MDS indicated Resident 2 required supervision and/or limited assistance for bed mobility, transfer between surfaces, and walking in corridors. A review of Resident 2 ' s Interdisciplinary team (IDT) progress note dated 6/9/22, indicated the IDT recommended staff provide supervision for Resident 2 from a distance, and allow Resident 2 to ambulate in the hallways, with all other resident room doors closed while Resident 2 ambulated. A review of Resident 2 ' s care plan titled, Behavior Problem, dated 7/1/22, and 7/12/22, indicated Resident 2 had behavioral issues of wandering, hallucinating, verbal and physical arguments towards staff, pulling the hair of a staff member who tried to redirect the patient on 6/22/22, and hitting another resident with towel on 7/8/22. The care plan ' s interventions included for staff to redirect the resident during episodes of inappropriate behavior, to close the doors of other resident rooms when Resident 2 was walking up/down the hallway, and to approach Resident 2 with a calm, relaxed voice and give instructions to direct him to his room. A review of Resident 2 ' s care plan titled, Wandering Behavior, dated 8/2/21, indicated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wandering care plan interventions included for staff to provide structured and supervised walking activities, and for staff to frequently monitor Resident 3. A review of Resident 2 ' s progress notes dated 8/10/22, indicated Resident 2 had wandered into a resident room (Room A) and threatened to kill a resident in Room A. A review of Resident 2 ' s physician notes dated 8/17/22, indicated Resident 2 had ongoing agitation and had physically attacked staff and other patients. A review of Resident 2 ' s progress notes dated 8/29/22, indicated Resident 2 had wandered into Room A again, grabbed the forearm of the resident in the room, and became verbally and physically combative with responding staff. During a concurrent observation and interview on 10/25/22, at 9:16 a.m., with Resident 1 in the shared room of Resident 1 and Resident 3, Resident 1 lay in bed with the head of the bed elevated; there were no discolored areas or visible injuries on Resident 1 ' s face. Resident 1 stated Resident 2 had wandered into his room uninvited on many occasions, but one day last month, Resident 2 had entered his room and yelled he was going to fight Resident 1. Resident 1 stated he told Resident 2 to leave his room, and Resident 2 came to Resident 1 ' s bedside, pushed over Resident 1 ' s bedside table, hit Resident 1 on the left side of his face, and then went to the foot of the bed and started shaking Resident 1 ' s feet. Resident 1 stated he yelled for help and pulled the emergency cord, and Resident 2 left his bedside and went to the bedside of his roommate, Resident 3, and started yelling until staff removed him from the room. Resident 1 stated he had been afraid during the incident, and he had a painful, swollen bruise on the left side of his face for several days afterwards. During an interview on 10/28/22 at 3:35 p.m., with Resident 3, Resident 3 stated he had been in bed in his room on 9/13/22, when Resident 2 entered his room threatening and cursing Resident 1. Resident 3 stated he heard a noise from behind the privacy curtain separating Resident 1 and Resident 3 which sounded like someone being hit. Resident 3 stated Resident 2 then came to his bedside and started shouting he wanted out. Resident 3 stated he felt helpless and was worried for his safety because he was unable to move without assistance. During a concurrent observation and interview on 10/25/22 at 10:30 a.m., with Resident 2, in Resident 2 ' s room, Resident with his eyes closed, lay in bed covered by a blanket; a staff member was seated nearby. When the staff member called Resident 2 by name, Resident 2 sat up. When asked if he had any problems with anyone, Resident 2 stated he had not hit anyone. During an interview on 10/27/22 at 5:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she had been administering medications on 9/13/22, when she heard screams and calls for help from Resident 1 ' s room. RN 1 stated she went into Resident 1 ' s room, and saw Licensed Vocational Nurse 1 (LVN 1) with Resident 1, who had a swollen area on his face. RN 1 stated she redirected the still combative Resident 2 out of the room. RN 1 stated the door to the shared room of Resident 1 and Resident 3 had been open, as all the residents ' doors were kept open for safety checks, unless there were infection control precautions in place. During an interview on 10/28/22, at 3:00 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she had been working down the hall from Resident 1 ' s room on 9/13/22, when she heard screams and saw a flashing call light above the door to Resident 1 ' s room. CNA 2 stated she responded to the calls and entered Resident 1 ' s room through the open door. CNA 2 stated she saw RN 1 handing an icepack to Resident 1, while LVN 1 was with Resident 2. CNA 2 stated the resident room doors were always kept open. During an interview on 10/28/22 at 3:30 p.m., with LVN 1, LVN 1 stated she had been administering medications on 9/13/22, when she heard screams and saw a flashing call light from Resident 1 ' s room. LVN 1 stated when she went into Resident 1 ' s room, Resident 2 was standing by the window, and Resident 1 was in bed. LVN 1 stated she noticed Resident 1 had swelling on the left side of his face. During an interview on 10/28/22 at 4:00 p.m., with the Director of Nursing (DON), the DON stated during the IDT meeting in June 2022, the IDT recommended staff allow Resident 2 to walk in the hallways with supervision from a distance while the other residents ' room doors were kept closed.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1 with her own clean clothes to wear according to her preferences. The failure to provide laundry services for Resident 1's dirty clothes resulted in Resident 1 crying due to emotional distress from not having her own clean clothes to wear for a routinely scheduled appointment at a public clinic for [CONDITION(S)] (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood). Findings: A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 5/15/22, indicated Resident 1 had a diagnosis of [CONDITION(S)] (kidney failure). The MDS indicated Resident 1 was able to understand others and be understood. The MDS indicated Resident 1 required extensive assistance from one person for dressing and used a wheelchair for locomotion. A review of Resident 1's Annual MDS dated [DATE] indicated it was very important to Resident 1 to choose what clothes she wore. A review of Resident 1's Physician Order, dated 5/23/22, indicated Resident 1 was scheduled for [CONDITION(S)] three times a week on Tuesday, Thursday, and Saturday. The order indicated Resident would be transported to and from the clinic by a contracted transporter, with a pick-up time from the facility to [CONDITION(S)] at 12:45 p.m. During an interview on 7/1/22, at 10:50 a.m., with Resident 1, Resident 1 stated none of her own pants were clean to wear for her [CONDITION(S)] appointment on 6/28/22. Resident 1 stated she was offered some other pants to wear, but she did not want to wear someone else's pants. Resident 1 stated she was upset and embarrassed when she had to go to the [CONDITION(S)] clinic wearing no pants, just an adult brief and a blanket available to cover her lower body. During an interview on 7/1/22, at 12:40 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 6/28/22, around 9 a.m., Resident 1 had no clean pair of pants to wear for her [CONDITION(S)] appointment. CNA 1 stated Resident 1 only had four sweaters, a few throws, and a bag of unwashed clothes on a shelf inside the resident's closet. CNA 1 stated the dirty laundry had not been picked up, so Resident 1 did not have any clean pants of her own to wear that day. During a telephone interview on 7/5/22, at 8:34 a.m., with [CONDITION(S)] Clinic Administrator (DC ADM), DC ADM stated Resident 1 arrived at the clinic upset and crying on 6/28/22, wearing just a shirt, adult briefs, and no covering of her lower body. During a telephone interview on 7/11/22, at 2:50 p.m., with Laundry Aide (LA), LA stated he worked Monday thru Friday. LA stated he gathered residents ' soiled clothing in the morning between 7 a.m. and 7:30 a.m., and laundered the clothes, and returned them between noon and 1 p.m. the same day. LA stated he routinely checked inside resident closets for dirty clothes and was unable to provide an explanation for how Resident 1's bag of dirty clothes had not been gathered for laundering prior to her 6/28/22 [CONDITION(S)] appointment. A review of the facility's policy and procedure titled, Resident Rights, revised date December 2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a dignified existence; be treated with respect, kindness, and dignity . Retain and use personal possessions to the maximum extent that space and safety permit .

