Every finding on record at Alameda Hospital D/P SNF

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received services in the facility with reasonable accommodation of resident needs when Resident 1's Active Order for skin care precautions indicating foot cradle (a supportive frame placed at the end or side of a mattress to elevate bed linens and to keep blankets/bedclothes away from the feet or legs of the user) use was not put in place. This deficient practice resulted in Resident 1 not receiving the needed care, assistive device, and/or service as ordered.A review of Resident 1's Inpatient Information, printed on 5/19/26, indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses that included dementia (memory loss), Cerebrovascular Accident (CVA, a stroke), and hemiplegia (muscle weakness on one side of the body, complete paralysis). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 12/24/25, indicated Resident 1 was dependent (helper does all the effort of which the resident required total assistance from two or more helpers) on all activities of daily living (ADLs). A review of Resident 1's Active Orders, printed on 5/19/26, dated 4/7/26, indicated Skin care precautions.foot cradle. During an observation on 5/19/26, at 10:12 a.m., in Resident 1's room, Resident 1 was lying asleep in bed, bilateral arms out, and resident's body fully covered with a blanket from chest down to the feet. There was no foot cradle observed in place. During a follow-up observation and concurrent interview on 5/19/26, at 11:15 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 1's room, Resident 1's lower extremities were assessed. Resident 1 was noted with foot drop (inability to lift or move the foot) to bilateral feet and with dry, parched heels. CNA 1 stated Resident 1 would remain in bed for the rest of the day since Resident 1 had showered yesterday. During a concurrent observation and interview on 5/21/26, at 10:52 a.m., with the Director of Rehabilitation (DOR), in Resident 1's room, a foot cradle was attached to the end of the bed with a blanket over the supportive frame. DOR stated foot cradle was used to off-load pressure and promote resident skin integrity to the feet when the resident was in bed, especially with heavy blanket use. During an interview on 5/21/26, at 11:00 a.m., with CNA 2, CNA 2 stated Resident 1 did not have a foot cradle when she last worked with Resident 1 two weeks ago. During a concurrent interview and record review, on 5/21/26, at 11:25 a.m., with Nurse Manager 1 (NM 1), Resident 1's Active Order, dated 4/7/26, indicated skin care precaution.foot cradle. NM 1 stated foot cradle should always be in place when the resident remains in bed to keep the pressure off resident's legs, feet, toes, and sensitive skin. NM1 was unable to explain when asked why Resident 1 did not have a foot cradle while in bed when this writer visited on 5/19/26. A review of the facility Policy and Procedure (P&P) titled, Assistive Devices and Equipment, revised in November 2025, indicated, The facility and staff maintain and supervise the use of assistive devices and equipment for the residents.Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include (but are not limited to) .safety devices.cradles, splints, etc.) . The following factors are addressed to the extent possible to decrease the risks of avoidable accidents associated with devices and equipment.Staff practices - staff aware of the use of devices and equipment and are available to assist and supervise residents as needed.

Based on observation, interview and record review the facility failed to protect one of three sampled residents, (Resident 1), from physical and emotional abuse when Resident 2 punched Resident 1 in the face twice with his fist and put him in a choke hold.This failure resulted in Resident 1 having a contusion (an area of skin discoloration caused by broken blood vessels under the skin, which happens when soft tissue is damaged by an impact), on Resident 1's face requiring transfer to an acute care hospital. Resident 1 stated he was fearful of Resident 2 and did not feel safe at the facility.During a review of Resident 1's admission Record, printed on 11/25/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of anxiety (excessive worry, racing thoughts and feeling of impending danger that is uncontrollable and interferes with daily life) and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 10/23/25, Section B indicated Resident 1 was able to make himself understood usually and was usually able to understand others.During a concurrent observation and interview on 11/25/25 at 11:25 a.m. with Resident 1, in the dining room, Resident 1 was sitting in his wheelchair at a table having lunch. Resident 1 stated he remembered Resident 2 coming up to him, hitting him in the face and choking him. Resident 1 stated he was surprised at the time. Resident 1 stated the incident scared him and he did not feel safe at the facility.During a review of Resident 2's admission Record, printed on 11/25/25, the record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of cognitive communication deficit, (communication difficulty resulting from changes in attention, memory or problem-solving), and dementia with psychotic disturbance, (condition that involves a loss of contact with reality, and disorganized thinking or speech).During a review of Resident 2's MDS assessment, dated 10/7/25, Section C, (Cognitive Patterns), the assessment indicated Resident 2's 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.) was 13 out of 15 indicating intact cognitive status.During a review of Resident 2's Care Plan (CP), printed on 11/17/25, the CP indicated Resident 2 had four separate instances of aggressive behavior on 3/2/25, 5/10/25, 10/23/25 and 11/13/25 where he had altercations towards other residents.During a concurrent observation and interview on 11/25/25 at 2:00 p.m. with Resident 2 while walking in the hallway, Resident 2 denied having an altercation with anyone at the facility.During an interview on 11/25/25 at 11:10 a.m. with Restorative Nurse Aide (RNA) 1, RNA1 stated on 11/13/25 she saw Resident 2 get up from his seat and abruptly turned to Resident 1. RNA 1 stated she saw Resident 2 punch Resident 1 in the face and wrap Resident 2's arm around Resident 1's neck as if to choke Resident 1. RNA 1 stated Resident 2 punched Resident 1 in the face again.During a telephone interview on 11/26/25 at 9:51 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was assigned to Resident 2 on 11/13/25 as a sitter, (a nonclinical caregiver who provides continuous one-on-one observation and support for facility residents needing close monitoring, focusing on preventing falls, self-harm or confusion while also offering basic comfort and companionship). CNA 1 stated Resident 2 got up from the chair and moved toward the exit of the dining room. CNA 1 stated Resident 2 suddenly turned and went to Resident 1, and hit Resident 1, Resident 2 put Resident 2' s arm around Resident 1's neck and hit Resident 1 again. CNA 1 stated Resident 2's behavior can change from calm to aggressive without warning.During a telephone interview on 12/3/25 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she assessed Resident 1 immediately after the incident on 11/13/25. LVN 1 stated Resident 1 complained of pain to the left side of Resident 1's face. LVN 1 stated she also noted slight bleeding from the front upper gum. LVN 1 stated she did not observe a contusion at that time.During a review of Resident 1's Nurses Notes, dated 11/13/25, the notes indicated LVN 1 documented around 10:50 a.m., she was called to assess Resident 1. [Resident 1] noted with bleeding on front gum . [complaint of] 10/10 pain on his [left] face. PRN [as needed] Tylenol administered .[applied] cold pack to face .911 was called .per doctor's order for further evaluation to acute hospital . [Resident 1] left the facility at 12:15 p.m.During a review of Resident 1's Emergency Department Provider's Notes from Acute Care Hospital, dated 11/13/25, the notes indicated Resident 1 status post assault at skilled nursing facility and sustained a contusion to his face. During a record review of Resident 2's Progress Notes, dated 11/17/25, the Progress Notes indicated Resident 2 hit Resident 1, Resident 2 wrapped Resident 2's arm around Resident 1's neck as if to choke Resident 1, and Resident 2 hit Resident 1 in the face a second time. During a review of the facility's Policy and Procedure (P&P) titled Resident Rights, dated July 2025, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse neglect, misappropriation of property and exploitation.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) were free from sexual abuse when Resident 2 sexually abused Resident 1 who had severe intellectual disability and was unable to provide consent. This failure resulted in Resident 1 ' s elbow pain from being held down during the sexual abuse and had the potential for serious physical and psychosocial injury. Findings: A record review of Resident 1 ' s admission record indicated Resident 1 was admitted with severe intellectual disability, weakness, schizophrenia (psychiatric disease which causes distrust of information and other people) and developmental delay. The record further indicated Resident 1 ' s family had conservatorship over them. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 11/12/24, the MDS indicated Resident 1 used a wheelchair for mobility and required supervision for bed mobility and had a Brief Interview for Mental Status score of 5 (The Brief Interview for Mental Status is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS has a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of zero to three was an indication of severely impaired cognitive status and 13 to 15 indicating intact cognitive status). During a record review of Resident 1 ' s physician order, titled Nursing Communication, dated 12/23/24, the order, dated 2/21/23, indicated Resident 1 did not have capacity to make healthcare decisions. A record review of Resident 2 ' s admission record indicated Resident 2 was admitted for weakness, heart failure and noncompliance with treatment. During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 required supervision for bed to chair transfer, was able to ambulate with assistive devices and had a BIMS score of 14. During a phone interview on 12/23/24, at 8:45 a.m., with Resident 1 family (RF), RF stated Resident 1 had severe cognitive disability, was unable to provide consent for sexual activity and the conservator did not give consent for Resident 1 to participate in any sexual activity. During a concurrent observation and interview on 12/23/24, at 10:00 a.m., with Resident 1, Resident 1 was in their wheelchair and was not interviewable. During an interview on 12/23/24, at 10:15 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated they had worked with Resident 1 for a long time. CNA 2 stated Resident 1 had an intellectual disability and staff typically tried to anticipate her needs due to communication difficulties. During a phone interview on 12/23/24, at 9:00 p.m., with CNA 1, CNA 1 stated on 11/30/24, at around 2:20 a.m., CNA 1 heard Resident 1 crying. CNA 1 immediately went into Resident 1 ' s room and found Resident 2 at Resident 1 ' s bed with his pants down thrusting his hip against Resident 1 ' s hip. Resident 1 was laying on their bed with their pants on but pulled down exposing the diaper. CNA 1 immediately called for RN 2 who came and pulled Resident 2 away from Resident 1. CNA 1 stated Resident 1 complained of arm pain to RN 1. CNA 1 stated while CNA 1 and RN 1 were assessing Resident 1 for injury, Resident 1 stated she was making babies. During a phone interview on 12/23/24, at 3:05 p.m., with RN 2, RN 2 stated on 11/30/24, at around 2:20 a.m., CNA 1 called RN 2 for help because Resident 2 was in Resident 1 ' s room. RN 2 stated she entered the room and saw Resident 2 at the side of Resident 1 ' s bed with his pants down. RN 2 stated Resident 2 was performing a rocking motion against Resident 1 ' s pelvis. RN 2 then pulled Resident 2 away, placed him on a wheelchair and removed him from the room. During a phone interview on 12/23/24, at 2:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated on 11/30/24, at approximately 2:20 a.m., she was called over to Resident 1 ' s room to check on Resident 1 for an incident. RN 1 stated she did not witness the incident and was called to assess Resident 1 after it. RN 1 stated Resident 1 told her he held my elbow and was complaining of elbow pain. RN 1 stated they gave Resident 1 pain medication. RN 1 stated Resident 1 began to claim she was pregnant and hadn ' t made those claims before. During a record review of Resident 1 ' s nursing progress note titled, Significant Event, dated 11/30/24, at 3:23 a.m., by RN 1, the progress note indicated CNA noted Resident 2 was standing beside bed with pants down by the hip with back and forth motion towards resident, she was lying on her back on bed with pants on .separated them right away. CNA reported that resident states, ' He wanna make a baby ' .complaint of pain on left elbow .acetaminophen (a pain relieving medication) . given as ordered for left elbow pain. During a record review of Resident 2 ' s nursing progress note titled, Significant Event, dated 11/30/24, at 3:36 a.m., by RN 2, the progress note indicated at 2:20 a.m. RN 2 was informed by CNA 1 that Resident 2 was in Resident 1 ' s room. When I entered the room, 2 CNAs .were already in the room. I found Resident 2 standing in front of [Resident 1] with pants down buttocks out, both hands leaning forward in bed. He was in the act of pumping the resident. During an interview on 12/23/24, at 1:00 p.m., with Social Services Director (SSD), the SSD stated Resident 1 was not able to make their own decisions for care and was conserved. During a record review of Resident 1 ' s hospital history and physical (H&P) titled ED Provider Notes Physician H&P Sexual Assault Response Team, dated 12/4/24, the H&P indicated a primary chief complaint of sexual assault of adult. H&P indicated hospital staff were unable to get history from pt - developmentally delayed with functioning of 3rd grade level, uses wheelchair .and doesn ' t stand up .Pt has 24hour care - sister is guardian - conservator. During a record review of police report titled, [City] Police Department Criminal Report, dated 1/13/25, the report indicated on 11/30/24, at 2:38 a.m., facility staff called the police to report Resident 2 in Resident 1 ' s room attempting to make a baby. The report indicated at 11/30/24, at around 2:20 a.m., Resident 1 was laying down perpendicular on [their] bed in the supine position. Resident 1 ' s feet were touching the ground and [their] head was against the wall. Resident 2 was between Resident 1 ' s legs with a wide stance. He was laying on top of Resident 1 (chest to chest) and was thrusting his hips towards Resident 1 .the entirety of his buttocks were exposed .his pelvis was in line with Resident 1 ' s pelvis while he was thrusting. The report further indicated Resident 1 ' s cognitive state caused her incapable of giving legal consent for sexual activity .did not believe she voluntarily turned her body 90 degrees on her own power .Resident 2 ' s medical documentation did not list any factors which would have reasonably indicated his cognitive function was so impaired that was not capable of committing a crime .based on the above evidence, I placed Resident 2 under arrest for: 261(a)(1) PC/664 PC - Attempted Rape of a Victim who is incapable of Giving Consent 220(a)(1) PC - Assault with Intent to Rape.

