Every finding on record at Apple Valley Care Center

Based on observation, interview, and record review, the facility failed to ensure that one of the three sampled residents (Resident 1) received timely incontinence care to maintain dignity and comfort when on February 17, 2026, Resident 1 was left in a soiled brief for more than 40 minutes while being served lunch. This failure resulted in Resident 1's dignity and comfort being diminished. Furthermore, Resident 1 experienced a reduction in her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Findings: A review of Resident 1's Face Sheet (a facility document containing demographics) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which include Left Femur Fracture (break in a bone causing pain, swelling, bruising, and inability to move the affected area), Gout (a common, painful form of inflammatory arthritis that causes sudden, intense attacks of redness, swelling, and pain in joints, most frequently the big toe), Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breathe), Hypertension (high blood pressure), and History of falling. During a concurrent observation and interview on February 17, 2026, at 11:41 AM, Resident 1 was observed in bed, stating that she had put her call light on at 11:00 AM because she needed a diaper change. Resident 1 stated a Certified Nursing Assistant (CNA) brought her lunch at 11:30 AM and refused to assist Resident 1 with a diaper change. During an observation on February 17, 2026, at 11:43 AM, Resident 1 activated her call light while this surveyor was in the room at her bedside. In less than a minute, CNA 1 entered the room without knocking or announcing her entrance. CNA 1 turned off the call light from the wall switch located above Resident 1's bed, ignored Resident 1 entirely, walked over and checked on the roommate, and was about to leave the room. Resident 1, visibly distressed, asked CNA 1 to assist with a diaper change so she could eat her lunch, which was getting cold on the table. CNA 1 stated, I can't change your diaper because your roommate is eating right now. Resident 1 stated, I never felt so disrespected and frustrated. I will not eat while still soiled. During an interview with CNA 1 on February 17, 2026, at 11:52 AM, CNA 1 explained that she had been on her lunch break from 10:40 AM to 11:20 AM and claimed that someone else had answered the call light earlier and should have changed Resident 1's diaper. CNA 1 stated that no one had informed her of Resident 1's needs when she returned from her break. CNA 1 further stated, The DSD (Director of Staff Development) had instructed us not to provide peri-care if someone in the room was eating. I even asked my Charge Nurse if I was allowed to do it, and she said NO.During an interview with the Charge Nurse (CN 1) on February 17, 2026, at 11:58 AM, CN 1 stated that she instructed CNA 1 to pull the privacy curtain around the bed and assist Resident 1 with the diaper change. CN 1 denied instructing CNA 1 not to change Resident 1's diaper because the roommate was eating.During an interview with the Director of Staff Development (DSD) on February 17, 2026, at 12:09 PM, DSD stated she never instructed staff to hold or delay resident's care because someone in the room was eating. DSD further added that her expectations are that staff follow facility's policies and procedures and attend to residents' needs immediately without delay. DSD stated CNA 1 should have pulled the privacy curtain and change the resident's diaper before serving her lunch. Furthermore, DSD stated the proper procedure for all staff is to stop current tasks and respond to residents' needs immediately. DSD denied the existence of a policy preventing changing residents while roommates are eating and insisted that proper protocol requires using privacy curtains when providing personal care.During a concurrent record review and phone interview with Director of Nurses (DON) on March 2, 2026, at 11:42 AM, the facility's Policy and Procedure (P&P) titled, Dignity, revised on February 2021, was reviewed. The P&P stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facilities stay . 5. When assisting with care, residents are supported in exercising their rights . 7. Staff are expected to knock and request permission before entering residents' rooms . 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures, 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents . promptly responding to a resident request for toileting assistance. The DON indicated the facility's P&P was not followed when staff members did not provide necessary personal care and left Resident 1 in a soiled diaper for more than 40 minutes. The DON acknowledged this is a violation of the facility's standards of care and the federal requirements as outlined in the Centers for Medicare & Medicaid Services (CMS) regulations, which mandate that residents must receive proper hygiene and personal care to maintain their dignity and well-being.