Based on interview and record review the facility failed to provide one resident (Resident 1) with written notice of discharge and appeal rights 30 days in advance or as soon as practicable before discharge and did not inform the ombudsman of Resident 1's discharge for eleven days. This failure resulted in Resident 1's unplanned discharge without preparation for discharge needs and prevented the ombudsman from assisting with Resident 1's discharge planning. Findings: A review of Resident 1's Patient Demographics sheet indicated Resident 1 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/30/21, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score of 15, an indication of unimpaired cognition. The MDS indicated Resident 1 used a wheelchair for locomotion. During an interview on 7/14/21, at 12:00 p.m., with the Director of Nursing (DON), the DON stated on 5/5/21, Resident 1 became verbally aggressive and advanced toward the DON in his wheelchair insisting the DON tell him the name of the staff person who had discarded his burrito. The DON stated she retreated as he continued advancing toward her, until she was able to enter her office, and closed the office door. The DON stated Resident 1 began hitting the office door, so the DON called law enforcement. The DON stated Resident 1's physician was in the building at the time of the incident on 5/5/21, and reviewed Resident 1's clinical records and determined Resident 1's no longer needed skilled nursing care. A review of Resident 1's facility Discharge Summary date of service 5/5/21 at 6 p.m. by Resident 1's physician, the Discharge Summary indicated, The patient presented obvious threat to the staff of this facility. Orders were written for discharge. During an interview on 7/14/21 at 12:30 p.m., with the Administrator (ADM), ADM stated on 5/5/21, by the time law enforcement arrived, Resident 1 was calm. ADM stated she proceeded to call Resident 1's emergency contact to arrange for his discharge to the home of the emergency contact, but Resident 1 refused to go to the home of the emergency contact. ADM stated Resident 1's belongings were packed up and he was given a list of medications and discharge instructions. ADM stated Resident 1 was picked up in the automobile of a family member. During an interview on 7/14/21 at 12 p.m., with the DON, the DON stated while Resident 1 waited for all his belongings to be picked up, she overheard Resident 1 call 9-1-1. The DON stated the facility had not given Resident 1 a 30 day advance written notice of discharge because the facility had not planned on discharging Resident 1 on 5/5/21, but had done so because of Resident 1's aggressive behavior. The DON stated the ombudsman had not been informed of the discharge until 6/16/21. A review of Resident 1's IDT (Interdisciplinary Team) Note on discharge date d 5/5/21, indicated, IDT met today to discuss resident's unplanned discharge to the community. A review of Resident 1's acute care hospital ED (emergency department) Provider Note date of service 5/5/21 at 8:55 p.m., the ED Provider Note indicated Resident 1 was in the ED after discharge from the skilled nursing facility for disruptive behavior. The ED Provider Note indicated the Plan was for either placement and a new facility or potentially return to the skilled nursing facility. The ED Provider Note indicated Resident 1 was not discharged back to the skilled nursing facility, but was discharged without treatment on 5/6/21 at 1:01 p.m.

Based on observation, interview, and record review, the facility failed to ensure one (Resident 1) of three residents' call lights were within reach for resident use, preventing Resident 1 from being able to notify staff for 30 to 60 minutes, that he needed suctioning to remove excess saliva. The failure to place Resident 1's air blow call light (a hands-free method used to activate a call light by blowing through a tube) within his reach resulted in physical and emotional distress and potentially contributed to a three-day hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility in July 2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/19/21, indicated Resident 1 had [CONDITION(S)] (a disorder of the brain and spinal cord). The MDS indicated Resident 1 was unable to move both sides of his upper and lower extremities and was totally dependent on assistance from one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 had a Brief Interview for Mental Status score of 15. (The Brief Interview for Mental Status, BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During an interview on 4/27/21 at 11:00 a.m., Resident 1 spoke in a voice slightly louder than a whisper and stated he had filed a police report after he was sent to the hospital. Resident 1 stated he filed the report because he had used his air blow call light to get assistance from staff because he felt like he was choking on his saliva. Resident 1 stated Certified Nursing Assistant 1 (CNA 1) came into the room, turned off the call light, moved the air blow call light out of Resident 1's reach and never asked what Resident 1 wanted and did not attend to his needs before CNA 1 left the room. Resident 1 stated he was upset and anxious as he struggled to reach the air blow call light. During a concurrent observation on 4/27/21 at 11:00 a.m., in Resident 1's room, Resident 1 blew into his air blow call light. When the call light was activated, a light was visible outside the resident's room above the door, and an audible alarm rang. A review of Resident 1's IDT (Interdisciplinary Team) Conference notes dated 4/6/21 at 10:01 a.m., indicated, [Resident 1] expressed a concern while at the acute hospital on 4/1/21 indicating that his call light was turned off by the staff. He asked the nurse to call the sheriff and report his concern. During an interview on 5/4/21 at 3:50 p.m. with CNA 1, CNA 1 stated he was assigned as the certified nursing assistant for Resident 1 on 3/31/21 during the evening shift (3 p.m. to 11:30 p.m.). CNA 1 stated the last time he saw Resident 1 that evening shift was at 10:30 p.m. CNA 1 stated at 11:10 p.m. the call light was on for the room shared by Resident 1 and Resident 2. CNA 1 stated he entered the shared room and went to Resident 2's bedside, but Resident 2 said he had turned on his call light for Resident 1. CNA 1 stated he turned off the television and left the room because Resident 1 had not asked for anything more. During an interview on 5/4/21 at 3:35 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she had been assigned to Resident 1 on 3/31/21 for the night shift (11 p.m. in the evening until 7:30 a.m. the next day). CNA 2 stated at the start of her shift on 3/31/21 at 11 p.m., she noticed Resident 1's call light was on and heard the call light's ring. She stated she told CNA 1 that Resident 1's call light was on and asked him to answer Resident 1's call light because she was busy with another resident. CNA 2 stated she noticed at 11:15 p.m., that Resident 1's call light was still on. CNA 2 stated she went into Resident 1's room to answer his call light and saw Resident 1 crying, with his air blow call light outside his reach. CNA 2 stated Resident 1 said he had been trying to call for assistance for an hour but had been ignored. During an interview on 7/7/21 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he had worked the 3/31/21 night shift. LVN 1 stated he noticed when he started his shift at 11:00 p.m., that the call light and audible alarm were activated for Resident 1's room. LVN 1 stated between 11:10 p.m. and 11:15 p.m., CNA 2 called him to Resident 