Based on observation, interview and record review, the facility failed to ensure discontinued medications were discarded when they were kept with ready to use medications in medication refrigerator. This failure had the potential to result in residents receiving the medication erroneously, which could lead to new health problems or adverse reactions. Findings: During an observation and interview on 09/18/24, at 11:47 a.m., with Registered Nurse (RN) 1, in the Nursing Station, the medication refrigerator was observed to have the following discontinued medications: -Admelog 100 unit (u)/milliliter (ml) (medication used for high blood sugar) for Resident 29. -Lantus 100 u/ml (medication used for high blood sugar) for Resident 100. -Lantus 100 u/ml (medication used for high blood sugar) for Resident 147. -Basaglar 100 u/ml Kwikpen (3 pens) (medication used for high blood sugar) for Resident 18. RN 1 stated she remembered Residents 100, 29 and 18 had not received insulin for some time and had either transitioned to oral medications to control their blood sugar or the medication was discontinued. During a record review on 09/18/24, at 12:52 p.m., with RN 1, Resident 29's Orders section of the electronic health record (EHR) indicated Resident 29's Admelog was discontinued on 09/04/24. During a record review on 09/18/24, at 12:54 p.m., with RN 1, Resident 100's Orders section of the EHR indicated Resident 100's Lantus was discontinued on 03/24. During a record review on 09/18/24, at 12:57 p.m., with RN 1, Resident 18's Orders section of the EHR indicated Resident 18's Basaglar was discontinued on 07/15/24. During a record review on 09/18/24, at 1:02 p.m., with RN 1, Resident 147's Orders section of the EHR indicated Resident 147's Lantus was discontinued on 07/17/24. During an interview on 09/18/24, at 1:05 p.m., with RN 1, RN 1 stated the facility kept the insulin just in case, and she believed the policy indicated the discontinued medications should be discarded after three months. During an interview on 09/19/24, at 11:57 p.m., with NM, NM stated the expectation was when the medication was discontinued, it needed to be removed and placed in the discarded medications area because there was a high chance that it could be used by mistake if left in the refrigerator. During an interview on 09/19/24, at 12:24 p.m., with Pharmacist (Pharm), Pharm stated discontinued medications needed to be separated from regular medications as soon as possible so they did not get used by mistake by other residents. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 2007, the P&P indicated, 4). The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. During a review of the facility's P&P titled, Discontinued Medications, dated 2001, .3). Discontinued medications are destroyed or returned to the issuing pharmacy .

Based on observation, interview and record review, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. Findings: During observations of care and services from 9/16/24 through 9/19/24, the following rooms and corresponding square footage per bed were identified: 1. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 2. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 3. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 4. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 5. room [ROOM NUMBER] had four beds, total sq. ft. is 287 and 71.75 sq. ft. per bed. 6. room [ROOM NUMBER] had four beds, total sq. ft. is 283.52 and 70.88 sq. ft. per bed. 7. room [ROOM NUMBER] had two beds, total sq. ft. is 154.9 and 77.45 sq. ft. per bed. 8. room [ROOM NUMBER] had two beds, total sq. ft. is 154.9 and 77.45 sq. ft. per bed. 9. room [ROOM NUMBER] had two beds, total sq. ft. is 156.68 and 78.34 sq. ft. per bed. 10. room [ROOM NUMBER] had two beds, total sq. ft. is 149.30 and 74.65 sq. ft. per bed. 11. room [ROOM NUMBER] had two beds, total sq. ft. is 149.76 and 74.88 sq. ft. per bed. During random observations of care and services from 9/16/24 through 9/19/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/ or safety concerns in the 11 rooms. Granting of room size waiver recommended.

Based on observation, interview and record review the facility failed to ensure infection control practices were implemented when one of four residents, Resident 21's bedside commode (a portable toilet) was visibly soiled. This failure placed the facility's residents at risk for healthcare-associated infections. Findings: During a review of Resident 21's Admission Record, dated 9/18/24, the Admission Record indicated Resident 21 was admitted to the facility on [DATE]. During a record review of Resident 21's Minimum Data Set (MDS- An assessment tool to guide care), dated 7/24/24, MDS indicated Resident 21 required supervision when walking from room to room and when performing toilet hygiene. The MDS indicated Resident 21 had an active diagnosis of Non-Alzheimer's Dementia (memory loss). During an observation on 9/16/24, at 12:41 p.m., in Resident 21's room, Resident 21 was sitting on the side of her bed eating lunch with her lunch tray on top of her bedside table. Resident 21's bedside table was positioned directly adjacent (next to) a bedside commode. The lid and seat of the bedside commode were made of plastic and were both gray in color. The armrests and legs of the bedside commode were made of metal. The lid of the bedside commode was closed. On the front of the lid were four smears of a brown, crusty material. Each smear measured approximately 1/2 inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an observation on 9/17/24, at 12:42 p.m., in Resident 21's room, Resident 21 was sitting on the side of her bed eating lunch on her bedside table. Resident 21's bedside table was positioned directly adjacent to a bedside commode. The lid of the bedside commode was closed. On the front of the lid were six smears of a brown, crusty material. Each smear measured approximately 1/2 inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an observation on 9/18/24, at 11:30 a.m., in Resident 21's room, Resident 21 was sitting on the side of her bed watching television. Resident 21's bedside commode was positioned directly adjacent to her. The lid of the bedside commode was closed. On the front of the lid were seven smears of a brown, crusty material. Each smear measured 1/2 inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an interview with Certified Nursing Assistant 1 (CNA 1) on 9/18/24, at 11:42 a.m., in the hallway outside of Resident 21's room, CNA 1 stated she had been assigned to Resident 21 previously and that she was familiar with her. CNA 1 stated any surfaces, including the bedside table and the bedside commode in Resident 21's room had to be sanitized and wiped down regularly because Resident 21 often walked around in her room and in the hallways and touched everything. CNA 1 then stated that all CNAs were responsible for cleaning and sanitizing surfaces such as bedside tables and bedside commodes in Residents' rooms. During an interview with the Nurse Manager (NM) on 9/18/24, at 11:48 a.m., at the Nursing Station directly across the hallway from Resident 21's room, NM stated Resident 21 used her bedside commode regularly. NM stated the CNAs were responsible for removing the waste from inside of the bedside commodes. NM stated if the bedside commode was visibly dirty, the CNA should clean it and sanitize it. NM stated she rounded to resident rooms daily to check for cleanliness. NM stated during the rounds, bedside commodes were checked for cleanliness. NM stated if a bedside commode was dirty, there was a risk of infections spreading. During an interview with CNA 2 on 9/18/24, at 11:53 a.m., in the hallway outside of Resident 21's room, CNA 2 stated she was assigned to care for Resident 21 today. CNA 2 stated she had checked Resident 21's bedside commode earlier in the morning and it appeared clean. During a concurrent observation and interview with NM and CNA 2 on 9/18/24, at 11:56 a.m., in Resident 21's room, Resident 21 was asleep in her bed. Resident 21's bedside commode was positioned adjacent to her bed which was positioned directly adjacent to where her head was laying on her pillow. The lid of the bedside commode was closed. On the front of the lid were seven smears of a brown, crusty material. Each smear measured 1/2 inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. CNA 2 stated the smears of brown, crusty material appeared to be fecal material (solid human waste consisting of undigested food, bacteria, mucus and cells which are passed out of the body). NM stated there were crumbs of food and what appeared to be fecal material on the bedside commode. CNA 2 and NM both stated the bedside commode did not look clean. CNA 2 then stated there was a risk of spreading infection from the fecal material on the bedside commode. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Residents' Rooms, dated August 2024, the P&P indicated, Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms and belongings. General Guidelines: 9. Clean medical waste containers intended for reuse (e.g., bins, pails, cans, bedside commodes, etc.) daily or when such receptacles become visibly contaminated with blood, body fluids or other potentially infectious materials .