Based on observation, interview, and record review, the facility failed to ensure their policy and procedure for Changes in Residents Condition (COC) or Status was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was assessed with discoloration on his lower back. 2. Resident 1 refused to receive Physical Therapy (a healthcare service that helps people restore movement, manage pain, and improve physical function after injury, surgery or treatments due to a condition. This failure had the potential for Resident 1's overall medical condition to decline and go undetected by the facility. Findings: 1.During a review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which there is too much sugar in the blood and the body is not able to control the sugar ), difficulty in walking ( unusual change in the normal walking pattern often due to problems with the brain nerves, leading to unsteadiness, limping, or other abnormal movements that affect mobility and coordination), muscle weakness ( reduction in muscle strength).During a review of Resident 1's admission Skin Assessment, dated October 29, 2025, at 7:30 AM, documented by the Wound Care Nurse (WCN), it indicated Resident had Discolorations on Lower Back.During a review of Resident 1's clinical records, there was no documented evidence to indicate the discolorations on Client 1's lower back were addressed by the facility.During a concurrent interview and review of Resident 1's clinical records with the WCN, on December 29, 2025, at 11:25 AM, the WCN stated that a monitoring of change of condition was not done for the discolorations of his lower back on admission skin. The WCN stated, I did not initiate the care plan as well. The WCN further stated that without the care plan they were not able to monitor the discoloration, nor assess or document the skin condition prior to Resident 1 transferring out of the facility. During an interview with the Director of Nursing (DON) on December 29, 2025, at 1:00 PM, the DON stated, The wound care nurse documented on the admission skin assessment that there is a discoloration on lower back. There should have been a change of condition notification to the primary physician and responsible party on admission. A care plan should have been initiated to monitor the discoloration for 14 days. The DON stated it should have been monitored and documented. 2. During a review of Residents 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus, difficulty in walking, and muscle weakness.During a review of Resident 1's admission Physician Orders, dated October 28, 2025, it indicated Resident 1 had an order for Physical Therapy Evaluation and Treatment.During a review of Resident 1's Physical Therapy Treatment Encounter notes from November 11, 2025, through November 16, 2025, it indicated Resident 1 refused to ambulate on four occasions, November 11, 2025, November 12, 2025, November 13, 2025, and November 16, 2025.During a review of Resident 1's clinical records, there was no documented evidence to indicate Resident 1's refusals to ambulate were addressed by the facility.During a concurrent interview and review of Resident 1's Physical therapy initial evaluation and treatment notes, on December 29, 2025, at 12:20 PM, with Physical Therapist (PT), the PT stated that Resident 1 often refused to get out of bed and walk with the walker on more than 2 occasions. The PT stated that she did not notify the licensed nurse and only documented the refusal on her notes.During an interview with the Director of Nursing (DON) on December 29, 2025, at 1:05 PM, the DON stated, Resident 1's refusal to get out of bed should have been communicated with the licensed nurse by the Physical therapist. DON further stated a care plan should have been initiated for refusal of treatment on more than 2 occasions so they can create a goal to minimize any decline in mobility.During an interview and concurrent record review with the DON, on December 29, 2025 at 1:10 PM, the DON reviewed and acknowledged the facility's policy and procedure titled Changes in Residents Condition or Status revised March 2025, which indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident right, etc.) . 1.The nurse will notify the resident's attending physician or physician on call when there has been .d. significant change in the resident's physical/emotional /mental condition.f. refusal of treatment or medications two (2) or more consecutive times. 2. c. Requires interdisciplinary review and /or revision to the care plan .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather pertinent information for the provider. 5. Notifications will be made to the responsible party when a change occurring in the resident's medical/mental condition or status. The DON stated there should have been a COC notification and documentation of discoloration of lower back on admission and a refusal of treatment when Resident 1 refused to ambulate on more than 2 occasions.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when:1. Resident 41, Resident 54, and Resident 139's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing (a thin plastic hose that delivers pressurized air from the nebulizer's air compressor machine to the medicine cup) was found unlabeled and not stored in plastic bags in accordance with the facility's policy and procedure (P&P).2. Resident 139's portable oxygen tank (a lightweight, mobile container that stores oxygen) nasal canula tubing (a small flexible plastic tube that connects to an oxygen source) was found unlabeled in Resident 139's room. 3. Licensed Vocational Nurse 3 (LVN 3) was observed entering Resident 51 and Resident 151's room on novel respiratory precaution without the required face shield or goggles in accordance with facility's policy and procedure (P&P).4. Resident 51, Resident 95, and Resident 160's nasal cannula (a lightweight, clear tube with two prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow for respiratory support) was found undated and unlabeled in accordance with facility's policy and procedure (P&P). These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 87 medically compromised residents and staff in the facility.Findings: 1.a. During a review of Resident 41's admission Record (contains medical and demographic information), the admission Record indicated Resident 41 was admitted to the facility on [DATE] with the diagnoses which included chronic respiratory failure with hypoxia ( The lungs have a long-term problem keeping enough oxygen in your blood, leading to low oxygen levels), Chronic Obstructive Pulmonary Disease(COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Asthma (a chronic lung condition where airways become inflamed, swollen, and narrow, making it hard to breathe). During a review of Resident 41's Physician Order dated February 26, 2025, the Physician Order indicated, . Change handheld nebulizer and put in new bag weekly. Initial and date HHN (handheld nebulizer) and bag every day shift every Thursday. During a concurrent observation and interview, with Licensed Vocational Nurse 2 (LVN 2) on February 15, 2025, at 10:50 AM, in Resident 41's room, LVN 2 confirmed Resident 41's nebulizer tubing was not in use and not stored in a plastic bag, she further confirmed the nebulizer tubing was not labeled per policy. 1b. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with the diagnoses which included, Chronic Obstructive Pulmonary Disease (COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Lobar Pneumonia (a lung infection that inflames the air sacs causing them to fill with fluid or pus making it hard to breathe), and Syncope and Collapse (a temporary loss of consciousness [fainting] and sudden fall). During a review of Resident 54's Physician Order dated December 8, 2025, the Physician Order indicated, . Change handheld nebulizer and put in new bag weekly. Initial and date HHN and bag every day shift every Thursday. During a concurrent observation and interview on December 15, 2025, at 11:40 AM with the Interim Infection Preventionist (IIP), in Resident 54's room, observed Resident 54's nebulizer tubing not in use on resident nightstand unlabeled and not stored in a plastic bag. IIP states it's the facility's policy for nebulizer tubing to be labeled and stored in a plastic bag when not in use. 1c. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to the facility on [DATE] with the diagnoses which included chronic respiratory failure with hypoxia (The lungs have a long-term problem keeping enough oxygen in your blood, leading to low oxygen levels), Chronic Obstructive Pulmonary Disease(COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Dependence on supplemental oxygen (extra oxygen supplied through a device to maintain enough oxygen in their bloodstream for their body to function properly). During a review of Resident 139's Physician Order dated December 8, 2025, the Physician Order indicated, . Change handheld nebulizer and put in new bag weekly. Initial and date HHN and bag every day shift every Thursday. During a concurrent observation and interview, on February 15, 2025, at 11:49 AM with IIP in Resident 139's room, observed Resident's 139's nebulizer tubing not in use, on Resident 139's nightstand unlabeled, and not stored in a plastic bag. IIP confirmed nebulizer should be stored in a plastic bag when not in use and it should be labeled. IIP further stated policy was not followed. During a concurrent interview and record review on December 17, 2025, at 2:00 PM, with the Director of Nursing (DON) in the DON's office, the facility's policy and procedure (P&P) titled, Respiratory Therapy-Prevention of Infection, dated 2001 was reviewed. The P&P indicated, . Steps in the Procedure. Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol .8. Label the nebulizer tubing and plastic bag with the date. Replace these items every (7) days or sooner if needed. Discard the administration set up every (7) days. The DON stated the P&P was not followed for Resident 41, Resident 54 and Resident 139 and should have been to prevent possible cross contamination. 2. During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was admitted to the facility on [DATE] with the diagnoses which included chronic respiratory failure with hypoxia ( The lungs have a long-term problem keeping enough oxygen in your blood, leading to low oxygen levels), Chronic Obstructive Pulmonary Disease(COPD- a progressive lung disease that blocks airflow, making it hard to breathe) and Dependence on supplemental oxygen (extra oxygen supplied through a device to maintain enough oxygen in their bloodstream for their body to function properly). During a review of Resident 139's Physician Order dated February 26, 2025, it indicated, .give (3) Liters/Minutes (L/M—a unit of measurement) oxygen per Nasal Canula every shift for COPD related to acute and chronic respiratory failure with hypoxia, COPD and dependence on supplemental oxygen. During a review of Resident 139's Physician Order dated February 26, 2025, the Physician Order indicated, .Change O2 (oxygen) cannula/mask tubing Q(Every)7 days or PRN (as needed) soilage every day shift every Thursday. During a concurrent observation and interview, on February 15, 2025, at 11:53 AM with IIP in Resident 139's room, the IIP confirmed there was no date on Resident 139's portable oxygen tank NC. IIP stated the facility's expectation is that all NC tubing should be labeled with the date, so staff know how old the tubing is and when to change it. During a concurrent interview and record review on December 17, 2025, at 2:13 PM, with the Director of Nursing (DON) in the DON's office, the facility's policy and procedure (P&P) titled, Respiratory Therapy-Prevention of Infection, dated 2001 was reviewed. The P&P indicated, . Steps in the Procedure. Infection Control Considerations Related to Oxygen Administration .5. Label the oxygen cannula, tubing and plastic bag every (7) days, or as needed.6. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. The DON stated the P&P was not followed and should have been for infection control prevention. 3a. During a review of Resident 51's admission Record, it indicated Resident 51 was admitted to the facility on [DATE], with diagnoses of Contracture of Muscle left lower leg (a permanent tightening and shortening of muscles, tendons, or skin, restricting joint movement and causing stiffness), Peripheral Vascular Disease (a circulation problem where narrowed or blocked blood vessels), and Dependence of Supplemental Oxygen (extra oxygen supplied through a device to maintain enough oxygen in their bloodstream for their body to function properly). During a review of Resident 51's Physician Order dated December 12, 2025, the Physician Order indicated, Novel Respiratory Isolation [strict infection control measures often use for unknown or highly contagious respiratory pathogens] times 10 days for COVID 19 [respiratory pathogen that causes difficulties in breathing] infection. During a review of Resident 151's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses of Encephalopathy (a disease of the brain caused by toxins, or infection which causes altered mental status), Transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, often from a blood clot traveling from another part of the body), and muscle weakness (a reduction in muscles' strength). During a review of Resident 151's Physician Order dated December 9, 2025, the Physician Order indicated, Novel Respiratory Isolation times 10 days for COVID 19 infection. During an observation on December 17, 2025, at 7:24 AM outside room [number of the room] (Resident 51 and Resident 151's room) observed novel respiratory precautions sign outside the door of room [number], COVID positive room. During an observation on December 17, 2025, at 7:27 AM outside room [number of the room] (Resident 51 and Resident 151's room) observed Licensed Vocational Nurse 3 (LVN 3) donning personal protective equipment (PPE), mask, gown and gloves prior to entering room. LVN 3 entered room without the required face shield or goggles. During an interview on December 17, 2025, at 7:35 AM with LVN 3, LVN 3 acknowledged that she did not adhere to the novel respiratory precaution requirements when entering room [number], a COVID-19 positive room, as she was not wearing the required face shield or protective goggles. During a concurrent interview and record review on December 17, 2025, at 12:45 PM, with the Director of Nursing (DON) in the DON's office, the facility's policy and procedure (P&P) titled, COVID-19, Prevention and Control, dated June 17, 2025, was reviewed. The P&P indicated, .F. Personal Protective Equipment.D. Eye Protection.a. Eye protection (which can be goggles or face shields) is no longer required for all direct resident care, including aerosol generate except: when caring for residents in the COVID care cohort or COVID isolation areas. The DON stated the P&P was not followed and it's important for staff to follow to prevent the spread of COVID-19 in the facility. 4. During a review of Resident 51's admission Record (contains medical and demographic information), it indicated Resident 51 was admitted to the facility on [DATE], with diagnoses of Contracture of Muscle left lower leg (a permanent tightening and shortening of muscles, tendons, or skin, restricting joint movement and causing stiffness), Peripheral Vascular Disease (a circulation problem where narrowed or blocked blood vessels), and Dependence of Supplemental Oxygen (extra oxygen supplied through a device to maintain enough oxygen in thier bloodstream for their body to function properly). During an observation on December 15, 2025, at 12:52PM, inside Resident 51's room, Resident 51 was observed receiving oxygen therapy via nasal cannula connected to an oxygen concentrator. The oxygen tubing was unlabeled and undated During an interview on December 15, 2025, at 12:54PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 acknowledged Resident 51 was on oxygen via nasal cannula unlabeled and undated, and should have been labeled and dated, but was not. During a review of Resident 51's Order Summary Report dated September 30, 2025, it indicated, .give (2) Liters/Minutes oxygen per Nasal Canula (a lightweight, clear tube with two prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow, connecting to an oxygen source) every shift for SOB related to dependence on supplemental oxygen. During a review of Resident 95's admission Record (contains medical and demographic information), it indicated Resident 95 was admitted to the facility on [DATE], with diagnoses of Acute and Chronic Respiratory Failure (a sudden worsening of breathing in someone with a pre-existing lung condition, like COPD, where the lungs can't get enough oxygen), and pneumonia (a lung infection that inflames the air sacs causing them to fill with fluid or pus, making it hard to breathe and get oxygen, and can be caused by bacteria, viruses, or fungi). During an observation on December 15, 2025, at 12:44 PM, inside Resident 95's room, Resident 95 was observed receiving oxygen therapy via nasal cannula connected to an oxygen concentrator. The oxygen tubing was unlabeled and undated During an interview on December 15, 2025, at 12:44 PM, with LVN 1, LVN 1 acknowledged Resident 95 was on oxygen via nasal cannula unlabeled and undated, and should have been labeled and dated, but was not. During a review of Resident 95's Order Summary Report dated June 20, 2025, it indicated, .Administer oxygen at (2) Liters/Minutes via Nasal Canula as needed. During a review of Resident 160's admission Record (contains medical and demographic information), it indicated Resident 160 was admitted to the facility on [DATE], with diagnoses of Paroxysmal Atrial Fibrillation (a type of irregular heartbeat where episodes start and stop on their own, typically resolving within seven days, though sometimes requiring treatment), and hydronephrosis with renal and ureteral calculous obstruction (kidney swelling caused by a kidney stone stuck in the ureter, blocking urine flow from the kidney down to the bladder, leading to urine backup, pain, potential infection). During an observation on December 15, 2025, at 11:28 AM, inside Resident 160's room, Resident 160 was observed receiving oxygen therapy via nasal cannula connected to an oxygen concentrator (a medical device that pulls in ambient air, filters out nitrogen and impurities, and delivers concentrated, purified oxygen (around 90-95%) to individuals needing supplemental oxygen for respiratory issues like COPD, via a nasal cannula or mask, providing a continuous supply for better breathing.) During an interview on December 15, 2025, at 11:33 AM, with LVN 1, LVN 1 acknowledged Resident 160 was on oxygen via nasal cannula unlabeled and undated, and should have been labeled and dated, but was not. During an interview and record review on December 16, 2025, at 4:13 PM with Interim Infection Preventionist (IIP), IIP acknowledged that Residents 51, 95, and 160 were on oxygen therapy via nasal cannula that are undated and unlabeled, and facility policy was not followed and should have been. During a review of Resident 160's Order Summary Report dated December 11, 2025, it indicated, .Administer oxygen at (2) Liters/Minutes via Nasal Canula continuously for diagnosis: shortness of breath (SOB) every shift. During a concurrent interview and record review on December 16, 2025, at 4:35 PM, with the Director of Nursing (DON), in the facility's conference room. the facility's policy and procedure (P&P) titled, Respiratory Therapy – Prevention of Infection revised 2001 was reviewed. The P&P indicated .Infection Control Consideration Related to Oxygen Administration. 5. Label the oxygen cannula, tubing and plastic bag every seven (7) days, or as need . The DON stated the P&P was not followed and should have been.