1's room to assess Resident 1. LVN 1 stated Resident 1 told him Resident 1 had been trying to call someone for 30-60 minutes because he had been having difficulty breathing. LVN 1 stated he checked Resident 1's oxygen saturation (a measurement of oxygen in the blood expressed as a percentage, with 100 percent the maximum amount of oxygen possible), and found a low oxygen saturation reading of 90%. LVN 1 stated Resident 1 was sent to the hospital between 2 a.m. and 3 a.m. because of continued low oxygen saturation. A review of Resident 1's acute care hospital, Emergency Department Provider Note, date of service 4/1/21 at 3:55 a.m., indicated Resident 1 entered the emergency department with shortness of breath; a heart rate of 123 beats per minute (normal range of 60 to 100 beats per minute); respirations of 28 breaths per minute (normal range of 12 to 16 breaths per minute); and an oxygen saturation of 85% (normal range of 95% - 100%). A review of Resident 1's acute care hospital, Hospitalists' SNF/Rehab Discharge Summary, dated 4/3/21, indicated Resident 1 was admitted to the hospital on 4/1/21, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, for one of two sampled residents (Resident 1), the facility failed to protect Resident 2 from sexual abuse with Resident 1 went into Resident 2's room and placed Resident 1's hand on his exposed genitals. This failure had resulted in Resident 2 (a blind female resident) screaming for help and had the potential for further sexual harm from Resident 1 had he not exited the room upon Resident 2's screaming. Findings: Review of the facility's Summary of Investigation signed and dated 4/27/21 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary indicated Resident 1 had a behavior of Wandering in the hall, inviting staff into his bed and displaying hypersexual behaviors of manipulating his genitals in the hallway and often times in his room and while talking to staff. He is re-directable and responds to boundary setting by staff and is visually monitored by staff for his whereabouts . The summary indicated Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/1/21 indicted Resident 2 was oriented to person, place, time and situation. The summary also indicated, on 4/21/21, around 11:45 a.m., staff responded to Resident 2 screaming inside her room. The summary indicated, at the same time Resident 2 was heard screaming, staff saw Resident 1 coming out of Resident 2's room . During an interview with Resident 2 on 4/23/21 at 1:12 p.m., through a translator, Resident 2 stated, while Resident 2 was on the bed listening to the television, a male, who Resident 2 thought was one of the facility staff, entered the room went to the left side of the bed. Resident 2 stated, thinking it was a facility staff who wanted to check Resident 2's blood pressure, she motioned for the male to take her left hand for blood pressure check. Resident 2 stated, the man, took Resident 2's hand, but instead of checking Resident 2's blood pressure, placed it on the man's genitals which were already exposed out of his pants. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/23/21 at 1 p.m., LVN 1 stated, while walking towards the medication room, LVN 1 saw Resident 1 coming out of Resident 2's room. LVN 1 stated, at the same time, Resident 2 screamed for Unit Clerk (UC) to come to the room. LVN 1 stated, on the way to the medication room, LVN 1 saw UC going towards Resident 2's room to respond. LVN 1 stated, Resident 1 had displayed inappropriate sexual behaviors in the past. LVN 1 stated, Resident 1 chased female staff down the hallway and doesn't do anything but masturbate . During an interview with Registered Nurse (RN) 1 on 4/23/21 at 12:30 p.m. RN 1 stated, UC had told her, per Resident 2's account, a man had entered Resident 2's room, and made Resident 2 touch the man's genitals. RN also stated, that same day, 4/21/21, she heard from other female staff that Resident 1 had been displaying inappropriate sexual behavior in the days prior to incident that involved Resident 2. Review of Resident 1's Significant Event notes dated 2/28/21 indicated, Resident 1 had inappropriate sexual behavior. The notes indicated, Resident 1 wanders up and down the hallway, placing hands in front to pant[s], noted wiggling private area as he ambulates in hallway. Makes inappropriate sexual remarks to female nurses. Focus his eyes on backside of female staff as they ambulate up and down the hallway. Seen standing in front of nursing station, staring at female staff while groping on self . Resident observed standing few feet behind a Certified Nursing Assistant (CNA), with his hand down inside the front of his pant, wiggling his private part, moving hips side-to-side, front and back, in a circular motion as female CNA leans forward to return used breakfast tray to the cart. Told one female staff, to get inside the bed with him so, they can make babies. Review of Resident 1's Progress Notes dated 4/19/21 (2 days prior to 4/21/21 incident) indicated, Resident 1 had episodes of Wandering in the Unit's hallway trying to go to the female resident's room. Resident also has episode of inappropriate sexual gestures/behavior towards the staff; putting his hand inside his pants walking on the hallway trying to touch female staff saying I love you so much to staff, inviting them to his bed, trying to bump his frontal private area to the staff and coming behind their back. Review of Resident 1's Progress Notes dated 4/20/21 (a day prior to 4/21/21 incident) indicated, Resident 1 was alert, oriented x 1 (oriented to person, knows self and can recognize significant others but does not know the day, month, year and where he is and not aware of the situation). The notes indicated, [Resident 1] had inappropriate sexual behavior towards female staff in hall way. [Resident 1] is touching himself putting hands inside the pants. During interview with Director of Nursing (DON) on 4/23/21 at 11:30 a.m., DON stated, after the incident on 2/28/21 of Resident 1 exposing private area to female staff, facility implemented new intervention to re-direct Resident 1 to his room. DON stated, on 3/2/21, facility assigned a male CNA to Resident 1. Review of Resident 1's Behavioral Symptoms care plan with a start date 1/14/21 indicated the following interventions with the dates: 3/1/21- Redirect [Resident 1] to his room for privacy when needing to engage in masturbation. Close the privacy curtain and offer extra towels and cleaning supplies . 3/2/21- Assign Resident 1 to male CNA. During an interview with DON on 4/23/21 at 12:50 p.m., DON stated, after the incidents on 4/19/21 and 4/20/21, there were no new interventions implemented to protect female staff and residents from Resident 1's sexual inappropriateness. DON stated, Interdisciplinary Team (a group composed of individuals representing different departments at the facility) was not alerted as they should have been, and would be an opportunity to educate licensed nurses on communication. DON stated, after the 2/28/21 incident with female staff, Resident 1 had been on 4:1 supervision. During an observation with Assistant Director of Nursing (ADON) on 4/23/21 at 1:20 p.m., Resident 1 was in the hallway. Resident 1 suddenly stood up and was on the way to the bathroom when Resident 1 saw a female staff inside a resident room. Resident 1 placed his hands inside his pants and started making sexual gestures while looking at the female staff.