Based on observation, interview, and record review, the facility failed to have the ordered antibiotic (medication used to treat infection) for one (Resident 1) of two residents. This failure to have the antibiotic in the facility on 6/29/23 and 6/30/23 resulted in Resident 1 ' s delayed treatment of infection and rehospitalization . Findings: During a review of Resident 1 ' s face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility June 2023, with diagnosis of Alzheimer ' s (progressive disease that destroys memory and other mental functions) disease and pneumonitis (inflammation of lung tissues) due to inhalation of food and vomit. A review of Resident 1 ' s Order Information Report as of 6/29/23, indicated an order, start date at 6/29/23 at 9:00 p.m., for amoxicillin-pot clavulanate (Augmentin) 600-42.9 mg/5 mL suspension 7.5 mL. The order indicated the Augmentin was to be given twice a day. During an interview on 7/19/23, at 9:30 a.m., with Director of Nursing (DON), DON stated the facility did not have the Augmentin. During an interview on 7/19/23, at 12:15 p.m., with Assistant Director of Nursing (ADON), ADON stated Resident 1 returned to the facility on [DATE] from the hospital with a discharge order for an antibiotic. The first dose was scheduled on 6/29/23 at 9:00 p.m. ADON stated PM shift Registered Nurse (RN) 1 ordered the antibiotic stat (urgent). Night shift Registered Nurse (RN) 2 faxed the antibiotic order to the pharmacy twice. At AM shift, there was still no antibiotic. ADON stated she would have aggressively contacted pharmacy and elevated the issue. During an interview on 7/19/23, at 12:50 p.m., with DON, DON stated Resident 1 missed two doses of antibiotics, the 9:00 p.m. dose for 6/28/23 and 9:00 a.m. dose for 6/29/23. During an interview on 7/19/23, at 2:00 p.m., with DON, DON stated not having the antibiotic affected patient care, accommodation of patient needs, disruption in treatment, and possible antibiotic resistance; it was imperative to complete antibiotic treatment. During an interview on 7/19/23, at 3:00 p.m., with AM shift Licensed Vocational Nurse (LVN) 1, LVN 1 stated she received report from RN 2 that the antibiotic had not arrived. LVN 1 stated during her 9:00 a.m. medication pass, she documented the antibiotic in the medication administration record (MAR) as not given. LVN 1 contacted the pharmacy and was informed the antibiotic was not filled as it was not covered by Resident 1 ' s insurance. LVN 1 stated pharmacy asked her if she would like to order the antibiotic and LVN 1 stated no. LVN 1 stated Resident 1 was left without the antibiotic. LVN 1 stated without receiving the prescribed antibiotic, the infection would not be treated and the infection would spread. During a review of Resident 1 ' s facility document, Progress Notes, dated 6/30/23, the Progress Notes indicated oxygen saturation (oxygen level carried by blood) was 89 (normal range 92-100). Supplemental oxygen was administered via nasal cannula (lightweight tube placed in the nostrils with the other end connected to an oxygen supply source). Resident 1 had difficulty swallowing and secretions were suctioned. Physician was notified and gave orders to send Resident out via 911. Resident 1 was re-hospitalized . During a review of the facility ' s policy and procedure (P&P) titled, Medication Orders Non-Controlled Medication Orders, dated 2007, the P&P indicated, The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not available.

Based on interview and record review, for one of five sampled residents (Resident 1), the facility failed to make prompt efforts to resolve a grievance when Resident 1's request to not receive care from Licensed Vocational Nurse (LVN) 1 was not honored. This failure had resulted in Resident 1's emotional distress. Findings: Review of Resident 1's Significant Event indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included exacerbated congestive heart failure (heart can't pump enough oxygen-rich blood to meet your body's needs), obstructive lung disease (condition that makes it hard to breathe) and diabetes (abnormally high levels of blood sugar). The record indicated Resident 1 was alert, responsive and oriented x 4 (understands who they are, where they are, approximate date or part of the day, and what is happening). [Reference:https://medical-dictionary.com]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 5/2/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15. The BIMS score range is from 0-15, with zero as the most impaired. [Reference:https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf] During a telephone interview on 5/30/23, at 12:56 p.m., with Resident 1, Resident 1 stated, before Resident 1 was transferred to the hospital on 3/21/23, the facility knew of Resident 1's complaint about LVN 1 turning off the CPAP (Continuous Positive Air Pressure, a machine that uses mild air pressure to keep airways open while you sleep) machine while Resident 1 was asleep. Resident 1 stated she returned to the facility on [DATE] from the hospital. Resident 1 stated, on 4/1/23, a day after returning from the hospital, Resident 1 communicated, via text message, with Associate Administrator (AA) about LVN 1's improper care. Resident 1 stated she told AA she did not want to be under LVN 1's care. Resident 1 stated, on 4/4/23, Resident 1 had to send a text message again to AA, after being under LVN 1's care again for two consecutive days (4/3/23 and 4/4/23). Resident 1 stated she felt like no one cared and felt terrified that LVN 1 continued to provide care against Resident 1's will. During an interview on 4/24/23, at 12:57 p.m., with AA, AA stated Resident 1 had complained on 4/1/23 about LVN 1 turning off CPAP machine while asleep on three separate occasions. AA stated Resident 1's complaint was received as a grievance and an investigation was started. During a review of Resident 1's Associate Administrator's Note, dated 4/3/23, the note indicated AA was aware of Resident 1's complaint against LVN 1 and of Resident 1's refusal of care from LVN 1. The note also indicated, This was addressed to the said nurse .Resident does not want the said nurse to work on her .Explained to the resident that [facility] already talk to the Nurse and it is hard to make changes to accommodate all residents need. The note also indicated, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Social Services Director (SSD) would talk to Resident 1 to discuss the concern further. During a joint telephone interview with SSD and DON, on 5/26/23, at 4:03 p.m., both stated talking to Resident 1 on 4/4/23 and that both reached a decision to remove Resident 1 from LVN 1's assignment (a list of residents under LVN 1's care). DON stated making a few telephone calls to LVN 1 that were missed. DON stated not being able to contact LVN 1 about the switch in the assignment. During a telephone interview with LVN 1, on 5/26/23, at 10:59 a.m., LVN 1 stated Resident 1 was on LVN 1's assignment during the night shift on 4/3/23 and 4/4/23. LVN 1 stated she had been working at the facility for many years and did not look at the schedule to check which residents belonged to her assignment. LVN 1 stated she showed up on 4/4/23 for work not knowing Resident 1 was already taken off LVN 1's regular assignment. LVN 1 also stated being told of the change in the assignment at the end of the shift on 4/5/23. During an interview on 6/1/23, at 10:15 a.m., with Staffing Coordinator (SC), SC stated she received an instruction from management to remove Resident 1 from LVN 1's assignment on 4/3/23 but did not tell LVN 1 of the change. Review of the facility's policy and procedure titled, Grievances/Complaints, Filing, last revised April 2017, indicated the facility's policy was for the Administrator and staff to make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. The policy further indicated, The Social Worker and/or designee, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) allowed one of three sampled residents (Resident 1) to refuse cleaning after a bowel movement. The failure to consider Resident 1's screaming and kicking a refusal of cleaning after a bowel movement resulted in Resident 1 sustaining a chipped tooth, a cut on the right side of her tongue, and a purplish discoloration on her left upper lip and slight swelling on her cheek after she bit CNA 1. Findings: A review of Resident 1's face sheet indicated Resident 1 had resided in the facility since [DATE]. A review of the facility's, Investigative Summary, undated, indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember. The BIMS score range is from ,d+[DATE], with zero as the most impaired.) score of five, an indication of severe impairment. During an interview on [DATE] at 11:15 a.m., with Registered Nurse 2 (RN 2), RN 2 stated she had been the primary licensed nurse for Resident 1 when she previously resided on RN 2 ' s unit. RN 2 stated Resident 1 was not able to speak and only made her needs known through gestures. RN 2 stated Resident 1 had episodes of kicking staff in the past especially when she had a soiled brief. RN 2 stated when Resident 1 got agitated, the assigned certified nursing assistant was instructed to leave Resident 1 alone until Resident 1 had calmed down, before returning to finish care provision. During a telephone interview on [DATE], at 10:15 a.m., with Resident 1's sitter (staff member assigned to provide one-on-one supervision to a resident), resident 1's sitter stated he arrived at the facility on [DATE], at 8:05 a.m. Resident 1's sitter stated he heard Resident 1 screaming when he entered the facility, and when he went to her room and checked on her, he noticed Resident 1 had feces on her bed and clothing. Resident 1's sitter stated he left Resident 1's room, and asked CNA 1 to come clean Resident 1. Resident 1's sitter stated he waited in the doorway while CNA 1 entered Resident 1's room and closed the privacy curtain around the bed. Resident 1's sitter stated he was unable to see or hear what CNA 1 did at the bedside because Resident 1 was constantly screaming. During a telephone interview on [DATE] at 1:50 p.m., with CNA 1, CNA 1 stated on [DATE], around breakfast time, CNA 1 had been placing soiled breakfast trays into the tray cart in the hallway. CNA 1 stated he heard Resident 1 screaming from inside her room, when Resident 1's sitter approached him and asked CNA 1 to go to Resident 1's room and clean Resident 1, who just had a bowel movement. CNA 1 stated he went into Resident 1's room where Resident 1 appeared to be upset and was continuously screaming. CNA 1 stated he approached Resident 1 and told her he had come to clean her, and Resident 1 kicked him twice in the stomach. CNA 1 stated he left Resident 1's bedside and asked Resident 1's sitter, who was waiting in the entryway, to talk to Resident 1. CNA 1 stated Resident 1's sitter talked to Resident 1, and then CNA 1 stated he approached Resident 1 again, turned Resident 1 to her right side, held her left shoulder with his right hand, and began cleaning Resident 1's buttocks with his left hand. CNA 1 stated Resident 1 turned her head, reached for CNA 1's right hand, and bit CNA 1's right middle finger before he could react. CNA 1 stated he left the room holding his bloodied right hand. CNA 1 stated it was better to leave the room and report to the charge nurse when residents had aggressive behavior during care. CNA 1 stated he had not informed Registered Nurse 1 (RN 1), the charge nurse, after Resident 1 had kicked him in the stomach. During a telephone interview on [DATE], at 9:45 a.m., with RN 1, RN 1 stated at the start of the morning shift on [DATE], she had administered calming medication to Resident 1, who was agitated. RN 1 stated she still heard Resident 1 screaming in her room a few minutes after the medication and went to Resident 1's room to check on her status. RN 1 stated she saw Resident 1 was upset and yelling, and CNA 1 was standing in the room with a bloody right hand. RN 1 stated she told CNA 1 to leave the room and arranged for another staff member to finish cleaning Resident 1. RN 1 stated if she had known Resident 1 had kicked CNA 1 at the start of the care provision, RN 1 would have arranged for another certified nursing assistant to assist CNA 1. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RN 1's Significant Event Addendum dated [DATE], indicated at around 8:30 a.m., when RN 1 responded to Resident 1 yelling in her room, RN 1 saw Resident 1 crying and screaming. RN 1 stated Resident 1 had blood in the mouth, Noted cut in the right side of the tongue and broken [right] upper [teeth]. Found piece of [teeth] in bed. There was a purplish discoloration on Resident 1's left upper lip and left cheek with slight swelling. Resident 1 was taken to the hospital for further evaluation. During a joint interview with Associate Administrator (AA) and Director of Nursing (DON) on [DATE] at 12:30 p.m., AA and DON both stated the expectation was for the certified nursing assistant to leave the room when a resident was agitated and inform the licensed nurse of the situation. The licensed nurse could assess the situation to see if Resident 1 needed medication to calm down, or if another CNA was needed to help provide care.