Based on observation, interview, and record review, the facility failed to ensure that call light was accessible for two of the three sampled residents (Resident 2 and 3), when Resident 2's call light was observed to be placed on the side of the bed, above the pillow, and beyond Resident 2's reach, while Resident 3's call light was found to be wrapped around the right bedrail, which was also out of Resident 3's reach.This failure had the potential to hinder Residents 2 and 3 from seeking help, when necessary, thereby elevating the risk of unaddressed care requirements and potential harm.During a review of Resident 2's face sheet (contains demographic and medical information) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture of unspecified part of neck of right femur (thigh bone), difficulty in walking. During a review of Resident 3's face sheet (contains demographic and medical information) indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (Hemiplegia is the complete paralysis of one side of the body, while hemiparesis is a milder weakness on one side) following cerebral infarction (a stroke) affecting right dominant side. During a concurrent observation and interview on November 18, 2025, at 11:47 AM, with Resident 2 in her room, when asked about the location of her call light, she indicated that she was unsure of where it was. It was noted that the call light was situated on the side of the bed, above her pillow, and was beyond her reach. During an interview on November 18, 2025, at 11:50 AM, with the Licensed Vocational Nurse (LVN 1), in Resident 2's room, LVN 1 indicated that Resident 2 is not under her care and verified that the call light is out of Resident 2's reach. She then placed the call light in Resident 2's hand and instructed Resident 2 to press the button on the call light whenever assistance is required. During a concurrent observation and interview on November 18, 2025, at 11:53 AM, with the Certified Nursing Assistant (CNA 1), in Resident 2's room, CNA 1 reported the last time she checked on Resident 2 was 30 minutes prior to her lunch break. However, she did not verify whether the call light was within Resident 2's reach. She stated that according to facility policy, she is required to check Resident 2's call light each time she enters the room, and to ensure the call light is accessible. During a concurrent observation and interview on November 18, 2025, at 12:00 PM, with Resident 3 in her room, Resident 3 was sitting on the right side of the bed close to the edge. Resident 3 stated she does not know where her call light is. During a concurrent observation and interview on November 18, 2025, at 12:03 PM, with CNA 1, in Resident 3's room, CNA 1 stated she is also responsible for Resident 3 and the last time she checked on Resident 3 was 30 minutes prior to her break. She further mentioned she did not verify the location of Resident 3's call light during her last check because she believed it had been removed by maintenance. Subsequently, CNA 1 searched for the call light and discovered it was wrapped around the right bedrail. The bed was lowered, causing the call light to hang down and touch the floor, making it unreachable for Resident 3. CNA 1 acknowledged she was not adhering to the policy by failing to ensure the call light was accessible to Resident 3. During an interview on November 18, 2025, at 12:08 PM, with the Maintenance (M1), in Resident 3's room, M1 indicated that the call light should not be encircled around the bedrail. M1 further stated the nursing staff must ensure the call light is accessible to Resident 3. He also mentioned that if a clip is required to secure the call light, the nursing staff should inform him. During an interview on November 18, 2025, at 12:41 PM, with the Minimum Data Set Nurse (MDS 1), in the conference room, MDS 1 stated that the policy requires the call light to be within reach. The call light is clipped onto the resident's gown, particularly for residents who exhibit weakness on either side. In this instance, Resident 3 has weakness on the right side, and the call light was secured around the right rail, rendering it out of Resident 3's reach. During a concurrent record review and interview on November 11, 2025, at 1:37 PM, with MDS 1, the facility's policy and procedure (P&P) titled, Call light dated September 2022, the P&P indicated, .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathroom facility and from the floor. MDS 1 confirmed that this is indeed their policy.

Based on interview and record review, the facility failed to provide the appropriate care and services to meet the needs of one of three sampled residents (Resident 1) when: Resident 1 was admitted to the facility for cholecystectomy (surgical removal of the gallbladder) and removal of drainage tube to surgical site, but the facility was unaware of when the surgery took place and follow up visits and treatments from Resident 1's surgeon. The facility did not have a care plan to address Resident1's previously identified behavior of pulling out the drainage tube. The facility did not notify Resident 1's physician regarding the incidents of Resident 1 pulling out the drainage tube. These deficient practices compromised the delivery of care and services and led for Resident 1 to be transferred to the hospital for pulling out the drainage tube attached to the surgical site. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cholecystectomy (surgical removal of the gallbladder), atrial fibrillation (irregular heart rhythm), biliary pancreatitis (gallstones blocking pancreatic duct), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1's Medical Record, on May 07, 2025, at 11:10AM, with the Director of Nursing (DON) the following were reviewed and verified: 1. [Acute Hospital Name] History and Physical dated April 04, 2025: A 92-yr old patient History of cholecystectomy presents to Emergency Department for removal of draining tube to surgical site. Per Emergency Medical Services (EMS) had cholecystectomy done and accidentally removed the draining tube, tube was meant to stay in place for approx. 6 weeks. (Facility does not know date or surgery or follow up on plan of care). 2. Order dated April 05, 2025: Right upper abdomen drain tube every shift monitor output. Right upper Abd drain tube site everyday shift cleanse with NS pat dry cover with dry dressing. (No ranges for output noted and when to notify physician). 3. Nurse Note April 06, 2025 @ 02:19: Patient observed pulling on drainage tube. Tubing remains patent and draining dark green fluid effectively. Education provided to patient on importance of keeping drainage tube patent . : 4. Nurse Note April 06, 2025 @2226: New admit, recent cholecystectomy for removal of drainage tube to surgical site. At 1626 resident attempted to remove drainage tube. Resident also been seen getting up out and wandering in the hallways . 5. Nurse Note May 04, 2025, 2143: At 2000 family members notified the Registered nurse (RN) and this License Vocational Nurse (LVN) they noticed the site around the residents Jackson Pratt (JP) (surgical drainage tube) drain was red, noticed pitting edema on both feet. Upon assessment, it was noted the (JP) drain was pulled out. Redness around the site .resident was transferred out by 2124. 6. Careplan: (No Notes for .At risk/attempts for pulling on JP drainage tube noted). During an interview on May 07, 2025, at 11:45AM, with the Certified Nursing Assistant (CNA), the CNA stated, Resident 1 was always messing with the (JP) tube, she would have it on her pant leg, hanging. I would stick in her pants and part hanging out. I was not here when she pulled it out. The nurse when I first started taking care of her told me to keep an eye out because she pulls the JP tube. She had an abdominal binder; she would take it off. During an interview on May 07, 2025, at 12:40PM, with the Director of Nursing (DON), the DON stated, Resident 1 Initial admission was April 04, 2025, for status post cholecystectomy she has acute pancreatitis, there was orders to monitor and drainage. She was taken to Emergency Department 4/4/25 because she pulled out tube cholecystectomy done JP to stay in place 6 weeks she has Dementia. I don't know when her actual surgery was done. When first admitted , we have a to check if there is any follow up appointments, if any procedures. We don't have that one for this resident. There is no documentation in system, us asking the family about the procedure, the JP tube incident of pulled out prior to admission. I can admit, she had episodes of her trying to pull out drainage tube but no documentation is noted of this. There was supposed to have an SBAR. I can agree this was already an issue of her pulling her JP tube before this resident got here. There is no follow through from us on this issue. We do SBAR first and inform the doctor and family and continue at least 72 hours monitoring and if still persist continue monitoring, we update the Careplan. I can agree there was no interventions set for her pulling the JP tube, she was sent out May 04. 2025, for pulling out her JP tube. We failed in not having Change Of Condition (COC) for her pulling on JP tube and no follow up regarding procedure (JT) tube from emergency Department or family. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revised June 2020, the policy and procedure indicated, Our facility shall promptly notify the resident, his or her Attending Physician and representative of changes in the residents medical/mental condition and or status .1a. accident or incident involving the resident .3.Prior to notifying the Physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider.7 the nurse will record in the residents medical record information relative to changes in the residents medical/mental condition or status. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered revised March 2024, the policy and procedure indicated, A comprehensive, person-centered care plan the includes measurable objectives and timetables to meet the resident's, physical, psychological and functional needs is developed and implemented for each resident. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents revised July 2024, the policy and procedure indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide-priorities.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) reviewed for assisted falls, when Resident 1 had a change in condition and an assisted fall which was not documented according to facility's policy. This failure had the potential for inaccurate communication between health care professionals, which can lead to delays in treatment, follow-up evaluations, and treatment plans for Resident 1. Findings: During the review of Resident 1's admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included systemic lupus erythematosus (a chronic autoimmune disease that occurs when the body's immune system attacks healthy cells and tissues), and difficulty in walking. During an interview on January 30, 2025, at 11:28 AM, with the Case Manager (CM 1), the CM 1 stated Resident 1 claimed that she slid and fell in her room, but she was unable to locate the incident report for Resident 1 when she searched for it. She also looked for a Change of Condition (COC) report in Resident 1's record, but she could not find one. During a telephone interview on January 30, 2025, at 11:56 AM, with the Certified Nursing Assistant (CNA 1), the CNA 1 stated on December 25, 2024, Resident 1 wanted to get up to use the restroom. When Resident 1 tried to stand, she slipped off the bed and was helped to the floor. The daughter of Resident 1 was present at the time. CNA 1 subsequently sought assistance from another CNA, and they successfully helped Resident 1 to the restroom together. CNA 1 stated that she informed the Licensed Vocational Nurse (LVN 1) of the incident. CNA 1 claimed that the resident was not assessed by LVN 1. CNA further explained, because Resident 1 was unharmed, she did not submit a report. However, the Director of Staff Development (DSD) gave her instructions to do so, and on January 3, 2025, she completed it and turned it in to the DSD. During an interview on January 30, 2025, at 12:08 PM, with the Director of Nursing (DON 1), the DON 1 stated nurses must still complete a COC report and enter it in the chart for assisted fall incidents. During a concurrent telephone interview and record review, on February 3, 2025, at 4:53 PM, with the MDS (Minimum Data Set- a computerized assessment) Coordinator (MDSC 1), the facility's fall protocol policy and procedure (P&P) titled, Fall Prevention Program undated, was reviewed. The P&P indicated, .ii Near/Assisted fall and residents found on another level i.e. from sitting position (on prior observation) found lying/sitting on the floor. *Fall Investigation-interviews and fall incident will be completed. MDSC 1 stated near fall is the same as assisted fall. During a telephone interview on February 4, 2025, at 3:21 PM with the LVN 1, the LVN 1 stated she has no documentation proving that she was notified of the December 25, 2024, occurrence. She went on to say that when reporting a change in condition, like an assisted fall, the CNA should complete a form known as stop and watch. If she was informed of the change, her signature will be on the form.