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to develop and implement an effective discharge planning process for a safe discharge when Resident 1, who had cognitive impairment, was not provided with an appropriate form of transportation during discharge. This failure had resulted in elopement, when Resident 1 wandered away from the receiving facility after being dropped off at the curb. Resident 1 went missing on 3/1/21, from 6:30 p.m. until 1:10 a.m., the next day, 3/2/21. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Initial Discharge Planning Assessment-Care Manager dated 2/16/21 indicated Resident 1 was alert and oriented x1 (oriented to Person. The resident knows his name and can recognize significant others.) and had history of wandering at the facility where Resident 1 used to live. Resident 1's discharge plan was for transportation to be arranged during discharge. During a telephone interview with Director of Nursing (DON) on 5/19/21 at 11:03 a.m., DON stated an elopement risk assessment upon Resident 1's admission to the facility was completed on 2/12/21. DON stated Resident 1 was assessed as No Risk for Elopement as there was no history of elopement at the previous facility. DON stated she was not aware of the initial discharge planning assessment documentation that Resident 1 had history of wandering. During a telephone interview and concurrent review of Resident 1's Resident Care Conference dated 2/21/21 with Registered Nurse (RN) 1 on 5/19/21 at 11:15 a.m., RN 1 stated she participated in the Resident Care Conference. RN 1 stated Resident 1 was alert but forgetful and needed verbal cueing to be able to perform activities of daily living like eating. RN 1 stated Resident 1 was directable as long as a staff was present to provide supervision and verbal cueing for simple tasks like instructing Resident 1 to sit on the bed while waiting for the meal tray. RN 1 stated she did not know if Resident 1 was able to recall complex instructions over a longer period of time. Resident 1's initial assessment indicated Resident 1 was confused with poor mentation, needs physical and verbal cueing . Review of Resident 1's Final Discharge Plan dated 3/1/21 indicated Resident 1 was ready to be discharged to a long-term care facility (Facility 2, receiving facility) on 3/1/21 and transportation would be arranged. During an interview with DON on 3/23/21 at 12:40 p.m., DON stated, on 3/1/21, after Resident 1 was picked up at the facility for transfer to Facility 2. DON stated, Facility 2 called after Resident 1 failed to show up. DON stated, Resident 1 went missing and was found by local law enforcement few blocks from Facility 2. During a telephone interview with RN 2 (licensed nurse at Facility 2) on 3/24/21 at 12:40 p.m., RN 2 stated, on 3/1/21, RN 3 had called to give report about Resident 1, who was to be discharged at 4:30 p.m. RN 2 stated, from the report given, what stood out was that Resident 1 was a wanderer. RN 2 stated the transportation was delayed and was re-scheduled for two hours later. RN 2 stated, when Resident 1 did not show up at 8 p.m., RN 2 had placed a telephone call to the facility to ask Resident 1's whereabouts. RN 2 stated, it was then when RN 2 was told Resident 1 was picked up at 6:30 p.m. by a taxi. During a telephone interview with RN 1 on 3/24/21 at 2:31 p.m., RN 1 stated, on 3/1/21 at 2 p.m., Resident 1 was ready for discharge. RN 1 stated Unit Clerk (UC) said transportation was already arranged for Resident 1 to go to Facility 2 via Lyft. RN 1 stated she had clarified with UC if the mode of transportation (Lyft) was discussed with Social Worker (SW) and UC answered yes. During a telephone interview with UC on 3/24/21 at 2:53 p.m., UC stated, SW and RN 1 had told her to call the transportation company to request for Lyft transport for Resident 1. UC stated she was told that Lyft was appropriate as it had been used in the past without any issues. During a telephone interview with Transportation Supervisor (TS) on 3/24/21 at 5:10 p.m., TS stated, Lyft was utilized as one of the non-emergency medical transport. TS stated, for non-emergency medical transport, residents are transported via door-to-door or curb-to-curb, depending on the needs of the resident. TS stated Lyft was a curb-to-curb transport service. TS also stated that if the customer who called and ordered transportation had communicated Resident 1 had any special needs, cognitive issues or any behavior that would make Lyft transport inappropriate, the dispatcher would have suggested another form of transportation that would provide a door-to- door service. TS stated there was a miscommunication on the part of the end user (UC) because the information provided about the resident was not sufficient enough to determine that another form of transportation was needed. During a follow-up interview with UC on 5/19/21 at 11:28 a.m., UC stated, she was not part of the Nursing Department and she did not know anything about Resident 1's behavior or cognitive status as reading a resident's chart was not part of her duties. UC stated when calling for transportation, UC would only make sure the transportation was covered by the resident's medical insurance. Review of Resident 1's Progress Notes dated 2/23/21, indicated, Resident 1 was forgetful, had confusion, wandered around and had to be provided with reality orientation/direction. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/19/21, under Section E Behavior, Resident 1 had wandered 1 to 3 days (over a 7-day observation period). MDS Section G, Functional Status (assesses a resident's ability to perform activities of daily living, i.e. walking and locomotion, and how much assistance from staff is required) indicated resident required supervision from staff in all activities of daily living. During a telephone interview with SW on 5/20/21 at 4:01 p.m., SW stated, discharge planning for Resident 1 started during Resident 1's admission to the facility on [DATE]. SW stated, the discharge plan would continue throughout the resident's stay and could change depending on whether there were changes in resident's overall status. SW stated the transportation arrangement was referred to the Nursing Department as they were the ones who knew Resident 1's most updated functional level. SW stated, she had reached out to the previous facility where Resident 1 was and was told about Resident 1's wandering. SW also stated she authored resident 1's Initial Discharge Planning assessment dated [DATE] that indicated Resident 1's wandering behavior at the former facility. SW stated she was not aware of Resident 1's current episodes of wandering, and would have requested for a more appropriate transportation that would assist Resident 1 inside the receiving facility. During a telephone interview with RN 3 on 3/24/21 at 2:44 p.m., RN 3 stated, on 3/1/21, RN 3 and Resident 1 waited for the Lyft driver in front of the building. When the transportation arrived, RN 3 stated she gave Facility 2's address (where Resident 1 was to be dropped off) to the Lyft driver. RN 3 stated no further instructions were given to the Lyft driver. During a follow-up telephone interview with RN 3 on 3/24/21 at 3:33 p.m., RN 3 stated she gave the discharge documents to Resident 1 but did not give any instructions to Resident 1. During a telephone interview with RN 2 on 3/23/21 at 5:46 p.m., RN 2 stated, the cameras in front of the building were reviewed and footage on 3/1/21 indicated Resident 1 was dropped off in front of the building, but instead of walking into the building, Resident 1 walked away from the facility entrance. RN 2 stated Resident 1 went missing from 6:30 p.m., was found and brought to Facility 2 at 1:10 a.m., on 3/2/21.