Based on observation, interview and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. The food preparation area was adjacent to the hand wash station/sink with inadequate protection from potential splashes of contaminated water and soap from handwashing. 2. The ready-to-use pans stored above the food preparation area were wet. 3. Dietary Clerk (DC) did not cover hair completely while in the kitchen and during tray-line. These failures had the potential to result in food-borne illnesses. Findings: 1. During an observation and concurrent interview on 8/22/22 at 10 a.m., with Assistant Director of Food and Nutrition (ADFN), in the kitchen, the food preparation area had a tray of chopped raw vegetables being prepared for lunch service. The chopped vegetable tray was approximately five inches away from a splash guard which separated the food preparation area from a handwashing sink. The length of the chopped vegetable tray extended beyond the edge of the splash guard for over six inches. There were visible droplets of soapy water on the kitchen floor on both the splash guard side and the front edge of the chopped vegetable tray/food preparation area. ADFN stated the handwash station was used by employees for handwashing during food preparation. 2. During an observation and concurrent interview on 8/24/22 at 9:50 a.m., with Systems Director of Food and Nutrition (SDFN) in the kitchen, there were food pans stacked in the storage area above the food preparation sink. The pan on top of the stack was still wet. SDFN stated all pots and pans should be allowed to air dry before being stored. Review of the facility's undated policy and procedure titled Cleaning Procedures for Pots and Pans indicated after pots and pans were washed and sanitized, Remove the ware from sanitizing sink and invert on drain board. Do not wipe and let air dry. 3. During a tray-line observation on 8/24/22 at 12:10 p.m., DC wore a cover coat with sleeves rolled up to the mid-forearm, exposing black-stained shirtsleeve cuffs. DC also wore a head cover, with hair protruding outside the confines of the head while placing the resident food trays inside the food carts for delivery. A review of the facility's policy and procedure titled, Dress Code for Food and Nutrition Services, last approved August 2016, indicated staff must, Maintain personal hygiene such as, daily bathe, brush teeth and wear a clean uniform/clothing. A review of the United States Food and Drug Administration Food Code 2017, under the section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES.

Based on interview and record review, for one (Resident 3) of three sampled discharged residents, the facility failed to complete and transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) within 14 days of discharge from the facility. The failure to complete and transmit the Discharge Assessment for five months and 25 days after Resident 3 transferred to the acute care hospital and did not return, resulted in lack of tracking of residents leaving the facility. Findings: A review of Resident 3's annual MDS dated [DATE], indicated Resident 3 had been in the facility for more than three years with a current diagnosis of respiratory failure (impaired breathing function). A review of Resident 3's progress notes dated 4/21/22, indicated Resident 3 was unresponsive, pulseless, and was transferred to the hospital. During an interview and concurrent record review on 8/25/22 at 10:51 a.m., with the Director of Nursing (DON), Resident 3's MDS records were reviewed. The DON stated the annual assessment dated [DATE], was the last MDS transmitted for Resident 3. The DON stated Resident 3 had become unresponsive and was transferred to the hospital on 4/21/22 and had not returned to the facility. The DON stated Resident 3 had not had a discharge MDS completed or transmitted yet. The DON stated a discharge MDS should be completed and transmitted within 14 days of a resident's discharge. A review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 2019, indicated, The following situations warrant a Discharge assessment, regardless of facility policies - when resident is transferred and admitted to a hospital or other care setting regardless of whether the nursing home discharges or formerly closes the record. The User's Manual indicated discharge assessments consist of discharge return anticipated and discharge return not anticipated. The User's Manual indicated a Discharge Assessment-Return Not Anticipated: must be completed within 14 days after the discharge date when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days and must be submitted within 14 days after the MDS completion date. The User's Manual indicated for Discharge Assessment-Return Anticipated: must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date.

Based on observation, interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 2 and CNA 3) demonstrated competency in skills and techniques for provision of resident care according to resident care plans. The failure to ensure CNA 2 and CNA 3 completed annual performance and competency appraisals had the potential to result in inadequate or improper care for the CNAs assigned residents. Findings: During a record review and concurrent interview on 8/24/22 at 11:47 a.m., with the Supervisor for HR Service and Compliance (SHRSC) the personnel files of CNA 2 and CNA 3 were reviewed. SHRSC stated CNA 3 had a hire date in January of 2019 and should have had an annual performance review in January of 2022, but CNA had not had a performance review this year. SHRSC stated CNA 2 had a hire date in August of 2008 but had not a performance evaluation completed since 2020. A review of the policy titled, Performance Appraisal, revised date 5/2020, the policy indicated the purpose of the performance appraisal was: To establish communication, focused on constructive performance feedback. To identify areas that need improvement and establish goals to facilitate positive change. To provide career counseling, coaching, mentoring and morale building. To challenge employees to higher levels of performance and competency. To recognize employee accomplishments and unique contributions. To evaluate staff performance in accordance with the Joint Commission HRM.01.07.01 . The policy further indicated an annual performance appraisal, based on the employee's month of hire or focal date, would be conducted between the employee and the employee's supervisor, to provide both oral and written feedback on performance.

Based on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when three medication errors were observed out of 28 opportunities. The medication error rate was calculated as follows: three divided by 28 then multiplied by 100, which was equal to 10 percent. This failure had the potential to result in ineffective medication regimen for the effected residents (Residents 104, 117, and 125). Findings: 1. A review on 8/23/22 of the manufacturers insert for Advair HFA (fluticasone/salmeterol-medication used for Asthma) indicated, INSTRUCTIONS FOR USE ADVAIR HFA .How to use your ADVAIR HFA inhaler Follow these steps every time you use ADVAIR HFA .Step 3. Breathe out through your mouth and push as much air from your lungs as you can .Step 7. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it . During an observation on 8/23/22 at 8:15 a.m., Licensed Vocational Nurse 1 (LVN 1) did not instruct Resident 104 to breathe out as much air as possible prior to the administration of the Advair HFA. LVN 1 did not provide Resident 104 with a water mouth rinse after breathing in the Advair HFA. During an interview on 8/23/22 at 8:45 a.m., LVN 1 stated she had not followed step 3 and step 7 as indicated by the Advair HFA manufacturers insert. LVN 1 stated she had forgotten to instruct Resident 104 to breath out as much air as possible prior to administration. LVN 1 stated the exhalation before administration was important so the medication could be fully distributed throughout the lungs. LVN 1 stated she had provided Resident 104 with a non-prescription mouthwash for a post-administration mouth rinse as a substitute for the manufacturer's water rinse direction. 2. A review on 8/24/22 of the manufacturers insert for Lantus Insulin Pen (Insulin Glargine-medication used for diabetes) indicated, Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) During an observation on 8/24/22 at 8:05 a.m., Registered Nurse 2 (RN 2) administered an injection of insulin via the Lantus Insulin Pen to Resident 117. RN 2 injected the insulin and without waiting for ten seconds, removed the needle immediately. During an interview on 8/24/22 at 9:30 a.m., RN 2 stated she had not injected the Lantus Insulin Pen for 10 seconds before removing the needle during administration of Resident 117's insulin. RN 2 stated she had not been aware it was necessary to hold the Lantus Insulin Pen for 10 seconds while injecting. 3. A review of Resident 125's clinical record on 8/24/22 indicated a physician's order for Artificial Tears: two drops into the left eye, and two drops into the right eye. During an observation on 8/24/22 at 8:30 a.m., Licensed Vocational Nurse 3 (LVN 3) administered Artificial Tears to Resident 125: one drop into the left eye, and one drop into the right eye. During an interview on 8/24/22 at 8:40 a.m., LVN 3 stated she had squeezed the Artificial Tears bottle twice for each eye when instilling the eye drops but had not given the bottle sufficient time to refill between squeezes, so had only instilled one eye drop into each eye.