Based on interview, document review, and facility policy review, the facility failed to resolve grievances voiced by 5 (Residents #20, #36, #66, #195, and #200) of 5 residents who attended the resident council meeting. Findings included: A facility policy titled, Grievances/Complaints, Filing, revised 04/2017, revealed, Residents and their representative have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. During the resident council meeting on 10/15/2024 at 1:32 PM, the residents in attendance stated the facility did not always follow-up on their grievances. The residents stated they had voiced grievances related to the noise at night in the hall and staff respond their call light and state they would be back, but never return. The residents stated they have spoken to the facility about their concerns, things get better, but due to the high staff turnover, things revert back. The residents stated the Activity Director (AD) was the person that reported their concerns to. During an interview on 10/17/2024 at 10:56 AM, the AD stated resident concerns voiced during the Resident Council meeting were not considered grievances. The AD stated if the concerns were not addressed, they were discussed in the next resident council meeting. The Resident Council Minutes for the timeframe May 2024 through October 2024, revealed call lights not being answered and/or the call light turned off without staff returning to provide services were listed as concerns from May 2024 to October 2024.

Based on record review, document review, and interview, the facility failed to ensure the discharge Minimum Data Set (MDS) was accurate for the location of disposition at the time of discharge for 1 (Resident #91) of 18 sampled residents. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2024, revealed The RAI process has multiple regulatory requirements. Federal regulation at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. The User's Manual specified, Knowing the setting to which the individual was discharged helps to inform discharge planning. An Admission Record revealed the facility admitted Resident #91 on 07/16/2024. According to the Admission Record, Resident #91 discharged home on 07/30/2024. A discharge MDS, with an Assessment Reference Date (ARD) of 07/30/2024 indicated Resident #91 discharged to a short-term general hospital. Resident #91's care plan, included a focus area initiated 06/21/2024, that indicated the resident wished to discharge to home when their therapy goals were met. Resident #91's physician orders revealed an order with a revision date of 07/29/2024, that indicated the resident would discharge home with family on 07/3/2024. In an interview on 10/17/2024 at 8:51 AM, the MDS Coordinator stated the information on Resident #91's discharge MDS was incorrect. In an interview on 10/17/2024 at 11:29 AM, the Director of Nursing (DON) stated her expectation was that the MDS should be completed timely and correctly. The DON stated the facility did not have a policy for MDS completion but followed the RAI guidelines. In an interview on 10/17/2024 at 11:39 AM, the Administrator stated she expected the MDS to be correct.

Based on interview, record review, document review, and facility policy review, the facility failed to notify the physician of pharmacy recommendations and failed to ensure the facility policy indicated a time frame for the physician response to pharmacy recommendations for 2 (Resident #40 and Resident #85) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, Policy Statement The consultant pharmacist reviews the medication regimen of each resident at least monthly. The policy specified, 4. The goal of the MRR [medication regimen review] is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The policy indicated, 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identified that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The policy did not indicate a time frame for the physician response. 1. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility admitted Resident #40 on 09/07/2023. The MDS revealed the resident had active diagnoses to include arthritis, cervical disc degeneration, disorders of bone density and structure, and chronic pain syndrome. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #40 took an opioid medication. Resident #40's Order Summary Report, that contained active orders as of 10/16/2024, revealed an order dated 08/20/2024, for Morphine Sulfate (concentrate) solution 20 milligrams per milliliter (mg/ml), give 0.5 ml by mouth every four hours for pain management. The facility medication regimen review report dated 10/04/2024, revealed a recommendation that directed the staff to call the physician now and write an order to clarify the dose of morphine sulfate that should be administered to the resident. In an interview on 10/17/2024 at 11:29 AM, the Director of Nursing (DON) stated the morphine order was still incorrect and had not been clarified. The DON stated she forgot to follow up because the pharmacist discussed the recommendation with the charge nurse, but the DON did not know which charge nurse it was. The DON stated she expected the physician to be notified within 48 hours of a pharmacy recommendation. The DON stated if the recommendation was not followed up on, there could be an adverse reaction. 2. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2024, revealed the facility admitted Resident #85 on 08/09/2024. The MDS revealed the resident had active diagnoses to include Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and encounter for palliative care. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Resident #85's Order Summary Report, that contained active orders as of 10/16/2024, revealed an order dated 09/12/2024, for lorazepam intensol oral concentrate 2 milligram (mg) per milliliter (ml), give 0.5 ml by mouth every six hours as needed for anxiety manifested by agitation /restlessness and an order dated 09/19/2024, for ABHR (a topical gel that contained four drugs: lorazepam, diphenhydramine, haloperidol, and metoclopramide that was used to treat nausea and vomiting and to subdue agitated residents) cream/gel apply 1 ml to inner wrist every six hours as needed for anxiety/agitation. The facility medication regimen review report dated 08/12/2024, revealed a recommendation for Resident #85 that indicated agitation, unspecified, or restlessness were not sufficient reasons for the use an antipsychotic medication and to limit the as needed Ativan (lorazepam) to 14 days. The facility medication regimen review report dated 10/04/2024, revealed a recommendation for Resident #85 that indicated agitation, unspecified, or restlessness were not sufficient reasons for the use an antipsychotic medication and to discontinue the as needed ABHR today because as needed antipsychotics were not appropriate in this setting. In an interview on 10/17/2024 at 9:36 AM, the Director of Nursing (DON) stated Resident #85 was on the PRN medications because the resident was on hospice services. The DON stated she spoke to the hospice nurse about the pharmacist's recommendations, who then spoke to the hospice physician; however, there was no documentation of the physician notification. In an interview on 10/17/2024 at 10:31 AM, the Consultant Pharmacist stated his expectation was that his recommendations would be followed up on within two weeks. In a follow-up interview on 10/17/2024 at 11:29 AM, the DON stated her expectation was that the medication regimen review recommendations should be followed up on within one week. The DON stated if the physician was not notified there could be an adverse reaction. In an interview on 10/17/2024 at 11:39 AM, the Administrator stated she expected the physician to be notified of any pharmacy recommendations.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 2 medication errors out of 31 total opportunities, which resulted in a medication error rate of 6.45% (percent) for 2 (Resident #23 and Resident #66) of 7 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, Medications are administered in a safe and timely manner, and as prescribed. The policy specified, 10. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.An Admission Record indicated the facility admitted Resident #66 on 07/01//2024. According to the Admission Record, the resident had a medical history that included a diagnosis of generalized muscle weakness. Resident #66's Order Summary Report revealed a physician's order dated 07/02/2024, for a multiple vitamin tablet to be given one time per day as a supplement. During an observation of medication administration on 10/15/2024 at 9:17 AM, Licensed Vocational Nurse (LVN) #6 administered one multivitamin with minerals tablet to Resident #66. During an interview on 10/15/2024 at 11:20 AM, LVN #6 stated she gave a multivitamin with minerals to Resident # 66, but she gave the wrong one because the physician's order was for a multivitamin with no minerals. During an interview on 10/15/2024 at 11:34 AM, the Director of Nursing stated the nurse should have read the label on the medication, followed the order, and gave the correct medication to Resident #66. 2. An Admission Record indicated the facility admitted Resident #23 on 11/13/2020. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. Resident #23's Order Summary Report revealed a physician's order dated 01/19/2022, for a multiple vitamin with minerals tablet to be given one time per day as a supplement. During an observation of medication administration on 10/15/2024 at 9:53 AM, Licensed Vocational Nurse (LVN) #7 administered one multivitamin tablet to Resident #23. During an interview on 10/15/2024 at 11:16 AM, LVN #7 stated she did not give Resident #23 the multivitamin with minerals, but gave the resident the multivitamin. LVN #7 stated she gave the multivitamin without minerals, which was not ordered. During an interview on 10/15/2024 at 11:36 AM, the Director of Nursing stated the nurse should have followed the order and compared the medication label to the medication administration record before she administered the medication. During an interview on 10/17/2024 at 11:18 AM, the Administrator stated the nurses should have read the label for both residents and compared it to what was ordered and gave the right medication as ordered. The Administrator stated if there was a question about the medication, the nurses should have stopped and called to double check the order with the doctor or asked the DON for direction.