Based on interview and record review, the facility failed to follow its policy and procedure for discharging Resident 1 when the facility: a. did not provide a notice of discharge 30 days prior to discharging Resident 1, and; b. did not provide the correct contact information for the entity which receives transfer/discharge appeal hearing requests. These deficient practices had the potential to result in Resident 1 not being ready for the discharge and also resulted in Resident 1's inability to file a transfer/discharge appeal. Findings: Review of Resident 1's Skilled Nursing Transfer and Discharge Notice (TDN), dated 11/3/20, indicated the effective date of Resident 1's discharge from the facility was to be effective 11/30/20. The TDN also indicated Resident 1 received the notice on 11/3/20. Further review of Resident 1's TDN indicated the incorrect contact information for the entity in charge of reviewing residents' transfer/discharge appeal. In an interview on 1/25/21 at 11 a.m., Administrator (ADM) stated the date the discharge notice was given to Resident 1 was on 11/3/20 with an effective date of discharge effective on 11/13/20. ADM further stated the timing of when the notice was given to Resident 1 and the date of discharge was not 30 days. ADM further stated Resident 1's TDN included the incorrect contact information for the entity in charge of a residents' transfer/discharge appeals. During a review of the facility's policy titled, Transfer or Discharge Notice, revised 5/2019, indicated .1. A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility .3. The resident and/or representative (sponsor) will be notified in writing of the following information .b. The effective date of the transfer or discharge .d. A statement of the resident's rights to appeal the transfer or discharge, including .(1) the name, address, email and telephone number of the entity which receives such requests

Based on interview and record review, for one (Resident 1) of three sampled residents the facility failed to implement Resident 1's broken television (TV) cord care plan when Resident 1 was not monitored hourly for safety. For Resident 1, this deficient practice placed Resident 1's safety at risk. Findings: Review of the Face Sheet, printed 2/24/20, indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's quarterly Minimum Data Set assessment (MDS-a tool used to guide care), dated 11/23/19, indicated Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's care plan titled TV cord was broken and reported, dated 2/5/20, indicated .12. hourly check provided by the staff for safety During a concurrent interview and record review the Director of Nursing (DON) on 2/24/20 at 12:34 p.m., she stated Resident 1 had hourly safety checks care planned. DON was not able to show documentation that hourly safety checks were done. Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised 12/16, indicated .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 received the necessary services to maintain personal hygiene. Resident 1 refused care from Restorative Nursing Assistant (RNA) 1 and Registered Nurse (RN) 1 and other facility nursing staff did not attempt to replace RNA 1 with another staff person to ensure Resident 1 received personal hygiene and repositioning. For Resident 1, this failure resulted in excessive body odor. Findings: Review of Resident 1's patient demographics sheet, printed 3/4/20, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's most recent Minimum Data Set (MDS - a resident assessment tool used to guide care), printed 1/29/20, indicated Resident 1 was cognitively intact (had the ability to clearly think, reason, and remember). The MDS also indicated Resident 1 was totally dependent on the assistance of two or more staff persons for bed mobility (turning side to side, moving to and from a lying position), dressing, personal hygiene, and bathing. Review of Resident 1's ADL care plan, start date 9/16/19, indicated Resident 1 was unable to carry out Activities of Daily Living (ADLs such as bathing, hygiene, dressing, bed mobility and grooming). The goal was for Resident 1 to be clean and odor free. Resident 1's ADL care plan included the following interventions: a. Resident 1 required total assist of five staff members to assist with bed mobility, bathing, hygiene, and dressing; b. Team leader to coordinate with staff from other units for possible Certified Nursing Assistants (CNAs) to float to help with Resident 1's bed mobility, toileting, bathing and wound care. c. If Resident 1 resisted ADL care, staff would explain importance of ADL and give Resident 1 one step directions to aid in participation in ADL care, and; d. The care plan also indicated, .If (Resident 1) continues to resist, leave for a few minutes and try again later with another staff member. Document non-compliance and report to provider if it continues Review of the facility document Day Shift Assignment, dated 1/16/20, indicated Resident 1 required complete bed bath and mechanical lift (an assistive medical device that uses electric, hydraulic, or battery power to transfer patients from surface to another) lift for repositioning. The assignment sheet for the afternoon shift indicated Resident 1 required total care (staff performs the entire activity without participation by the resident). During an interview with Director of Nursing (DON) on 1/29/20, at 10 a.m., DON stated Resident 1 required a five-staff team to provide ADLs like repositioning, hygiene, and wound care. DON stated that on Tuesdays, Wednesdays, and Thursdays Resident 1 had a Restorative Nursing Aide (RNA - a CNA with specialized training in restorative nursing care that helps patients gain an improved quality of life by increasing their level of strength and mobility) program. DON stated Resident 1's five-staff team on Tuesdays, Wednesdays, and Thursdays consisted of the three RNAs in the building, Resident 1's assigned CNA, and Resident 1's assigned Registered Nurse (RN). DON stated the five-staff person team provided Resident 1 with personal hygiene, repositioning, and wound care while the three RNAs were in the room providing RNA program. DON stated on the other days of the week (Sunday, Monday, Friday, and Saturday) that Resident 1 did not have RNA program, three CNAs were floated from other units and added to Resident 1's assigned CNA and RN to make up the five-staff team. During an interview with Resident 1 on 1/29/20, at 12:42 p.m., Resident 1 stated he refused to receive care from RNA 1 on 1/15/20. Resident 1 stated that on 1/16/20, when he told RN 1 that he did not want RNA 1 to be in the team, RN 1 told him because he refused RNA 1, it was as though he was refusing the care provided by the whole team. Resident 1 stated the only thing he refused was for RNA 1 to enter his room, Resident 1 stated he did not refuse the care. Resident 1 also stated the facility did not offer to get another CNA from other units to replace RNA 1. Resident 1 stated he did not receive hygiene care for his back side or wound care for his sacrum (large triangular bone at the base of the spine) pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin). During an interview with Registered Nurse 1 (RN 1) on 1/29/20, at 12:15 p.m., RN 1 stated that on 1/16/20, Resident 1 told RN 1 that he did not want for RNA 1 to be in his room to provide care. RN 1 stated, because Resident 1 refused RNA that day, Resident 1 did not receive ADL care in the morning as scheduled. RN 1 also stated Resident 1 had told her to tell DON about his refusal of RNA 1. Review of Resident 1's Progress Notes, dated 1/16/20, written by RN 1 indicated Resident 1 said .tell them I am not refusing my care but I don't want that RNA (RNA 1) .per DON that if he is refusing RNA (RNA 1) meaning he is refusing RNA care and his morning care During an interview with Certified Nursing Assistant 1 (CNA 1) on 1/29/20 at 11:10 a.m., CNA 1 stated Resident 1 and his room would stink so one would know that Resident 1 refused the RNA. CNA 1 stated she continued to encourage Resident 1 to allow hygiene but CNA 1 stated she could not do it on her own, there had to be five people in the room. Review of Resident 1's Progress notes indicated the following: a. 1/22/20, Assigned CNA, RN 1, and RNA 1, RNA 2, and RNA 3 entered Resident 1's room To do his back care which is to clean his back body, wound care, and situate him in proper position after the care. Resident 1 refused and stated he did not want RNA 1. b. 1/22/20, Resident 1's room And resident had foul smell. c. 1/23/20, RNA 1, RNA 2, and RNA 3 were to enter Resident 1's room, Resident 1 refused. (Resident) aware his care requires five staff and by refusing (one RNA) his care cannot be provided at this time. d. 1/28/20, Resident 1 refused care after RNA 1, RNA 2, and RNA 3 entered the room to provide care. Will endorse to next shift to offer care. e. 1/29/20, RNA 1 arrived in Resident 1's room together with four other staff to provide care. Resident 1 refused care. Will endorse to next shift to offer care. During another interview with RN 1 on 1/29/20, at 1:01 p.m., RN 1 stated that after Resident 1 refused RNA 1, she did not coordinate with other units for them to float a CNA to replace RNA 1 so that ADLs would still be provided. RN 1 stated she received instructions from management that since Resident 1 refused RNA 1, Resident 1 was also refusing care from RNA 2 and RNA 3. RN 1 stated management had instructed her to relay the message to Resident 1 which she did. During an interview and concurrent review of Resident 1's care plan with Assistant Director of Nursing (ADON) on 1/29/20 at 1:12 p.m., ADON stated Resident 1's ADL care plan was not revised to reflect interventions for when Resident 1 refused RNAs. During interview with DON on 1/29/20 at 1:15 p.m., DON stated when Resident 1 refused care from RNA 1, staff did not offer to arrange for another CNA from other unit to help with care.