Based on observation, interview, and record review, the facility failed to ensure one employee (Certified Nursing Assistant 1, CNA 1) wore required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) and performed required hand hygiene after providing direct care to a resident in a room on contact, droplet, and airborne precautions. (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions. Airborne precautions are actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air.) The failure to wear a gown and gloves and to perform hand hygiene after direct care and before exiting from a room with a resident in isolation for exposure to COVID-19 (a contagious respiratory disease that can result in difficulty breathing and death), had the potential to result in spread of COVID-19 infection. Findings: A review of Resident 50's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/10/22, indicated Resident 50 was admitted in March 2022 with a need for rehabilitation after having a stroke (impaired circulation to the brain). During an observation, on 8/22/22, at 10:05 a.m., the door to Resident 50's room was open, with a posted sign on the hallway side of the door which indicated: Contact and Droplet and Airborne Precautions. COVID-19 PUI (Persons Under Investigation, a person without symptoms or a positive lab test, but potentially infectious with COVID) Yellow Zone (the color code for the area used for PUI residents). The sign indicated, Everyone must: perform hand hygiene before entering and leaving room, wear gown before entering room, wear gloves before entering room . Visible through the open doorway, Resident 50 sat in a wheelchair adjacent to her bed, while CNA 1 adjusted Resident 50's bed linen and a face towel on top of the bed. CNA 1 wore no cover gown or gloves. CNA 1 then exited Resident 50's room without performing hand hygiene. During an interview on 8/22/22, at 10:06 a.m., with CNA 1, in the hallway outside Resident 50's room, CNA 1 stated she had not worn a cover gown or gloves because it was hot. During an interview on 8/25/22 at 8:45 a.m., with the Infection Preventionist (IP), IP stated CNA 1 should have worn a cover gown and gloves when in direct contact with a Yellow Zone resident/resident's environment. During a review of the facility's policy and procedure (P & P) titled, Covid-19 Mitigation Plan, dated 8/2/22, the P & P, indicated, Personal Protective Equipment (PPE) - For patient care activities in the yellow zone, HCP generally need to wear eyewear (face shield or goggles), N95, gloves and gown . A review of the Centers for Disease Control, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 2/22/22, indicated, HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). During a review of the facility's policy and procedure (P & P) titled, Handwashing/Hand Hygiene, dated August 2019, the P & P indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P & P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial of non-antimicrobial) and water for the following situations: .Before and after direct contact with residents After contact with a resident's intact skin; . After contact with objects .in the immediate vicinity of the resident; .Before and after entering isolation precaution settings; .when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions .

Based on observation and interview, the South Shore facility had 11 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings. Findings: During an observation on 8/24/22 at 10:00 a.m., with the Operations Manager (OP),the following resident rooms and corresponding square footage (sq.ft.) were identified: Room- Activity- Room- Size- Floor Area 1 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 2 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 3 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 4 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 5 Res Room- 4 bedroom [ROOM NUMBER] sq.ft. 71.75 sq.ft. 6 Res Room- 4 bedroom [ROOM NUMBER].5 sq.ft. 70.88 sq.ft. 7 Res Room- 2 bedroom [ROOM NUMBER].88 sq.ft. 77.45 sq.ft. 8 Res Room- 2 bedroom [ROOM NUMBER].88 sq.ft. 77.45 sq.ft. 9 Res Room- 2 bedroom [ROOM NUMBER].69 sq.ft. 78.34 sq.ft. 10 Res Room- 2 bedroom [ROOM NUMBER].22 sq.ft. 74.65 sq.ft. 11 Res Room- 2 bedroom [ROOM NUMBER].77 sq.ft. 74.88 sq.ft. During random observations of care and services from 8/22/22 to 8/25/22, there was sufficient space for the provision of care for the resident in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concern in the 11 rooms. Recommend granting room size waiver.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Resident 2, a resident with escalating assaultive behaviors, was roomed with Resident 1, a dependent resident, without adequate supervision. This failure resulted in Resident 2 hitting Resident 1 in the right leg with a front wheeled walker (a rolling assistive device for walking) while Resident 1 slept. Resident 1 awoke crying with right leg abrasions (scrapes) which needed wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Admission Record, undated, indicated Resident 1 was admitted to the facility in January 2021. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 4/19/22, indicated Resident 1 had severely impaired mental status with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 1 required limited assistance from one person for bed mobility, total assistance from one person for transfer between surfaces, and extensive assistance from one person for locomotion in a wheelchair. A review of Resident 2's Admission Record, undated, indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's facility document titled, SNF History and Physical (H & P), encounter date 3/16/22, indicated Resident 2 had no capacity to make his own healthcare decisions due to a mental disorder which caused abnormal thought processes and deregulated emotions. The H & P indicated Resident 2 was admitted with nursing orders to monitor for combativeness and agitation related to use of medications for his mental disorder. A review of Residents 2's MDS dated [DATE], indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score was three, an indication of severe impairment. The MDS showed Resident 2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 2 only required supervision from one person to transfer between surfaces and move within his room; Resident 2 used a walker for locomotion and was not steady during transitions/walking but was able to stabilize himself without assistance. The MDS indicated Resident 2 had no behaviors during the seven-day look-back assessment period in the facility. A review of Residents 2's untitled care plan dated 3/16/22, indicated Resident 2 was to have 1:1 sitter due to possible elopement and behavior history . A review of Resident 2's, Psychoactive medication, dated 4/2022, indicated a daily, shift-by-shift documentation of Resident 2's behaviors for combativeness and agitation: easy irritability and constant yelling. The documentation indicated Resident 2 exhibited a total of 45 episodes for agitation and a total of 11 episodes for combativeness during the period from 4/11/22 to 4/21/22. A review of Resident 2's progress notes dated 4/19/22, indicated, . around 2:30 a.m. [Resident 2] had an episode of screaming in the hallway, redirection ineffective . [Resident 2] hit two staff with his FWW [front wheel walker] . During a phone interview on 5/9/22, at 3:45 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 4/19/22 at 2:30 a.m., Resident 2 had swung his walker and hit her right upper leg and thigh. LVN 1 stated her leg and thigh were red and painful after Resident 2 hit her. During a phone interview on 5/9/22, at 6:40 a.m., with LVN 1, LVN 1 stated Resident 2 needed a sitter to always watch him due to his known aggressive behaviors. LVN 1 stated she had provided break relief for Resident 2's assigned sitter on 4/21/22 starting at 2 a.m. LVN 1 stated she sat in a chair by the exit door of Resident 1 and 2's shared three-bed room, to provide supervision. LVN 1 stated Resident 1's bed (A-bed) was closest to the exit door and her chair; Resident 2's bed was the middle bed, adjacent to Resident 1's bed. LVN 1 stated the curtains were open between Resident 1's bed and Resident 2's bed. LVN 1 stated Resident 2 suddenly woke up screaming, and said, I want to get out of here. LVN 1 stated she was scared when she saw Resident 2 screaming and being out of control. LVN 1 stated Resident 2 stood up and grabbed his front wheel walker, went toward Resident 1's bed, raised his walker in the air, and hit Resident 1's legs. LVN 1 stated when Resident 1 was hit, he woke up crying. LVN 1 stated Resident 1's right lower leg had abrasions and looked red and dented. A review of Resident 2's nurse progress notes dated 4/21/22 at 3:17 a.m., by LVN 1, indicated at 2 a.m., resident awake and got up. Redirection provided but ineffective. Continue to scream out loud. Resident walked near the room mate (A-bed) and raised his walker and hit him his legs . During a concurrent observation and interview on 5/3/22, at 10:41 a.m., with Registered Nurse 1 (RN 1), Resident 1 lay in bed with his right leg exposed. Resident 1 had a dime-sized dry scab on his right lower leg. RN 1 stated Resident 1's scab was caused by his previous roommate, Resident 2, hitting him in the leg. A review of the facility ' s Investigative Summary dated 4/21/22, indicated Resident 1 sustained abrasion on his right shin measuring 5.5 centimeters (cm is a metric unit of length) x 3.5 cm, right knee measuring 4 cm x 2 cm, and above knee measuring 4 cm x 2.5 cm when Resident 2 hit Resident 1's leg on 4/21/22. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility's policy and procedure (P&P) titled, Victims of Abuse: Allegations Against Patients or Hospital Staff dated 3/2018, indicated the purpose of the P&P was to protect facility residents and staff . The P&P also indicated, abuse is the willful infliction of injury .Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

Based on interview and record review the facility failed to protect one of three sampled residents (Resident 1) from injury during transfer between a wheelchair and a bed by use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another). The facility failure to ensure staff coordinated use of the mechanical lift to safely transfer Resident 1 resulted in a sling (cloth harness used to hold the resident during transfer) hitting the left side of Resident 1's head, and Resident 1's foot hitting the side of the bed, causing Resident 1 transient pain and dizziness. Findings: During a review of Resident 1's Patient Demographics indicated that Resident 1 admitted to the facility with multiple diagnosis including obesity and chronic pain. Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/17/21, Resident 1 was totally dependent on two or more persons for transfer between surfaces, and used a wheelchair for locomotion. During an interview with Resident 1 on 6/4/21, at 10:10 a.m., Resident 1 stated Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2), and some other staff tried to transfer her from the wheelchair to the bed, but she was hit by the mechanical lift on her head and foot in the process. Resident 1 stated after the incident she had a headache and dizziness. During an interview with CNA 2 on 8/9/21, at 3:39 p.m., CNA 2 stated she and other staff had been using the mechanical lift to transfer Resident 1 from her wheelchair to her bed on 2/24/21. CNA 2 stated the staff temporarily lost control of the lift during the transfer, which resulted in Resident 1 being hit on the head and foot. Review of Resident 1's nurse progress notes, date of service 2/24/21 at 3 p.m., indicated Resident was on wheel chair and was transfer back to bed by the help of four CNA in [brand name mechanical lift]. While transferring from W/C [wheelchair] to bed, resident left side of the head was hit by the slings and her right foot was hit at the side of the bed