Based on interview and record review the facility failed to follow their policy for one of three sampled residents (Resident 1) when informed consent was not provided by resident or representative prior to psychotropic medication was administered (medications that affects mind, emotion and behavior). This failure resulted in Residents 1's representative rights to be violated and risks, benefits, adverse reactions and right to refuse the administration of the medication. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: senile degeneration of brain (mental deterioration, loss of intellectual ability), palliative care (specialized care for people with serious illness), unspecified dementia (impaired ability to remember, think or make decisions), anxiety (feeling of fear, feeling tense and restless), delirium (mental state of confusion, disoriented, and lack of awareness). During a concurrent interview and record review of Resident 1's with the Director of Nursing (DON), reviewed are as follows: 1. Physician Telephone Order (Hospice) Dated July 27, 2023, Medication Order: Haloperidol (antipsychotic medication used to treat certain types on mental disorders) LAC 5 mg/mL vial inject 1 mL IM every 6 hours as needed .Signed July 28, 2023. 2. Documents: Apple Valley Care Center, Facility Verification of Residents Informed Consent Psychotherapeutic Drugs of Prolonged Use of Device Dated July 27, 2023: Resident Representative as Charter Hospice [Name] Registered Nurse, Relationship: [Name] Registered .Nurse receiving Order [Name] Registered Nurse .doctor signature dated July 28, 2023. (No resident or Resident Representative (spouse) signature of consent noted). 3. Medication Administration Record (MAR) July 2023: Haldol injection 5mg/mL, inject 1 mL intramuscularly every 6 hours as needed for r/t agitation, Administered July 28, 2023, at 11:12 and 1754. During an interview with the Director of Nursing DON (DON), the DON stated, The hospice nurse told me she called the wife for Haldol consent. I will not give medication if there is not a verbal or a signed consent. The hospice nurse told me she was the one who called the wife to get the consent, but I see the document, she [the hospice nurse] signed on the wrong space, it has her name in the resident representative. When asked, based on this document reviewed does it state the wife was called and a verbal consent was given? No, it has the hospice nurse on both lines on the consent form. During a review of the facility's policy and procedure titled, Verification of Informed Consent for Psychotherapeutic Medications revised May 2024, the policy and procedure indicated: Policy Statement: Each resident has the right to be free from psychotherapeutic drugs and, to provide informed consent before treatment with psychotherapeutic drugs. Informational materials concerning psychotherapeutic drugs. The facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months .Procedure 2. If the resident or resident's representative cannot sign the informed consent form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. The personal exam and the signatures of the prescriber, resident, or representative can be completed and signed using remote technology. 4.Signed written consent will be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the president's health record contains written informed consent with the required signatures.

Based on observation, interview, and record review, the facility failed to maintain resident room temperatures between 71- and 81-degrees Fahrenheit ( F) in 39 of 41 rooms when temperatures dropped below 71 F in the resident bedrooms during the time in which the facility's heating system became inoperable on (January 10, 2024) and needed to be replaced. Furthermore, resident room temperatures continued to intermittently be below 71 F nearly one month later while the facility's heating system was still undergoing assessment and maintenance. This failure had the potential for all 95 of 95 residents living within the facility to experience physical discomfort, and emotional distress associated with exposure to cold temperatures throughout the facility. Findings: During an interview on January 12, 2024, at 2:25 PM, with the facility's Maintenance Director (MD), the MD stated the facility's heating system had not been functioning properly since January 10, 2024, and a vendor came out to replace the boiler (a device which heats water to work in conjunction with a coil and fan to provide warm air for heating). The MD further stated the heating systems boiler was over [AGE] years old and he believed the age of the system was a contributing factor to why the heating system was not working. During an interview on January 12, 2024, at 2:45 PM, with the Administrator (ADMIN), the admin stated to maintain appropriate temperatures, the facility purchased and was using space heaters for use in some resident rooms and the hallways as needed. The ADMIN further stated the facility staff were recording resident room temperatures every 3 hours. During an observation on January 12, 2024, at 3:09 PM, with the MD, Resident 1 was observed to be in her room under a blanket. The temperature of the room was taken using the facility's infrared thermometer gun at the wall near the head of the bed and at bed level. The room temperature was 65.5 degrees Fahrenheit, The MD verified the temperature. During an observation on January 12, 2024, at 3:11 PM, with the MD, the temperature of room [ROOM NUMBER] was taken using the facility's infrared thermometer gun at the wall near the head of the bed and at bed level. The room temperature was 68.2 degrees Fahrenheit, the MD verified the temperature. During a review of the facility document titled, Monitoring for Patient's Comfort and any Change of Condition (a document used to record room temperatures of every room in the facility), dated January 16, 2024 (six days after the facility's heating system was determined to be malfunctioning), at 2:00 AM (time temperatures were checked), the document indicated out of 45 rooms where residents resided, 39 of the rooms had temperatures recorded below 71 F; Of these 39 rooms, 19 of them had recorded temperatures below 65 F. During an interview on January 18, 2024, at 11:55 AM (eight days after the facility initially experienced problems with the heating system), with the ADMIN, the ADMIN stated the facility was still experiencing room temperatures under 71 degrees Fahrenheit and the vendor who installed the new heating system was in the process of inspecting the new system to determine why the heater was still unable to maintain warmer temperatures. During an interview on February 8, 2024, at 2:40 PM (29 days after the facility initially experienced problems with the heating system), with the ADMIN, the ADMIN stated the facility still had tube heaters (temporary heaters which utilize heated air to provide warmth) in use in the facility's hallways because the facility's own heating system was still unable to consistently maintain room temperatures above 71 F in 3 resident rooms. The ADMIN stated a 3rd party vendor is scheduled to be onsite next week (week of February 16, 2024) to assess and fix the facility's heating system. The ADMIN further stated she was informed that although the boiler was now working, the hot water pipes (pipes which distribute heated water throughout the facility so it can be used in conjunction with coils and fans to provide warm air for heating) were identified to be corroded and clogged in some areas which affected the hot water flow and was ultimately decreasing the efficiency of the heating system. During a review of the facility's policy and procedure titled, Extreme Weather - Heat or Cold, (undated), the policy indicated, .The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate this risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator . During a review of the facility's policy and procedure titled, Homelike Environment, Revised February 2023, the policy indicated, Residents are provided with a safe, clean comfortable and homelike environment .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) .

Based on observation, interview, and record review, the facility failed to maintain a safe environment for all 95 residents living within the facility when portable space heaters were in use in multiple resident rooms during the time the facility's heating system was being repaired. This failure had the potential for all 95 residents to be at risk of physical injury due to the increased risk of fire hazards associated with the use of space heaters. Findings: During an interview on January 12, 2024, at 2:25 PM, with the facility's Maintenance Director (MD), the MD stated the facility's heating system had not been functioning properly since January 10, 2024, and a vendor came out to replace the boiler (a device which heats water to work in conjunction with a coil and fan to provide warm air for heating). The MD further stated the heating systems boiler was over [AGE] years old and he believed the age of the system was a contributing factor to why the heating system was not working. During an interview on January 12, 2024, at 2:45 PM, with the Administrator (ADMIN), the admin stated the facility purchased a space heater for every room and was using the space heaters in resident rooms as needed if the temperature in the room dropped to less than 70 degrees Fahrenheit. The ADMIN further stated she would provide a list of resident rooms which currently had space heaters in use. During an observation on January 12, 2024, at 5:40 PM, Resident rooms [ROOM NUMBERS] were observed to have space heaters in their room which were approximately three feet high. The space heaters were plugged into an electrical outlet in the room and both space heaters were turned on and in use. During a concurrent interview and record review on January 12, 2024, at 5:00 PM, with the ADMIN, the ADMIN provided a document titled, Heaters, (undated). The document was reviewed and indicated a checkmark next to the following rooms: 108, 201, 202, 206, 207, 402, 406, 503, 509. The Admin stated the document indicated a checkmark next to each resident room which currently had space heaters in use. During an interview on January 12, 2024, at 5:45 PM, with the ADMIN, the ADMIN stated the facility was not considering any other plans to heat the facility which did not include the use of space heaters. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated January 2020, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's policy and procedure titled, Electrical Appliances, revised January 2023, the policy indicated, .2. Portable space heaters are not allowed in resident areas.

Based on observations, interviews, and record review, the facility failed to ensure call light (a device that triggers a visual and/or auditory queue when a resident needs assistance) was accessible for one of three sampled Residents (Resident 1) when Resident 1 ' s call light was not plugged into the wall and not accessible to Resident 1. This failure had the potential to place Resident 1, at risk of harm, as Resident 1 may have experienced an emergency or needed assistance and would not have been able to call for help. Findings: During a review of Resident 1 ' s clinical record titled, Admission Record (contains demographic and medical information), it indicated Resident 1 was admitted on [DATE] to the facility, with diagnoses, which included aphasia (difficulty speaking, reading and/or writing) following nontraumatic intracranial hemorrhage (brain bleed), difficulty in walking, and muscle weakness. During a concurrent observation and interview on September 6, 2023, at 12:38 PM, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 requested help and stated she could not find her call light. Resident 1 ' s call light was not plugged into the wall and was hanging below the right side of Resident 1 ' s bed. During an interview on September 6, 2023, at 12:40 PM, in Resident 1 ' s room, Resident 1 ' s roommate, Resident 2 states she will press her call light to get help for Resident 1. Resident 2 further states that she has to do this for her neighbor, Resident 1, because her call light either comes unplugged or she unable to find her light. During a concurrent observation and interview on September 6, 2023, at 12:50 PM, with the Certified Nursing Assistant (CNA 1), in Resident 1 ' s room, the CNA 1 responded to Resident 2 ' s call light. CNA 1 stated Resident 1 ' s call light cord was not plugged into the wall or with in Resident 1 ' s reach. CNA 1 stated the resident would not be able to call for help if needed. During a concurrent interview and review of the facility ' s policy and procedure (P&P) titled, Call Light- Answering, undated, on September 6, 2023, at 2:45 PM, with the Director of Nursing (DON), in the conference room, the DON stated that facility policy was to have resident call lights be plugged in, operational and within easy reach of the resident. The DON further stated that facility staff was to ensure that call lights are in working order and within resident ' s reach prior to leaving the resident ' s room, and it was not acceptable to have the call light not plugged in and out of Resident 1 ' s reach. During a review of the facility ' s P&P titled Call Light - Answering, undated, the P&P indicated, .All residents will have a call light in place at all time . Nursing Action . 3. Check to see that the system is functioning .5. Keep constant watch on call lights .