Based on interview and record review, for one (Resident 1) of three sampled residents the facility failed to investigate and provide a written summary to Resident 1 of the outcome of grievances/complaints investigation within 7 working days of the filing when Resident 1 reported frustrations with his interaction with Certified Nursing Assistant (CNA 1). For Resident 1, this failure resulted in feelings of neglect and emotional distress. Findings: Review of Resident 1's Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 3/4/19, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS also indicated Resident 1 required the physical assistance of two or more staff persons with to move to and from lying position, turning side-to-side, and transfer to or from bed, chair, and wheelchair. The MDS also indicated Resident 1 had clear speech, was able to express his ideas and wants, and understood what others said to him. The MDS further indicated that Resident 1 had no verbal or physical behavioral symptoms directed towards others. During an interview on 12/17/19, at 12:30 p.m., Resident 1 stated he was scared and afraid because Certified Nursing Assistant (CNA 1) worked double shifts and was always so sleepy when she was assigned to him. Resident 1 stated he filed his concerns/grievances via email to the Director of Nursing (DON) about CNA 1, but he had not gotten a response regarding the outcome. During an interview on 12/19/19 at 2 p.m., CNA 1 stated Resident 1 refused care from her. CNA1 stated she was not aware that Resident 1 had a grievance about the care she provided. Review of Resident 1's grievance emails provided by the DON, dated 10/10/19, indicated Resident 1 felt neglected had grievance about care provided by CNA 1 and did not feel safe in CNA1's presence because he felt neglected. During an interview and concurrent record review on 12/17/19, at 1:30 p.m., the Activity Director (AD) stated she was responsible to coordinate and file documentation of resident grievances. AD could not provide documentation of the investigation result of Resident 1's grievance regarding CNA 1. During an interview on 1/10/20, at 11:01 a.m., DON could not provide documentation of the investigation and the actions that were taken to correct any identified findings of Resident 1's grievance regarding CNA 1. During an interview on 12/17/19, at 12:40 p.m., the Administrator (Admin) could not provide documentation of the investigation result of Resident 1 grievance regarding CNA 1. Admin could not provide documentation to indicate Resident 1 was informed of the findings of the investigation. The facility's policy and procedure titled, Filing Grievances/Complaints, revised (MONTH) (YEAR), indicated .6. Upon receipt of a grievance and/or complaint, the Grievance Official will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint maintain anonymity if complaint is made anonymously. 7. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be take. 8. The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Grievance Official will make such reports in writing within 7 working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will be provided to the resident, and a copy will be filed with the Grievance Official

Based on interview and record review, the facility did not provide competency training to provide services for [MEDICAL TREATMENT]-dependent ([MEDICAL TREATMENT] - a process where a machine filters the blood of wastes when the kidneys are not healthy enough to do it) residents in accordance with the facility assessment. This failure had the potential to result in [MEDICAL TREATMENT]-dependent residents receiving inappropriate care and services. Findings: Review of the Facility Assessment last reviewed 7/12/19 indicated the average number of residents on special treatments and conditions included 6-10 residents who were on [MEDICAL TREATMENT] (also known as [MEDICAL TREATMENT]). Staff training/education and competencies needed to provide level of requirements were also included in the facility assessment. The nursing staff skill sets that were evaluated annually included specialized care such as [MEDICAL TREATMENT]. During an interview and concurrent review of competency trainings with Clinical Instructor (CI) on 9/26/19 at 10:36 a.m., CI stated she had just started work in (MONTH) 2019 and has not given competency training on [MEDICAL TREATMENT] care and management to licensed nurses. During an interview with Director of Nursing (DON) on 9/26/19 at 11:57 a.m., DON stated there was no competency training provided to licensed nurses recently. DON stated the last training provided was in (YEAR). DON stated training should be provided every year because of the resident population and characteristics that the facility had. (Refer to F760 for additional information regarding Residents 49 and 76)

Based on interview and record review, for one of 24 (Resident 65) sampled residents, the facility failed to consistently monitor Resident 65's behaviors and side effects related to the use of [MEDICAL CONDITION] (capable of affecting the mind, emotions, and behaviors) medications during the months of (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. For Resident 65, this deficient practice had the potential to result in the physician receiving and using inaccurate information to make decisions regarding the need to continue, increase, or decrease of the use of [MEDICAL CONDITION] medications. Findings: Review of Resident 65's Face Sheet indicated Resident 65 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 65's Minimum Data Set (MDS - an assessment tool used to direct care), dated 7/16/19, indicated Resident 65 had [DIAGNOSES REDACTED]. Review of Resident 65's Physician order [REDACTED]. a. [MEDICATION NAME], order dated 5/30/19, for a severe chronic mental disorder manifested (m/b) by auditory hallucination and talking to self; b. Trazadone ([MEDICATION NAME]), order dated 5/27/19, for [MEDICAL CONDITION] associated with depression m/b sleeplessness, and; c. [MEDICATION NAME] ([MEDICATION NAME]), order dated 5/30/19, for depression. Review of Resident 65's Medication Administration Records (MARs), dated (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, indicated that there was inconsistent monitoring of Resident 65's behaviors for the use of [MEDICATION NAME] and [MEDICATION NAME], and inconsistent monitoring of Resident 65's time spent sleeping related to the use of Trazadone on multiple days and across multiple shifts (days, afternoon, and night shifts). The MARs also indicated there was inconsistent monitoring of side effects related to Resident 65's use of [MEDICATION NAME] on multiple days and across multiple shifts (days, afternoon, and night shifts). During an interview and concurrent record on 9/26/19, at 8 a.m., Registered Nurse (RN) 4 stated Resident 65's behavior and side effect monitoring was not consistent for multiple days and across multiple shifts from (MONTH) to (MONTH) 2019. RN 4 stated it was important to monitor the (Resident 65's) behaviors and presence of side effects during [MEDICAL CONDITION] drug use in order (for the physician) to know the need for continued use, increase, or decrease of the [MEDICAL CONDITION] medications. In an interview with the Director of Nursing (DON) on 9/26/19 at 12:20 p.m., and concurrent record review of Resident 65's MAR from (MONTH) to (MONTH) 2019, DON stated some of the licensed nurses were noncompliant with the behavior and side effects monitoring documentation for resident's [MEDICAL CONDITION] drug use from (MONTH) to (MONTH) 2019. DON stated the Interdisciplinary Team's (IDT's) recommendations for the [MEDICAL CONDITION] drugs' Gradual Dose Reduction (GDR) were based on the identified number of incidents of behavior manifestations and medication side effects monitored. Review of the facility's policy and procedure titled, Antipsychotic Medication Use, with revised date (MONTH) (YEAR), indicated .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental cause of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review