Based on observation, interview and record review, for one of three sampled residents (Resident 1), the facility failed to inventory all of Resident 1's personal belongings upon her admission to the facility when two pieces of jewelry (toe rings) were not entered into Resident 1's inventory upon admission. For Resident 1, this failure had the potential to result in a nonreimbursable theft. Findings: Review of Resident 1's Inventory of Personal Effects form indicated the form was initially completed on 2/12/20. During a telephone interview with Family Member (FM) 1 on 9/28/20 at 10:43 a.m., FM 1 stated in a recent conference with facility management, there were issues with regard to Resident 1's personal property that have not been resolved. FM 1 stated some of Resident 1's personal property had not been entered into Resident 1's personal inventory sheet. During an observation and concurrent interview with Assistant Director of Nursing (ADON) on 9/28/20 at 11:50 a.m., Resident 1 was up in wheelchair. Resident 1 was wearing two toe rings, one on each foot. ADON stated she was not sure if these two items were documented in Resident 1's inventory sheet. During an interview and concurrent review of Resident 1's Inventory of Personal Effects form with Licensed Vocational Nurse (LVN) 1 on 9/28/20 at 1:10 p.m., LVN 1 stated the toe rings had not previously been on Resident 1's inventory form, but they were just entered today 9/28/20 (7 months after the form was originally completed on 2/12/20). During a telephone interview with FM 1 on 10/19/20 at 4:38 p.m., FM 1 confirmed Resident 1 had two toe rings since her admission to the facility. During a telephone interview with Certified Nursing Assistant (CNA) 1 on 10/20/20 at 2:42 p.m., CNA 1 stated Resident 1 has had the two toe rings since admission to the facility, which Resident 1 had strongly refused to take off. CNA 1 stated she was assigned to care for Resident 1 on the day of admission and that the charge nurse must have documented them in Resident 1's inventory sheet. Review of the facility's policy and procedure titled Personal Property, last revised September 2012 indicated the facility's policy was for residents' personal belongings and clothing to be inventoried and documented upon admission.

Based on interview and record review, the facility failed to ensure one of three (Resident 1) sampled residents were free from abuse (the willful infliction of injury with resulting physical harm, pain, or mental anguish) when Resident 2 willfully (means the individual must have acted deliberately) shoved Resident 1 to the floor. For Resident 1, this deficient practice resulted in pain in his legs. Findings: Review of Resident 1's Admission Record, dated 8/2/19, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 2/20/19, indicated Resident 1 was able to repeat words, recall events, and knew the correct year and month. The MDS also indicated Resident 1's [DIAGNOSES REDACTED]. Review of Resident 2's MDS, dated [DATE], indicated Resident 2 was able to repeat words and recall events. The MDS also indicated Resident 2 had [DIAGNOSES REDACTED]. Review of Resident 2's Psychiatry Consult, dated 7/27/19, indicated Resident 2 had the capacity to make simple decisions. During an interview on 8/19/19, at 11:55 a.m., Resident 1 stated he was standing in the doorway of Resident 2's room talking to Resident 2's roommate. Resident 1 stated Resident 2 was carrying a tray, and he (Resident 1) moved to the side so Resident 2 could enter the room. Resident 1 stated he told Resident 2 if he was aware of him trying to enter the room, he (Resident 1) would have moved out of the way immediately. Resident 1 stated he and Resident 2 exchanged innocuous (not harmful or offensive) words, and then Resident 2 put both his hands on Resident 1's chest and pushed him hard. Resident 1 stated he fell hard on the hallway floor, and he felt pain on his back and buttocks. Resident 1 stated shortly after the incident, Resident 2 came into his room and apologized for pushing him. Resident 1 stated he told Registered Nurse (RN) 1 about the incident. During an interview with Resident 2 on 8/19/19 at 11:35 a.m., Resident 2 stated he pushed Resident 1 because Resident 1 was standing in the entrance of his room. Resident 2 stated he had asked Resident 1 twice to move, but Resident 1 did not move out his way. Resident 2 stated he did not call for the staff to help because he did not see any staff members in the hallway. Resident 2 stated while carrying a tray, he walked around Resident 1 and entered his room. Resident 2 stated initially he did not intentionally shove Resident 1 when he (Resident 2) walked around him (Resident 1) to enter the room. Resident 2 stated after he put his tray down, he turned around and pushed Resident 1 because Resident 1 had been in his room before. Resident 2 stated after he pushed Resident 1, Resident 1 left his (Resident 2's) room. Resident 2 stated a few minutes after he had pushed Resident 1, he went to Resident 1's room and told him he was sorry for pushing him. Resident 2 stated he reported what happened to a nurse and to the Administrator (ADM). During an interview on 8/21/19, at 11:45 a.m., RN 1 stated on 8/14/19 Resident 2 told her and the ADM that he had pushed Resident 1. RN 1 stated Resident 2 told her he pushed Resident 1 because Resident 1 would not move out of his way. RN 1 stated Resident 2 told her that he and Resident 1 had a verbal exchange and then he pushed Resident 1. RN 1 stated when she talked to Resident 1 regarding what happened, Resident 1 told her that he was standing in Resident 2's doorway, and he did not hear Resident 2 say excuse me to enter the room. RN 1 stated Resident 1 told her he and Resident 2 exchanged words and then Resident 2 shoved him, and he (Resident 1) fell and slid across the hallway floor. RN 1 stated Resident 1 told her his legs were hurting, and she gave Resident 1 his regularly scheduled pain medicine. Review of Resident 1's Nursing Progress Notes/Condition Change Form, dated 8/14/19, indicated Resident 1 reported .he was shoved to floor . by Resident 2 after a verbal exchange. Review of Resident 2's Nursing Progress Notes/Condition Change Form, dated 8/14/19, indicated Resident 2 stated he shoved Resident 1 into the wall after a verbal exchange. During an interview on 8/19/19, at 1:03 p.m., ADM stated that on 8/14/19 Resident 2 told her he had pushed Resident 1 because Resident 1 was in his way. Review of the facility's Summary of Investigation, dated 8/14/19, indicated Resident 2 stated .he shoved . Resident 1 to the floor. Review of the facility's policy and procedure titled Resident Rights, revised 12/2016, indicated residents were to .c. be free from abuse

Based on observation and interview, and record review, the facility failed to ensure food was prepared under sanitary conditions when: a. a manual can opener had metal shavings on the blade, and; b. Dietary Aide 2 rinsed the peeled boiled eggs in the 3 compartment sink. These failures had the potential to result in food contamination and food-borne illness. Findings: a. During an observation and concurrent interview on 6/17/19, at 9 a.m., in the presence of the Regional Director of Dietary and the Dietary Manager, the facility's manual can opener had metal shavings on the blade and on the inner portion of the device. The Regional Director of Dietary stated the canopener should have been cleaned before use. Review of the facility's Cleaning Procedures for Can Opener Policy & Procedure (not dated), indicated instructions for the dietary staff to clean the can opener before and after using the equipment. 2. During observation on 6/18/19, at 10:54 a.m. Dietary Aide 2 peeled boiled eggs and rinsed them in the rinse sink of the three compartment sink (used for washing, rinsing and sanitizing dishes) that had dishes in it. During an interview on 6/18/19, at 10:57 a.m., the Director of Food and Nutrition told Dietary Aide 2 to discard all the eggs and make a new batch. Director of Food and Nutrition also stated the facility had a separate sink for food.