Based on interview and record review, the facility failed to report a low diastolic blood pressure of 50 mm Hg (a low blood diastolic blood pressure is less than 60 mm Hg) during an initial assessment for one of three sample residents (Resident 1). This failure had the potential to cause symptoms of dizziness and lightheadedness for Resident 1. Finding: During a review of the clinical record for Resident 1, the document title Admission Record dated May 01, 2023, indicated Resident 1 was admitted to the facility with diagnoses which included of Syncope (loss of consciousness caused by a fall in blood pressure). Resident 1 was not at the facility during investigation. During a review of the clinical record for Resident 1, the document title, Admission / Readmission Assessment - V 3 dated May 01, 2023, at 11 PM, it indicated, A4. Vital Signs. aa. Most Recent blood pressure: 100 / 50 mm Hg. There is no documentation in Resident 1's clinical record the doctor was notified of Resident 1's low diastolic blood pressure. During an interview with director of nurses (DON) on May 16, 2023, at 1:58 PM, the DON confirmed there was no documentation in Resident 1's clinical record the doctor was notified of Resident 1's low diastolic blood pressure. The DON stated that a diastolic of 50 mm Hg should be reported to the MD. The DON further stated that her expectations from the nurse is to notified MD that Resident 1 diastolic blood pressure was low, but the nurse did not notified MD. The Facility policy and procedure title, Vital Signs Monitoring, undated, indicated, B. Unusual findings, like irregular, rapid or slow pulse or respiratory rate, quality of pulse, blood pressure above or below set parameters shall be reported to the physician and recorded on the license nurses' notes. The DON acknowledge that nurse failed to follow the facility's policy and procedure.

Based on observation, interview, and record review, the facility failed to ensure one of 3 resident's (Resident 1) rights were honored when the facility did not notify and/or request from the physician a continuation of Resident 1 ' s home medications. This failure had the potential to cause pain and affect his psychosocial wellbeing. Findings: An abbreviated survey was conducted on August 8, 2022, at 11:07 AM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated an admitted [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 1, on August 8, 2022, at 11:33 AM, Resident 1 stated, I was on several medications at home: muscle relaxers, like [MEDICATION(S)], [MEDICATION(S)] (treats nerve pain) and [MEDICATION(S)]. [MEDICATION(S)] is a psychiatric medication for depression. There are several other meds that I take at home that were not continued here. This shoulder isn ' t going to get any better without a muscle relaxer to help it. I told them on admission that I wanted my home medications. During a review of the clinical record for Resident 1, the Active Home Medication List, undated indicated Resident 1 was prescribed [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] by a physician to take at home as well as other medications. During an interview and concurrent record review with Supervising Registered Nurse (RN) on August 8, 2022, at 1:32 PM, RN stated, Case management should have gone over the medication list when he was admitted . I don ' t see anything about the home medications. If the patient says I ' m supposed to be on this or that then I tell the Doctor. It will say in the notes, all medications verified with the Doctor. Home medications are given per the resident and then verified with the Doctor. I don ' t see any of that there. There are no notes about the home medications. The list of home medications is here but there is no note to address it. During an interview with Director of Nursing (DON) on August 8, 2022, at 2:10 PM, DON stated, There should have been a note that stated the medication list from home was verified with the Doctor. That it is okay to continue to take the home medications. I don ' t see any notes or notes even in the IDT (interdisciplinary Team) that they reviewed the home medication list. DON stated further, Importance of continued home medications. It is from their Primary Care Physician (PCP). It is to be continued. It is important for Resident 1 to continue to take his medications for his diagnoses. The PCP should have been informed of the home medications. We should have documented regarding the residents request of his home medications. The facility policy and procedure titled, Resident Rights dated 2017, indicated Purpose: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (Facility) will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The (facility) will protect and promote the rights of the resident.

Based on interview and record review the facility failed to follow their Policy when the licensed nurse failed to follow physician medication order for two of four sampled Residents (Resident 1, 2). This failure had the potential to place a clinically compromised Residents (Resident 1, 2) health and safety at risk. When not getting glucose checks and receiving the necessary medication as prescribed by the physician. Findings: During review of resident 1s Admission Record (general demographics) on July 06, 2022, indicates admitted to facility on March 09, 2022, with diagnosis (DX) of Type 2 Diabetes Mellitus with [CONDITION(S)] (body doesn ' t produce insulin), Difficulty in walking, Muscle weakness, Chronic Pulmonary Disease (block airflow, difficult to breathe), Acute [MEDICATION(S)] (urinary tract infection), Gout (uric acid deposit in feet), Obesity (over weight), [CONDITION(S)] (low oxygen in red blood cells), [CONDITION(S)] (low activity of [CONDITION(S)]), Dementia (memory loss), [CONDITION(S)] (high fats in blood), Hypertension (high blood pressure). During review of resident 1s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] =8 <70, give 4oz OJ call MD; 200-250=10; 251-300=12;301-350=14;351-400=16>401 Give 18 Units, Call MD, subcutaneously before meals and at bedtime for DM. During review of Diabetic Administration Record (DAR) on July 06, 2022, indicates no blood sugar reading for the following dates June 07, 2022@1130, June 11, 2022@1130, and June 16, 2022@1130. During a review of Resident 2s Admission Record (general demographics), indicates admitted to facilityJuly 01, 2022 with (DX) of [CONDITION(S)] (irregular heart rate, poor blood flow), Difficulty walking, Muscle Weakness, [CONDITION(S)] (slow heart rate), Type 2 Diabetes Mellitus with [CONDITION(S)] (body doesn ' t produce insulin), Obesity (overweight), [CONDITION(S)] heart disease of native Coronary Artery without [CONDITION(S)] (build up of fats in artery walls), [CONDITION(S)] (low activity of [CONDITION(S)]), Gastroenteritis, [CONDITION(S)] (Inflammation of stomach/intestines), [CONDITION(S)] (high cholesterol), Hypertension (high blood pressure), Repeated falls. During review of Resident 2s Diabetic Administration Record on July 06,2022 at 11:38AM, indicates, [MEDICATION(S)] Solution 100 Unit/ML (Insulin [MEDICATION(S)]) Inject 20 unit subcutaneously every 12 hours for DM: No documentation of administration for the following dates and times, July 04, 2022 @2200 and July 05, 2022 @1000. During review of Resident 2s Diabetic Administration Record on July 06, 2022, at 11:38AM, indicates, [MEDICATION(S)] Solution 100 Unit/ML (Insulin [MEDICATION(S)]) Inject as per sliding scale: If 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units, subcutaneously before meals and at bedtime for DM CALL MD FOR BS <60 OR>400. No documentation of glucose checks on the following dates, July 04, 2022 @1630, 2030 and July 05, 2022 @1130. During concurrent interview and record review with DON on July 06, 2022, at 12:21PM, when asked, based on the record review of the (DARs) for Resident 1 and 2; What is the expectation of your nursing staff? States, to follow orders, and they were not following orders. During concurrent interview and record review with the Administrator on July 06, 2022, at 1:35PM, when asked, what is the expectation for your staff in following physician orders? States, they should follow physician orders. Did agree the facility is not with standard practice when it comes to glucose monitoring. Informed, during record review of the residents sampled, documentation shows there are a few missing glucose checks and medication administration is that correct? States, yes. When asked, so if the glucose checks are not being done, the residents are not getting their possible needed insulin, is that correct? States yes. During review of the facility ' s policy and procedure titled, Medication and Treatment Administration, POLICY STATEMENT: Medications and treatments will be administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so .PROCEDURE Administration of Medications I. The licensed nurse administering the medication or treatment shall record the date and time, dose of the medications, type of treatment in the patients individual Medication/Treatment Record immediately after . Based on interview and record review the facility failed to follow their Policy when the licensed nurse failed to follow physician medication order for two of four sampled Residents (Resident 1, 2)