Based on observation, interview and record review, for one of four sampled residents (Resident 1) the facility failed to provide supervision to prevent accidents when: 1. Certified Nursing Assistant (CNA) 1 left Resident 1 unsupervised in front of the facility and Resident 1 eloped (left the facility's property without permission), and; 2. the facility did not monitor the functionality of Resident 1's individual WanderGuard (a system that tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area) device or the functionality of the WanderGuard door monitors (three of 12 door monitors did not sound an alarm). These failures had the potential to result in serious injuries or harm for the six residents in the facility with WanderGuards. It was determined to constitute an Immediate Jeopardy (IJ) situation. The Administrator (ADM), Chief Administrative Officer (CAO) and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (IJ) on 11/1/17, at 5:16 p.m. The facility failed to provide adequate monitoring for Resident 1 who wore an individual WanderGuard device and the facility did not have fully functioning WanderGuard system. Through interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of action through in-services of employees regarding WanderGuard placement and monitoring. The facility repaired the nonfunctioning WanderGuard door monitors at the three exit doors. The IJ was abated on 11/1/17 at 7:23 p.m. Findings: 1. Review of the Resident Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 8/17/17, indicated Resident 1 was able to recall and repeat words and knew the correct year and month. Resident 1's MDS also indicated he required supervision (oversight, encouragement, or cueing) with locomotion (movement) on and off the unit. Further review of Resident 1's MDS indicated he had active [DIAGNOSES REDACTED]. During an interview with CNA 1 on 10/31/17, at 12:34 p.m., CNA 1 stated that on 10/29/17, she was not aware Resident 1 was off the unit until she transported another resident outside to smoke and noticed Resident 1 was outside smoking in front of the building. CNA 1 stated Resident 1 had an individual WanderGuard on his wrist. CNA 1 stated she asked Resident 1 if he wanted to come upstairs for lunch, and he said no. CNA 1 stated the second time she went outside to check on Resident 1, he was not there and CNA 1 stated she then notified Registered Nurse (RN) 1. CNA 1 stated she and RN 1 looked for Resident 1 inside and outside the facility but did not find him. During an interview with CNA 1 on 11/1/17, at 2:45 p.m., CNA 1 stated she was aware Resident 1 required supervision. CNA 1 stated she should have reported Resident 1 being outside to the charge nurse when she first noticed him outside. Review of Resident 1's Care Plan, dated 8/14/17, indicated Resident 1 had impaired mobility and was to ambulate (walk) with general supervision on the nursing unit with a WanderGuard. Resident 1's Care Plan, dated 8/17/17, indicated he was to wear a WanderGuard while on the unit, and was to be supervised if he left the unit. Resident 1's Care Plan, dated 8/24/17, indicated he had confusion and wandering behaviors and staff were to act quickly when the WanderGuard alarm was activated and to redirect or reorient Resident 1. During an interview with Registered Nurse (RN) 1 on 10/31/17, at 12:13 p.m., RN 1 stated that on 10/29/17, at 1:40 p.m., Certified Nurse Assistant (CNA) 1 informed her Resident 1 was not in the outside smoking area when she went to look for him at 1:30 p.m. RN 1 stated CNA 1 also told her she (CNA 1) last saw Resident 1 at 12:30 p.m. in the smoking area. RN 1 stated she and CNA 1 looked inside and outside the facility, but did not find Resident 1. During an interview with the Charge Nurse (CN) on 11/1/17, at 1:51 p.m., the CN stated Resident 1 should have been supervised by a staff member when Resident 1 was off the unit. The CN stated the staff should know residents with individual WanderGuards need supervision. Review of the facility's investigation summary, dated 11/2/17, indicated CNA 1 attempted to redirect Resident 1 back to the unit, but Resident 1 wanted to stay outside. The investigation summary also indicated CNA 1 stated she left Resident 1 outside, and Resident 1 left the campus. Review of Resident 1's Clinical Notes (Notes), dated 10/29/17, at 2:12 p.m., indicated CNA 1 last saw Resident 1 (on 10/29/17) at 12:15 p.m. in the smoking area in front of the facility. 2. In an observation 11/1/17, at 12:15 p.m., the ADM, DON, and the Nurse Manager (NM) tested an individual WanderGuard device at exit doors with WanderGuard door monitors. During testing at the following dates and times, the WanderGuard alarm was not activated at the following locations with WanderGuard door monitors: 1. 11/1/17, at 12:18 p.m. - First floor exit door between units B1 and B2; 2. 11/1/17, at 12:22 p.m. - First floor exit door 200, and; 3. 11/1/17, at 12:32 p.m. - Second floor exit door 300. During an interview with the DON and ADM on 11/1/17, at 12:40 p.m., the DON and ADM stated the WanderGuard device should have activated the sensor alarm at all the exit doors with WanderGuard door monitors. During an interview with the DON and ADM on 11/1/17/17, at 11:57 a.m., the DON stated the facility did not have a standardized method of monitoring the WanderGuard alarm system (individual monitoring devices or the door monitors). The ADM stated she thought the facility's engineering team monitored the WanderGuard alarm system. The ADM further stated the facility did not have a policy and procedure for the WanderGuard alarm system. Review of the WanderGuard system device manufacturer's instructions indicated .Band attachment instructions .Make daily inspections to confirm the band is in place and is not damaged in any way .Testing the signaling device .test each signaling device before using .test the device daily and record the results in the resident's records .Testing without a signaling device tester 1. Move the signaling device within (three feet) of a properly operating door monitor. 2. Open the door or activate the passive infrared (PIR) device. The alarm will sound if the signaling device is functioning properly. 3. Move signaling device away from the monitored area and reset alarm During an interview with Engineering Services Manager (ESM) on 11/1/17 at 1:32 p.m., EMS stated the WanderGuard system was monitored and tested on ce a year. EMS stated the WanderGuard sensor (door monitor) at exit door 200 was painted over and that was the cause of the malfunction for exit door 200. EMS stated his department does not keep up with the day to day maintenance of the WanderGuards. During an interview with ESM on 11/1/17, at 2:26 p.m., the ESM stated the facility did not have a portable device to check the function of the WanderGuard alarm system. The ESM stated he did not have a log of when the WanderGuard alarm system was checked. Review of a facility email document titled, WanderGuard Install Update, dated 11/1/17, indicated the facility's WanderGuard system was last completed and tested (the vendor physically demonstrated to the facility the completed work with functional tests of each operating device) on 7/2/17. During an interview with the Charge Nurse (CN) on 11/1/17, at 1:40 p.m., the CN stated the facility does not have a process in place for monitoring the WanderGuard alarm system. The CN was not able to show documentation that Resident 1's individual WanderGuard was monitored. During an interview with DON and Chief Administrative Officer (CAO) on 11/1/17, at 2:53 p.m., the DON and CAO stated they did not know how long the WanderGuard system had not been functioning properly.