Based on observation, interview, and record review, the facility failed to provide needed social services for one (Resident 22) of 25 sampled residents and two (Residents 27, 28) of 14 randomly sampled residents. 2. For Resident 22, a non-English Speaking Resident, the facility failed to develop an effective means of communication. This failure resulted in Resident 22 not receiving activities, goods, and services in a language he understood, causing him to be left in his room and not provided sensory stimulation. 3. For Resident 28, a non-English speaking resident, the facility failed to develop an effective means for staff to communicate assessment and medical instructions in language she understood. This failure resulted in the nurse not being able to effectively assess Resident 28 for pain and to effectively communicate assessment and treatment instructions to Resident 28. 3. For Resident 27, the facility failed to know the status of the audiologist's recommendation for hearing aides. DEFINITION: Sensorineural Hearing Loss- Permanent hearing loss occurs when inner ear nerves become damaged and do not properly transmit their signals to the brain. Those who suffer from this condition may complain that people seem to mumble or that they hear, but do not understand, what is being said. The aging process is a very common cause of sensorineural hearing loss. As we get older, the inner ear nerves and sensory cells gradually die. The condition is not often medically or surgically treatable. In most cases, the symptoms can be significantly minimized with hearing aids. (http://www.ucsfhealth.org/conditions/hearing_loss/signs_and_symptoms.html) [DIAGNOSES REDACTED]- An abnormal skin growth in the middle ear behind the eardrum is called [DIAGNOSES REDACTED]. Repeated infections and/or a tear or pulling inward of the eardrum can allow skin into the middle ear. Over time, the [DIAGNOSES REDACTED] can increase in size and destroy the surrounding delicate bones of the middle ear leading to hearing loss that surgery can often improve. Permanent hearing loss, dizziness, and facial muscle paralysis are rare, but can result from continued [DIAGNOSES REDACTED] growth. (https://www.entnet.org/HealthInformation/[DIAGNOSES REDACTED].cfm) [DIAGNOSES REDACTED] (also spelled hyperacousis) is a health condition characterized by over-sensitivity to certain frequency and volume ranges of sound (a collapsed tolerance to usual environmental sound). A person with severe [DIAGNOSES REDACTED] has difficulty tolerating everyday sounds, some of which may seem unpleasantly or painfully loud to that person but not to others. (http://en.wikipedia.org/wiki/[DIAGNOSES REDACTED]) Findings: 1. Review of the clinical record for Resident 27 on 3/22/14, showed the facility admitted Resident 27 on 6/26/11 (re-admitted [DATE]), with [DIAGNOSES REDACTED]. Review of the Department of Head and Neck Surgery Exam, dated 4/17/12, showed Resident 27 "Referred for mild left [DIAGNOSES REDACTED] with symptoms of left otorrhea (ear drainage) for the last few years, ear infections, itchiness, [DIAGNOSES REDACTED], ear pain and headaches. Vertigo (dizzy spells) - Balance has been " off " for several years, difficulty with depth perception. Has had 3 falls in the last two years." Audiological (Ear) assessment dated [DATE] showed, "Need to speak louder than normal and face the person, asymmetrical loss may present problems understanding speech in background noise, hearing people on left side. Degree of hearing loss Right side- Mild to Moderate, Left side- Moderate to Profound. May benefit from Stereo Amplified Listener ($40 at local electronic store). Good Hearing Aid Candidate. Follow up needed by the facility. Refer to Primary Care Physician for Prescription for right and left Hearing Aids." physician's orders [REDACTED]." During an interview on 3/20/14 at 1:45 p.m., the Social Services Designee (SSD) stated there had been an audiology consult but she would need to see where it was in process. She stated she is not responsible for submitting the Treatment Authorization Request (TAR) to Medi-Cal and that she would check with the audiologist for the progress. When asked although she doesn't complete the TAR or submit the TAR, is she responsible for assuring that its done, the SSD replied, "Yes." The facility had no documentation of a TAR Request to Medi-Cal or any estimated/expected date for delivery for Resident 27's hearing aids. 2. During the Initial Tour of the facility on 3/17/14 at 9:30 a.m., Resident 22 was observed in bed making eye contact and tracking. He did not speak, but was gesturing and shaking his head that he wanted something. The Director of Nurses (DON) could not make out what he was gesturing for. Resident 22 responded to verbal stimuli non-verbally however the DON could not understand. The DON stated Resident 22 was Bosnian speaking and did not speak or understand English. The DON stated that he was alert and verbally responsive in his native language. When asked how one would communicate with Resident 22, the DON stated, " We call the son. " When asked if the son was called everyday on all shifts, the DON stated, "no." The DON stated, none of the staff spoke Bosnian. The DON spoke to Resident 22 in English without the use of a communication tool. There was no communication board within sight. The DON stated, even with a communication board communicating with Resident 22 was difficult because their particular dialect is not the normal Bosnian Dialect. The following signs were observed posted at Resident 22 ' s bedside: -Pain scale (written in English), - " How do I Manage My Pain " sign on wall next to bathroom door (Written in English) -Sign above his bed with his name and "Family will be doing his Laundry." (Written in English). -Residents Rights (written in English) -Sign on bathroom door (written in English, Spanish and Tagalog,{ a Philippine dialect}) Review of the facility postings and activities etc., were all printed in English including the Ombudsman information. After the facility tour, Resident 22's son was called and was not available several times. Review of the clinical record on 3/17/14, showed the facility admitted Resident 22 on 3/20/13, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool used to plan and direct resident care), dated 12/20/13, showed Resident 22 was totally dependent upon staff for all of his activities of daily living (ADLs- feeding, dressing, toilet use, mobility, movement while in bed, and movement to and from bed). The "Verbal Communication Impaired" Care plan dated 12/20/13 showed: Goals: " Resident (22) will be able to effectively express needs and desires. He will express needs by pointing to what he wants. Will communicate successfully with cards and board notes. Resident will have language translation needs met as evidenced by absence of frustration when conveying. " Interventions: Request Bosnian speaking staff, Utilize translator, Refer to the communication board for translation. Review of the Interdisciplinary Team (IDT) Meeting Notes for 3/12/14 showed the Activities Director (AD) wrote, "Resident unable to respond in English and is unable to participate in group activities." Recommendations/Comments: "Resident is alert and verbally responsive in his native language." Physician order [REDACTED]. During an interview, on 3/17/14 at 11:15 a.m., the Social Services Designee (SSD) stated that she had encouraged the family to create a Bosnian communication board for staff to use. The SSD stated that she will also work with the IDT team to get the signs posted translated to Resident 22's language." During an interview, on 3/21/14 at 11:45 a.m., CNA 4 stated that it was difficult to communicate with Resident 22 because he could not use his hands to show you anything because he's had a stroke. CNA 4 says he pretty much is just in the room by himself all day. Resident 22's son was not available from 3/17/14 through 3/21/14, 8 a.m. to 2:30 p.m. when calls were attempted. 3. Review of the clinical record showed the facility admitted Resident 28 on 6/18/13 with [DIAGNOSES REDACTED]. During observation of Medication Pass on 3/20/14 at 9:30 a.m., Registered Nurse (RN) 2 gave Resident 28 Tylenol 650 milligrams (mg) with other medications. Afterwards when asked the indication for the Tylenol, RN 2 responded "it ' s for her pain." When asked where her pain was and a severity level RN 2 said, "Let me ask her." RN 2 went to Resident 28 (A Spanish speaking resident) and attempted a pain assessment. Resident 28 could not understand. RN 2 was asked to use whatever tools were available to her to communicate with Resident 28 about pain. When RN 2 was unable to assess the location of Resident 28's pain, Resident 28 was asked "donde dolor senora?" and Resident 22 grimaced and stated "Mucho dolor" while pointing to her neck and back. Resident 28 said, "Mas o menos" and RN 2 replied, "I don't know what that means." RN 2 then applied a mask to Resident 28's face and started an Atrovent Nebulizer (A machine that administers respiratory medication through a vapor or mist to be breathed into the lungs) Treatment. Resident 28 wasn't given any instructions. When asked how you would advise Resident 28 to breathe deeply, RN 2 stated, "I'm not sure." Resident 28's Spanish Communication Board lacked general terms to assist a nurse with instructions and assessment.

Based on observation, interview, and record review, the facility failed to provide care and treatment to prevent Pressure Ulcers for two (Resident 29, 21) of 39 sampled residents. 1. For Resident 29, the facility failed to do a complete wound assessment and to obtain treatment orders when the resident had blackened/purplish areas at the top portion of both his (big) great toes. This failure resulted in Resident 29 not being provided with the treatments to prevent further injury or to lessen the symptoms and severity of his current injury. 2. For Resident 21, the facility failed to properly stage (classify to reflect the level of tissue injury or damage) and assess a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear) and provide a pressure relieving device in her wheelchair to her back. This failure placed Resident 21 at risk to develop further pressure ulcers and for her current pressure ulcer to worsen. Findings: For clarification, the following terms were used in this report: Pressure Ulcer - any lesion caused by unrelieved pressure that results in damage to the underlying tissues. Staging - classification to reflect the level of tissue injury or damage) Stages of Pressure Ulcer as defined by the NPUAP (National Pressure Ulcer Advisory Panel), February 2007: Stage I - intact skin with non-blanchable redness of a localized area over a bony prominence. Stage II - partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as a blister. Stage III - full thickness tissue loss, subcutaneous fat may be visible, bone, tendon or muscle are not exposed. Stage IV- full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on the wound bed. Unstageable - full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar. DTI - Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Braden Scale- an assessment for predicting pressure sore risk, total score of 15-18 equals Mild Risk, total score of 13-14 equals Moderate Risk, total score of 10 -12 equals High Risk and total score of 9 or less equals Severe Risk. On 3/21/14 at 9:30 a.m., the Responsible Parties (RP1 and RP2) of Random Resident (RR) 29 complained of lack of foot care and treatment to RR 29's feet. They reported they had previously informed Certified Nursing Assistant (CNA 1) of ashen, dried and flaky skin on RR 29's legs and feet. RP 2 stated "CNA (1) said, "That's the way black people's skin is supposed to look." The RPs had pictures of RR 29's feet in the ashen and scaly condition. They also reported having informed RN 5 of Blacked Purple areas filled with blood at the top of Resident 29's great toes in early March. The RPs took photos of the toes on March 8th, 2014. RN 1 stated that she and the facility had copies of the photos taken on March 8th, 2014 by RP 2. Review of the clinical record on 3/21/14, showed the facility admitted RR 29 on 6/4/12, with [DIAGNOSES REDACTED]. The Braden Scale (a scale used to assess patients at risk for developing pressure ulcers) and Skin Risk Assessments for January, February and March 2014 placed RR 29 at "High Risk" for skin breakdown due to decreased range of motion (decreased distance and direction a joint can move to its full potential) and incontinence (inability to sense and feel when you have to have a bowel movement or urinate). The "Impaired Activities of Daily Living" (ADLs) Care Plan dated, 6/14/13 (last updated 3/11/14), showed RR 29 was totally dependent upon facility staff for transfers and movement in bed, transfers from bed to chair or to wheelchair, dressing, eating, toilet use, personal hygiene and bathing. Goals included "will be clean and well-groomed." Interventions included: Assist the resident with ADLs as needed. The Licensed Nurse's assessments for March 2014 showed nursing staff documented the skin was clean dry and intact and did not document the blistered purplish blackened areas on RR 29 s Great toes. There were no measurements by licensed staff available on 3/21/14 when requested. The facility had no record of any Podiatry Consult or notes for RR 29. "Skin Inspection" sheets showed Certified Nursing Assistants (CNAs) documented on 2/28/14, 3/2/14, 3/3/14, 3/4/14, 3/6/14, 3/8/14, 3/9/14, 3/10/14, 3/11/14, 3/12/14, 3/13/14, 3/17/14, 3/18/14, and 3/19/14 that fingernails, toenails, were inspected and that RR 29 had no bruises, skin tears, red areas, or open areas. During an observation on 3/21/14 at 10:15 a.m., Resident 29's feet presented with dry skin and both great toes had a blackened/purplish blood filled area at the top of the toes. RR 29 did not respond verbally yet nodded his head, "Yes," when RP 1 asked did his feet hurt. During an assessment of RR 29's feet and concurrent interview on 3/21/14 at 10:25 a.m., Registered Nurse (RN) 1 stated she assessed the areas were Deep Tissue Injury (DTIs - a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and she could not stage (classify to reflect the level of tissue injury or damage) the wound until it opens up, if it opens up. RN 1 stated she was going to call the doctor to obtain treatment orders. When asked regarding the previous skin assessment sheets and wound staging, RN 1 stated the areas had not been documented until this morning (3/21/14). When asked regarding previous documentation, RN 1 stated that the RP1 and RP2 stated they had informed RN 5 and she (RN 5) had not documented anything in RR 29's clinical record. RN 1 stated she attributes the cause of the DTIs to Resident 29 ' s shoes are too tight, causing pressure on the big toes. 2. During the initial tour (Observation and Interview) of the facility on 3/17/14 at 9:45 a.m., Resident 21 complained of pain in her back. Resident 21 was in a wheelchair. The Director of Nurses stated that Resident 21 had been with the facility for [AGE] years. Review of the clinical record on 3/17/14 showed the facility readmitted Resident 21 on 8/17/08 with [DIAGNOSES REDACTED]. Review of the nurse's notes and Skin/Wound Pressure Ulcer Assessment Tool dated 3/17/14 showed Resident 21 had a 1 centimeter (cm) x 0.7 cm Stage II Pressure Ulcer (Facility Acquired) at her left lateral [MEDICATION NAME] vertebrae. Most recent Braden Score was 16 which means Resident 21 was assessed as a high risk to develop a pressure ulcer. Observation, concurrent interview and record review on 3/18/14 at 9:00 a.m., showed a wound on Resident 21's back with wound gel (a dressing that provides a protective, hydrating, and lubricating layer over the wound that promotes healing.). The undated wound gel was removed by RN3. When questioned regarding the staging of Resident 21's pressure ulcer, RN 3 stated " it ' s a Stage 2. " When asked to describe the inner aspect of the wound bed, RN 3 stated, "There is sloughing." When asked if there was a pressure relieving device for back of Resident 21's wheelchair, RN 3 stated, " No. " During an interview on 3/18/14 at 9:15 a.m., RN 1 stated that if the wound has sloughing she has trained staff to assess it as a Stage III or above. Resident 1 stated that Resident 21's wound was staged wrong and she had corrected the paperwork and obtained a physician's orders [REDACTED].