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food safety practices to prevent food-borne illnesses as evidenced by: 1. Six pie crusts were inside the freezer in an unsealed packaging, with no label nor dates which can result in food contamination and quality deterioration. 2. Food debris, black grime, and trash, were observed under the kitchen stove, tilting skillet, and center island that had the potential to contaminate food. 3. Food crumbs and debris were observed at the base of the cabinet attached to the kitchen stove that had the potential to contaminate food. 4. Wet pans and trays were stacked together which could promote bacterial growth. 5. The nourishment refrigerator's internal temperature was above 41 degrees Fahrenheit (refrigerator temperatures should be maintained at/or below 41°F), which had the potential to cause food-borne illness. These failures had the potential to result in food contamination and food-borne illnesses to a medically compromised population of 87 residents who receive nutrition from the facility kitchen. Findings: 1. During a concurrent observation and interview on January 3, 2022, at 9:35 AM, with the Dietary Service Supervisor (DSS), six pie crusts were inside the walk-in freezer in an unsealed packaging, exposed to air. There was no label nor date on the unsealed packaging. The DSS stated the foods inside the freezer should be sealed, labeled, and dated. During a record review of the facility's policy and procedure (P&P) titled, Procedure for Freezer Storage, dated 2018, the P&P indicated, .5. Store frozen food in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. The same policy further indicated, .6. All frozen food should be labeled and dated. 2. During a concurrent observation and interview with the DSS on January 3, 2022, at 10:08 AM, there were food debris, black grime, and trash seen under the stove, tilting skillet and center island. The DSS stated that staff had been taking days off due to Covid (COVID-19 is a virus that can cause mild to severe respiratory illness, including death) and they have not kept up with cleaning under the equipment. The DSS further stated the floor should be kept clean and free from debris and trash. During a record review of the facility's P&P titled, General Appearance of Food & Nutrition Department, dated 2018, the P&P indicated, .8. Mop under and around equipment, along the walls and in corners. In a review of the FDA (Food and Drug Administration) Federal Food Code 2017, 4-402.12 titled, Fixed Equipment, Elevation or Sealing, the Food Code indicated, The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food. 3. During a concurrent observation and interview on January 3, 2022, at 10:13 AM, there were food debris and crumbs noted at the base of the cabinet attached to the stove. The DSS stated there should be no food debris inside the cabinet. In a review of the FDA Federal Food Code 2017, 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the Food Code indicated, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4. During a concurrent observation and interview on January 3, 2022, at 10:21 AM, wet trays and pans were stacked on top of each other. Dietary Aide 1 (DA-staff whose duties include preparing and cooking food dishes, delivering food to patients and assisting the kitchen staff in maintaining a clean, sanitary workplace) stated they are usually air-dried on the counter after washing then stored, and that they should not be stacked wet. During an interview on January 6, 2022, at 11:23 AM, the Registered Dietitian (RD-experts in the disciplines of food and nutrition) stated that pans and trays should be air-dried before being stored. The RD further stated that they shouldn't be stacked together wet because this can promote microorganism growth. During a record review of the facility's policy and procedure titled, Dishwashing, dated 2018, the policy indicated, .5. Dishes are to be air dried in racks before stacking and storing. In a review of the FDA Federal Food Code 2017, 4-901.11 titled, Equipment and Utensils, Air Drying Required, the Food Code indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 5. During a concurrent observation, interview, and record review, on January 5, 2022, at 8:54 AM, the door for the nourishment countertop refrigerator was not closed completely. There were two thermometers inside, one on the door which indicated a temperature of 50 degrees Fahrenheit, and another at the backend of the refrigerator that indicated 38 degrees Fahrenheit. The temperature was validated by sampling the temperature of a carton of milk inside the refrigerator, which indicated 48 degrees Fahrenheit. The DSS stated that Dietary staff checks the refrigerator twice a day. A record review of the Nourishment Room Refrigerator Temperature Only log for January 2022, indicated that the last check was on January 5, 2022, at 6:01 AM, with a temperature of 35 degrees Fahrenheit. The DSS verified that it was a Dietary Aide 2 (DA 2) who signed for the log. During an interview on January 5, 2022, at 9:30 AM, DA 2 verified that she was the one who checked the nourishment refrigerator at 6:01 AM. DA 2 stated she checked on the thermometer inside the refrigerator, and not the one on the door. During an interview on January 6, 2022, at 11:23 AM, the Registered Dietitian (RD) stated there are two thermometers inside the refrigerator, and the thermometer on the door inside the refrigerator would give a more accurate representation of the temperature inside. During a record review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, the policy indicated, 1. Refrigerator- 41°F or lower Freezer- 0°F or lower. The same policy indicated, .2. Two thermometers, placed to be easily visible for checking, should be inside all walk-in, reach-in refrigerators. The second thermometer is a check against the first thermometer for accuracy. A temperature will be logged twice daily by a designated employee upon opening of the kitchen and upon closing of the kitchen.

Based on observation, interview, and record review, the facility failed to maintain the garbage storage area in a sanitary condition when one of two garbage dumpsters was overflowing with the lid open, and trash and leaves were accumulating around the garbage dumpster. This failure had the potential for harborage and feeding of pests within and around the facility. Findings: During an observation on January 5, 2022, at 8:50 AM, one of two garbage dumpsters outside the facility was observed to be overflowing with bags of trash, which caused the lid to remain open. Trash and leaves were accumulating on the surrounding area of the garbage dumpster. During an interview on January 5, 2022, at 9:03 AM, the Maintenance Supervisor (MS) stated the garbage dumpster should not be overflowing and the lids should be closed and there should be no trash and leaves accumulating around the dumpster. During a record review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Rubbish Disposal, dated 2006, the policy indicated, .7. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter and picked up daily except Sunday. In a review of the FDA (Food and Drug Administration) Federal Food Code 2017, 5-501.115 titled, Maintaining Refuse Areas and Enclosures, the Food Code indicated, A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, as specified under § 6-501.114, and clean.

Based on interview and record review, the facility failed to have all the required members (Director of Nursing, Medical Director, Administrator, and Infection Preventionist) at the monthly and quarterly Quality Assurance Performance Improvement (QAPI - meeting to identify opportunities for improvement, implement improvement plans and monitors effectiveness of interventions to improve the quality of life, care, and services to residents) meetings per facility policy and procedure, per regulatory requirements, when monthly and quarterly meetings did not have the required members documented as being present at these meetings. This failure had the potential to leave important issues unidentified for residents impacting their quality of life, care, and services. Findings: During a concurrent interview and record review, on January 10, 2022, at 9:44 AM, with the Administrator (Admin), the facility document titled, Quality Assurance & Performance Improvement [facility name] QAPI Attendance Record, dated January 2021 through December 2021, were reviewed. The Admin stated the QAPI committee meets every month with the required members, and quarterly with the Medical Director. For September 2021 through December 2021, it was noted the Medical Director had not signed the attendance record, and the Admin stated the Medical Director had not appointed a designee. The Admin further stated the Medical Director should have been there for the November 2021 meeting and was not present. During a telephone interview on January 10, 2022, at 10:33 AM, with the Medical Director, when asked about not being present for QAPI meetings from September 2021 through December 2021, the Medical Director stated, I attended meetings January to October, I missed November and December. I usually attend monthly. I missed a couple of months. A review of the QAPI Attendance Record indicated there was no documented evidence the Medical Director attended the meetings from September 2021 through December 2021. During a concurrent interview and document review on January 10, 2022, at 11:15 AM, with the Infection Preventionist Nurse (IPN), a review of the facility document titled, Quality Assurance & Performance Improvement [facility name] QAPI Attendance Record, dated January 2021 through December 2021, the IPN validated the Director of Nurses (DON) and the Admin were not signed in on the signature sheet for December 2021. The IPN further stated, during review of the QAPI Attendance Record for September 2021 through December 2021, Sometimes the Medical Director does not attend. During an interview and record review on January 10, 2022, at 11:41 AM, with the Admin, a review of the QAPI Attendance Record, indicated the DON was not present for the December 2021 meeting. The Admin stated, The DON wasn't at the meeting because she was on vacation. When asked why she, the Admin, was not present, the Admin stated she was there, she just forgot to sign in. When asked why the Medical Director was not present at the meetings, according to the sign-in sheet, the Admin stated, I told [medical director's name] he could attend once every three months and we would be good. A review of the facility's policy and procedure (P & P) titled, Quality Assurance Performance Improvement Program, dated April 1, 2016, the P & P indicated, .Procedure: 1. Quality Assurance Performance Improvement [QAPI] Committee: The QAPI Committee shall consist of the following members: a. Administrator - Committee Chairman b. Medical Director c. Director of Nursing Services . 2. The QAPI Committee shall meet on a monthly basis and more frequently as necessary or deemed appropriate by the Chairman of the Committee . 16. The QAPI Reports and Records: The minutes of all QAPI meetings will include at a minimum of the following information and shall be documented on the Meeting Minutes Form: a. Date and start time of the meeting b. Names and members present .