Based on interview and record review, the facility failed to assess, plan and provide care to one (Resident A) of one residents reviewed to ensure that he did not develop a pressure sore. Staff did not assess Resident A ' s skin and Resident A developed a pressure sore on his left foot. Resident A left lower leg was amputated after the facility did not assess, plan care or provide care to Resident A ' s left foot in a timely manner to prevent infection and gangrene from a pressure sore. Definitions: Ankle foot orthosis or commonly known as AFOs are used in the treatment of [REDACTED]. " Gas gangrene is a type of moist gangrene that is commonly caused by bacterial infection. Once present in tissue, these bacteria produce gasses and poisonous toxins as they grow. Gas gangrene is a medical emergency because of the threat of the infection rapidly spreading via the bloodstream and infecting vital organs. (Reference: http://medical-dictionary.thefreedictionary.com/Gangrene) Findings: Record review on 12/16/11 showed the facility admitted Resident A on 7/13/11. Resident A had [DIAGNOSES REDACTED]. physician's order [REDACTED]. Resident A's plan of care, for [MEDICAL CONDITION]/[DIAGNOSES REDACTED], with the 'problem date' of July 13, 2011, listed under "Approaches" the following intervention, "Observe lower extremity circulation, check skin integrity, provide foot care. Communicate with MD (medical doctor) if with findings." On 8/15/11, Resident A complained of stomach pains and then chest pains and was transferred to a local hospital for evaluation. Resident A was readmitted to the facility on [DATE]. RN 3 completed a form, " Admission Database and Nursing Assessment. " RN 3 recorded that Resident A was alert and oriented x 3, had, " weakness on the right side ", and his skin was intact (had no wounds). The licensed nurse indicated that Resident A was not impaired for feeling pressure related discomfort and that he was at risk for developing pressure sores. According to the assessment instructions, " braces, " were, " factors further increasing risk. " physician's order [REDACTED]. An inventory of Resident A ' s personal property, dated 8/17/11, included, a " left foot brace. " A facility Policy and Procedure, dated as revised on October 2011, contained instructions for use of assistive devices that included braces. Item 4 included the following information: " All braces are evaluated for appropriate fit, comfort ...Skin should be checked frequently to monitor for potential skin breakdown ... " A PT evaluation, dated 8/19/11, described Resident A as able to walk 16 feet within parallel bars while wearing AFOs on both feet/legs. PT planned to continue therapy for Resident A to further improve his functional ability. Dr. P, a podiatrist recorded a visit to assess and treat Resident A ' s feet, on 8/24/11. Dr. P described Resident A as having diabetes with [MEDICAL CONDITION]. " ... [MEDICAL CONDITION], a result of nerve damage, often causes numbness and pain in (the) hands and feet ... One of the most common causes is diabetes. " (Reference: <http://www.mayoclinic.com/health/peripheral-[MEDICAL CONDITION]>) Dr. P recorded that Resident A had, pedal pulses (pulsation of blood flow in the feet) on the right and left. Dr. P trimmed Resident A ' s toenails and instructed, " protect both feet, no tight shoes (secondary) to [MEDICAL CONDITION] ... " Dr. P made no mention of AFOs in his report of care and assessment. Review of the medical record showed no nursing or PT plans or interventions to ensure that Resident A ' s feet were protected and his footwear was not tight. physician's order [REDACTED]. The facility ' s comprehensive assessment of Resident A ' s condition, dated 10/11/11, showed that the facility had determined that Resident A had no pressure sores nor other wounds or skin problems, to include foot problems. The assessment indicated that Resident A had no splint or brace assistance provided by restorative nursing programs, however, Resident A had received services from Physical Therapy. Further review of PT records showed a review of Resident A ' s abilities that was dated 10/24/11. PT recorded additional progress by Resident A. With assistance, Resident A could now walk with a front wheel walker assistive device for a distance of 30 feet. Resident A wore AFOs on both feet/legs. PT ' s goal was for Resident A to further improve in his ability to walk with on-going therapy. Review of the, " Nursing Measures Record, " with daily entries for the month of November, 2011, showed that Certified Nurse Aides (CNA) check- marked that Resident A ' s skin was observed at least every eight hours, " ...inspected for red areas. " There was a checkmark for each nursing shift, from 11/1/11 to 11/23/11. Additionally, there was a pre-printed care area field for information, " splints as scheduled, " however, there were no corresponding checkmarks at all. The medical record contained no information as to who applied the AFOs to Resident A ' s feet/legs or when the devices were used. On 11/23/11 at 12 noon, Physician A recorded in a progress note the following: " New wound, " Left lateral foot, " deep ulcer, " positive for surrounding [MEDICAL CONDITION] (reddened area and inflammation around the wound). The wound was described as, " unstageable, " deep, and the, " size of a nickel. " Physician A ordered a topical antimicrobial dressing and a wound care evaluation. A licensed nurse ' s progress note, dated 11/23/11 at 12:30 p.m., recorded, " CNA assigned to the resident showed me his left lateral foot - scab is off and discoloration noted. " Until this licensed nurse ' s entry, there was no record of any injury or scabbed area to Resident A ' s foot. The facility ' s color photographs of the wound were dated 11/23/11. A hand written notation next to the photo of Resident A ' s foot said that this was a, " dry scab and now it ' s off. " In addition to the wound there was a band of reddened skin that crossed the bottom of Resident A ' s foot. Licensed nurses ' progress notes, dated 11/27/11 and 11/28/11 contained entries that described Resident A as feeling weak. On 11/28/11, the licensed nurse recorded that the physician wished for Resident A to be transferred to the hospital for evaluation of his left foot ' s condition. Photographic record, dated 11/28/11, taken at the hospital on the date of admission, showed that Resident A now had an open wound on the bottom of his left foot. The picture of the open wound showed blackened tissue that was surrounded by deep red discoloration. A hospital wound care consultant documented an assessment of Resident A ' s left foot on 11/30/11. The consultant described the wounds as being filled with dead tissue and purulent fluid and they had, " strongly foul odors. " An x-ray result, dated 11/30/11 recorded that x-rays were taken showing three different views of Resident A ' s left foot. The report of findings stated that there was, " soft tissue gas, " next to the bones on the side of Resident A ' s left foot. The bone of the foot that led to Resident A ' s left small toe was eroded and " suspicious " for infection of the bone due to infection of the surrounding soft tissue. Physician B, a hospital vascular surgeon, evaluated Resident A on 11/30/11 and concluded that the wounds on Resident A ' s foot were, " pressure induced necrotic tissue with infection. " Surgeons ' reports, dated 12/ 1/12, 12/2/11, and 12/6/11, described the need for and actual amputation of Resident A ' s left leg below the knee. The left foot was not salvageable due to infection and resulting destruction of the bones in the feet and gas gangrene. The surgeons determined that Resident A had palpable pulses in his left leg. In an interview, on 12/16/11 at p.m., CNA 1 stated that CNAs caring for Resident A put the braces on in the morning and the evening shift CNAs take them off. CNA 1 stated that she had not cared for Resident 1 on days just prior to 11/23/11. On 11/23/11 she found the wound on Resident A ' s foot and had reported it to the charge nurse. CNA 1 described the wound as a sore that was purplish with redness leading to the bottom of the foot. In an interview on 1/15/12 at 4:15 p.m., the PT Manager stated that when assistive braces were needed for PT and walking, that a physician's order [REDACTED]. The PT Manager confirmed that there was no physician's order [REDACTED]. In an interview with PT, on 2/15/12 at 3:30 p.m., she stated that Resident A had a left side brace on admission to the facility and she had provided a right side brace. She stated that it would be the physician ' s role to instruct the facility in an order as to when to put on and take off the braces. In an interview with Resident A, on 2/15/12 at 3 p.m., he stated that facility staff put the braces on when he got up from bed and facility staff removed the braces at night. In an interview with Registered Nurse 1 (RN), on 3/9/12 at 12:10 p.m., she confirmed that nursing weekly summaries lacked information regarding the use of Resident A ' s AFOs. RN 1 located the PT evaluation document that contained information that the AFOs were used, but confirmed that there were no instructions for nursing staff. In an interview with RN 2, on 3/9/12 at 12:55 p.m., she confirmed that there were no care plan interventions for the use of AFOs for Resident A. There was, " just a note that says he has them. " In an interview and concurrent record review with the facility ' s Podiatrist, Dr. P, on 3/9/11 at 1:05 p.m., he confirmed that he had evaluated and treated Resident A on 8/24/11. Dr. P stated that according to his progress notes that Resident A had no evidence of skin breakdown on his feet. Dr. P stated that Resident A had decreased sensation in his feet and so would not have felt discomfort from AFO pressure. When shown the facility ' s photo of Resident A ' s left foot wound, Dr. P stated, " that ' s a pressure point, it is the base of the fifth metatarsal. " Dr. P stated that the wound was not likely to have developed overnight.