Based on interview and record review, the facility failed to monitor the necessary blood testing for one (Resident 1) of three residents who received a daily dose of [MEDICATION NAME], a drug that inhibits the formation of clotting agents so that the blood cannot clot as easily. Resident 1 had two antibiotics which when taken with [MEDICATION NAME] would increase the risk of bleeding. [MEDICATION NAME] time and INR are two blood testing necessary to be monitored when a person takes [MEDICATION NAME] to determine the blood clotting time status and adjust or discontinue the dose of [MEDICATION NAME] according to the blood results. The staff interviews and record reviews showed that there were at least 14 different licensed nurses and a pharmacist over a six week period of time who failed to ensure that Resident 1 had the necessary blood testing while on [MEDICATION NAME]. The failure to monitor the clotting time resulted in Resident 1's brain hemorrhage and contributed to her death Definitions: Anticoagulation is a means to make a person's blood clot more slowly with the use of drugs. [MEDICATION NAME] time (PT) is a blood test that measures how long it takes the blood to clot in patients receiving oral anticoagulation. The normal range is 11.1 - 13.1 seconds. International Normalized Ratio (INR) is a calculation made to standardize [MEDICATION NAME] time. INR is based on the ratio of the person's [MEDICATION NAME] time and normal mean [MEDICATION NAME] time. A normal INR for a person who takes [MEDICATION NAME] is 2.0 to 3.0 times the normal PT. Findings: Review of the [MEDICAL CONDITION] Consultation Report dated [DATE] showed that the facility admitted Resident 1 on [DATE] from a rehabilitation center, for failure to wean from the ventilator. Resident 1's admission [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] Consultation Report indicated that [MEDICATION NAME] must be continued on admission and to monitor the INR. The [MEDICAL CONDITION] Consultation Report showed that on admission to the facility, Resident 1 had a [MEDICAL CONDITION] or breathing tube through the neck and able to talk with the use of a special valve or "talk leak." During an interview on [DATE]`2 at 4:05 p.m., RN A said that Resident 1 was alert, "a very nice lady," who communicated by talking and typing on the computer. Resident 1 communicated with a son by e-mails. The nurses notes dated [DATE] at 12:15 p.m. to 12:46 p.m. showed that Resident 1 was unresponsive with dilated pupils and had [MEDICAL CONDITION]. The blood work results dated [DATE] at 12:25 p.m. showed that Resident 1's PT was more than 63.2 seconds and the INR was more than 6.17, that indicated a complication related to the use of [MEDICATION NAME]. The facility transferred Resident 1 to the acute care hospital on [DATE] at 12:46 p.m.. Review of the Neurology Consult dated 9XXX,[DATE], at 2 p.m. to 5:30 p.m. showed that Resident 1 remained unresponsive with the voluntary movements and that the CT scan showed a large intracranial (brain) hemorrhage. On [DATE] at 11:35 a.m. , the neurologist declared Resident 1 to have brain death. The Discharge Summary Death Summary dated [DATE] showed that Resident 1 died on [DATE] at 3:30 p.m. of "[MEDICAL CONDITION] secondary to over anticoagulation, felt to be adverse drug reaction secondary to flucanazole." Further review of the medical records showed that on [DATE] the admission orders [REDACTED]. According to Lexi-Comp ONLINE, a nationally recognized drug information source, both drugs potentiate the effect of [MEDICATION NAME] that increase the risk of bleeding. Resident 1's MAR (Medication Administration Record) showed that Resident 1 received Fluconazole for the full seven days and [MEDICATION NAME] for three days while on [MEDICATION NAME]. The summary laboratory results of the blood drawn on [DATE] showed that Resident 1's PT was 22.1 seconds (normal range 9.6 - 12 seconds) with an INR of 2.09. The Order Set of the facility showed that the desired INR for residents receiving [MEDICATION NAME] to prevent clot formation was ,[DATE] to 2.2 times the normal PT. Resident 1's INR and PT results were within therapeutic range on [DATE] when admitted on [MEDICATION NAME]. There was no written order for subsequent INR and PT after [DATE]. Review of Resident 1's Anticoagulation Sheet from [DATE] to [DATE] where the licensed nurses would document the INR results and the [MEDICATION NAME] given, showed that 14 different licensed nurses initialed that [MEDICATION NAME] was given. There was no INR documented on the Anticoagulation Sheet. Interviews of eleven facility staff that included the administrator, pharmacist, licensed nurses and physicians regarding Resident 1 showed that the facility failed to coordinate and follow the written guidelines on monitoring the INR and PT while Resident 1 was on [MEDICATION NAME]. On [DATE] at 9:25 a.m., the Director of Pharmacy (DOP) stated that the pharmacist was to check a resident's INR while on [MEDICATION NAME]. The DOP stated that the facility did not have any documentation that the pharmacist checked Resident 1's INR from [DATE] to [DATE]. On [DATE] at 4 p.m., the administrator said that the Order Set approved on [DATE], constituted the policy and procedure for ordering lab work for residents on [MEDICATION NAME]. The Order Set as reviewed, indicated that while on [MEDICATION NAME], the INR must be checked every Monday for residents in the subacute unit of the skilled nursing facility. The administrator verbally acknowledged that the facility staff did not check Resident 1's INR in six out of six Mondays ([DATE] to [DATE]) while on [MEDICATION NAME]. During an interview on [DATE] at 3:30 p.m., Physician A, the admitting physician of Resident 1, could not remember if the wrote or gave a verbal order to continue monitoring the INR. Physician A said he relied on the facility's practice to routinely monitor the PT and INR as written on the Order Set, which he said, was not consistently used in the subacute care unit. On [DATE] at 4:05 p.m., RN A said during review of Resident 1's Anticoagulation Sheet and interview that she administered [MEDICATION NAME] to Resident 1 on [DATE] and [DATE]. RN A said that as a facility practice, the Order Sheet would only be used if a resident had [MEDICATION NAME] the first time. On Resident 1, RN A said that the Order Sheet was not used because she was on [MEDICATION NAME] when she was admitted to the facility. RN A verbally acknowledged that the original blood test record was missing from Resident 1's chart when admitted and the need for PT and INR order was overlooked. On [DATE] at 4:55 p.m., during an interview, RN B had a different explanation regarding the facility's practice on anticoagulation therapy. RN B said, she administered [MEDICATION NAME] to Resident 1 on [DATE] to [DATE] daily. According to RN B, the policy in effect during Resident 1's stay in the facility was to check the PT and INR every second Wednesday of the month on all residents on [MEDICATION NAME]. RN B said that nurses did not need a doctor's order and automatically placed an order for [REDACTED]. RN B said she did not order the PT and INR because Resident 1 had not been in the facility for a month. RN B said, she thought Resident 1's PT and INR were due on [DATE], the second Wednesday of September. On [DATE] at 5:25 p.m., LN C said, she administered [MEDICATION NAME] to Resident 1 eight times in August, none in September. According to LN C, the day shift nurse would call the physician with blood testing results and get an order for [REDACTED]. RN D said during an interview on [DATE] at 5:45 p.m. that she administered Resident 1 [MEDICATION NAME] on [DATE] and [DATE]. RN D said that she would not automatically enter an orders for PT and INR int he computer without a doctor's order. RN D said, there was pre-printed Order Set to use for residents on [MEDICATION NAME] which alerts the staff to order blood tests every Monday. The Order Set was part of the admission packet and the nurse who admits a resident should initiate the pre-printed Order Set. During a phone interview on [DATE] at 12:10 p.m., RN E, the licensed nurse who admitted Resident 1 said that the Order Set was not in use when the facility admitted Resident 1 on [DATE]. RN E indicated that it was the responsibility of the nurse who administered [MEDICATION NAME] to check the lab work prior to its administration. On [DATE] at 3:10 p.m., during the phone interview, RN F said she gave Resident 1 [MEDICATION NAME] on [DATE] and [DATE]. RNF said that on [DATE], Resident 1 had blood from the trachea upon suctioning and she notified Physician B. RN F said that Physician B gave instructions to watch Resident 1 for further signs of bleeding, but did not order PT and INR. RN F said that the subacute unit's protocol required a doctor's order and the nurses were not to automatically order blood tests. On [DATE] at 9:45 a.m., Physician B, the on-call physician for Resident 1 on the evening of [DATE] said that he knew Resident 1 was on [MEDICATION NAME] when the nurse said the last PT and INR were within therapeutic range. Physician B said that many residents who have tracheostomies have blood tinged secretions. Physician B said that in retrospect, he wished he had done more. Physician B did not know that there was no recent PT and INR done on Resident 1. On [DATE] at 3:30 p.m., during a phone interview LVN G said that she gave Resident 1 [MEDICATION NAME] on [DATE]. LVN G said that from [DATE]/to [DATE]. Blood testing for PT and INR was done every month for residents on [MEDICATION NAME]. LVN G did not know that Resident 1 did not have PT and INR done for over a month. LVN G said that she did not call Physician A for a PT and INR order because Resident 1 had no side effects such as bleeding from [MEDICATION NAME] on [DATE].