Based on interview and record review, the facility failed to ensure, for one of three sampled residents (Resident 1), that the resident received supervision and assistance outlined in the resident's care plan to prevent falls. This failure resulted in the resident not being transferred using a mechanical lift, having a fall and sustaining a fracture requiring hospitalization . Findings: During a review of the medical record for Resident 1, it showed the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a note written by Certified Nurse Assistant 1 (CNA 1), undated, showed the following: On 9/29/19 @(at) approx (approximately) 1400 (2:00 p.m) Found pt (patient) playing with her fecal matter (bowel movement). Cleansed pt up pt trying to get out of bed put pt on the edge on the bed. While transfering pt (room number) to wheelchair pt started to fight (mid-transfer) & scratch (fall assist) let her down to the floor. She continued to fight the wheelchair @ the side of the bed. pt kepted (kept) leaning toward the wheel chair. I let the bed down and called for assistance. We put her on the bed. I asked (roommate) for help press her call light but she had her phone in her hand. (CNA 1) went outside the room for help instead. A review of a written statement by CNA 2 dated 9/30/19, showed the following: September 29, 2019 approximately 130 pm I was standing at the nursing station and (CNA 1) call me for help with resident in room (number). Then resident was sitting on the floor with her back to bed, legs straight in front of her. Bed in low position. We both transferred her back to bed with our arms underneath her arms and the other hand holding the back of her pants. We lifted her and resident tried to bite me during transfer. We sat her on the bed, the resident began to lean backward on the bed. (CNA 1) placed the resident legs on the bed. I then called for the charge nurse. The charge nurse entered the room and (another staff member) with her. Resident was speaking Spanish. The bed had no linen on it. The charge nurse told (CNA 1) to leave the room and me and charge nurse will put the linen on the bed. We rolled the resident over and noticed them swelling above the right eye. I left the room and notified (CNA 1) that the resident had a knot on her head. (CNA 1) said I don't know how she got it. A review of a Nurse's Note dated 9/30/19 at 4:08 p.m., showed the following: CNA reported that resident became agitated and combative during transfer from bed to chair .Noted hematoma (blood under the skin-bruise) at left forehead and hematoma above the left eyebrow with slight redness noted . A review of the x-ray of the left knee results dated 9/30/19 at 9:16 a.m., showed the following: Modest [MEDICAL CONDITION] of the left knee. Acute avulsion fracture (an injury to the bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone) of left lateral femoral condyle (the two rounded prominences at the end of the femur-thigh bone) with mild displacement . A review of a Nurse's Note dated 9/30/19 at 3:53 p.m., showed the following: Received pt in bed in semi -fowlers position (head of bed elevated). Pt L (left) leg was elevated on pillow with ice packs on her knee. Pt was asleep and arousable. Noted increased swelling and pain on L knee, xray result of L knee and skull came and MD (medical doctor) made aware of results. Dr (doctor) order to send out to (name of hospital) for further evaluation. (name of ambulance company) called and daughter notified. A review of a facility document Fall Risk Evaluation, shows under the section titled Instructions .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. A review of Resident 1's Fall Risk assessment dated [DATE] at 2:40 p.m., (two months before the resident's fall), showed a fall risk score of 23. A review of the MDS (Minimum Data Set-a comprehensive resident assessment) for Resident 1 dated 7/16/19, showed under Section G-Functional Status that the resident required extensive assistance with two persons for transferring the resident. A review of the ADL (activities of daily living) care plan for Resident 1 dated 12/5/18, showed for transfers, Use mechanical lift based on manufacturer's recommendation and specifications. Staff to maintain and properly secure resident prior, during and after device use . During an Interview with the MDS nurse on 10/1/19 at 4:15 p.m., she stated Resident 1 needs assistance with transfer with more than one person. During an interview with the Director of Nursing on 10/1/19 at 9:00 a.m., she stated CNA 1 should have left the resident on the bed and gone to get help. During an interview with the Resident Care Coordinator on 1/10/20 at 8:50 a.m., she stated the Hoyer lift (mechanical lift) transfer intervention was in place before her fall. She could not bear weight. A review of a facility policy and procedure titled, Transfer of Resident From/To Bed, undated, showed the following: It is the policy of this facility to assess and provide appropriate and safe transfer techniques for each resident based on individual need.

Based on interview, and record review the facility failed to ensure one (1) of three (3) sampled residents (Resident A) was wearing non-skid socks when he ambulated to the restroom. This failure resulted in a slip and fall in the restroom and Resident A hitting his head and consequently sustaining a subdural hematoma (a collection of blood outside the brain caused by a severe head injury, the bleeding and increased pressure on the brain can be life threatening). Findings: A review of Resident A's factsheet (demographics) indicated, Resident A was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission orders [REDACTED] a. Fall Precaution b. [MEDICATION NAME] (a medication to treat blood pressure) 0.1 MG (milligrams) give one (1) tablet by mouth every 4 hours. c. [MEDICATION NAME] (a medication used to treat anxiety) 0.5 MG give 1 tablet by mouth every 8 hours as needed for anxiety. A review of the Admission Fall Risk Assessment, dated (MONTH) 12, (YEAR) at 10:17 PM, indicated the following: #4. Medication Use - Antihypertensive (a class of medications used to treat high blood pressure) and Benzodiazepines (a class of drugs used to treat anxiety) were not marked as medications taken more than three (3) X (times)/(per) week, including prn's (as needed). #11. Gait Analysis - Assess a residents gait while, standing in one spot, walking straight forward and while making a turn - this section was left blank. Fall risk score 6, Moderate Risk During an interview with the Director of Nurses (DON) on (MONTH) 15, (YEAR) at 12:30 PM, she stated Resident A's Initial fall risk assessment was incorrect. The DON stated Resident A should have been a high-risk fall for falls because Resident A had history of falls at home, a weak gait and used a cane. During an interview with a Licensed Vocational Nurse (LVN 1) on (MONTH) 26, (YEAR) at 3:13 PM, she stated she completed Resident A's initial fall risk assessment. LVN 1 stated the initial fall risk assessment was inaccurate because Resident A was currently taking [MEDICATION NAME] (a medication to treat high bloodpressure) and she did not mark Antihypertensive. LVN 1 stated Resident A was currently taking [MEDICATION NAME] (a medication that treats anxiety) but she did not mark Benzodiazipine. LVN further stated did not ask Resident A question # 11, if he used a a cane or a walker. A review of Resident A's Care Plan, indicated, Resident A is a high risk for falls related to history of fall, syncopal ([MEDICAL CONDITION]) episode, [MEDICAL CONDITION] (dizziness), unsteady gait. Goals: Resident A will be free of falls . Resident a will be free of minor injury . Resident A will not sustain serious injury . Interventions: Ensure that Resident A is wearing appropriate footwear (non-skid socks) when ambulating . During an interview with LVN 3 on (MONTH) 15, (YEAR) at 12:12 PM, she stated a Certified Nurse's Assistant (CNA 1) informed her that Resident A reported he had fallen in the restroom. LVN 3 stated as she walked in to Resident A's room to assess him, CNA 1 was changing his regular socks to non-skid socks. LVN 3 stated she assessed Resident A and a bump to Resident A's head was noted. Resident A was interviewed and he stated he ambulated to the restroom, slipped, and fell because he was not wearing non-skid socks. LVN 3 stated she did not know why Resident A was not wearing non-skid socks. The following day (February 23, (YEAR)) Resident A's son approached LVN 3 and reported Resident A was in pain and was nauseas. LVN 3 immediately assessed Resident A and Resident A was grimacing, complaining of 10/10 head pain. Subsequently 911 was called and Resident A was transported to the General Acute Care Hospital (GACH). During an interview with CNA 1 on (MONTH) 26, (YEAR) at 2:23 PM, she stated Resident A reported the fall incident to her on the morning of (MONTH) 14, (YEAR) (day of the incident). CNA 1 stated while conducting morning rounds, she observed Resident A sitting on his bed rubbing his head. CNA 1 stated she asked Resident A what happened, Resident A reported he fell in the restroom. CNA 1 stated Resident A was wearing regular socks. CNA 3 stated the truth is, that he (Residnet A) fell beacuse he did not have non-skid socks on, he had on regular socks on. During an interview with LVN 2 on (MONTH) 26, (YEAR) at 2:53 PM, she stated she was the assigned LVN on the N[NAME] (night shift). LVN 2 stated she did not know if Resident A was wearing non-skid socks on (MONTH) 13, (YEAR) (the night prior to the fall incident) because she did not assess Resident A for non-skid socks. A review of the Nurses Progress Notes, dated (MONTH) 21, (YEAR) at 10:49 AM, indicated, Resident stated he went to the bathroom, fell and hit his head on the toilet. Resident noted to have a bump to the top of head. A review of the Nurses Progress Notes, dated (MONTH) 22, (YEAR) at 8:00 AM, indicated, Resident c/o (complained of) severe head pain Resident states he thinks it's from the fall yesterday. Resident transferred out to hospital for further evaluation. During an interview with the DON on (MONTH) 26, (YEAR) at 3:30 PM, she stated the fall investigation concluded the casue of the fall was Resident A was in a hurry to use the restroom and he slipped because he was not wearing non-skid socks. The DON stated the care plan was not followed. A review of the Hospital Evaluation Report, dated (MONTH) 22, (YEAR), indicated, Resident A was transferred from the receiving GACH for a fall he sustained at the rehab facility with a [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. Resident A stated he fell at the rehab facility and hit his head on the toilet. CT scan of the head showed subdural hematoma. Neurosurgery evaluated Resident A and he will be admitted to Neurosurgery services. A review of the Neurosurgery Inpatient Progress Note, dated (MONTH) 23, (YEAR) at 5:00 AM, indicated, [AGE] year old male s/p (status [REDACTED]. CTH (CT scan of head) showed subdural hematoma (a collection of blood outside the brain caused by severe head injuries, the bleeding and increased pressure on the brain can be life threatening). Continue [MEDICATION NAME] (a medication that treats [MEDICAL CONDITION]) for a total of 7 days. A review of the facesheet (demographics) indicated, Resident A was readmitted to the facility on (MONTH) 23, (YEAR). During an interview with the Physical Therapist (PT) on (MONTH) 27, (YEAR) at 11:00 PM, he stated Resident A's readmission evaluation (February 25, (YEAR)) indicated, Resident A was weaker upon transferring from a sitting position to a standing position compare to the initial PT evaluation conducted on (MONTH) 13, (YEAR). The PT further stated Resident A had a decline in transfers from minimal assitance to moderate assistance from the initial evaluation. A review of Resident A's Physical Therapy Plan of Care, dated (MONTH) 13, (YEAR), indicated, the following: Initial Assessment: Functional Deficits (Limitation or impairment of physical abilities/function), Transfers, Bed, chair: minimal assistance Transfers, Wheelchair, Mat: minimal assistance Transfer, Sit to Stand: minimal asisstance Transfer, Stand to Sit: minimal assistance A review of Resident A's Physical Therapy Plan of Care, dated (MONTH) 25, (YEAR), indicated, the following: Functional Deficits, Initial Assessment: Transfers, Bed, chair: moderate assistance Transfers, Wheelchair, Mat: moderate assistance Transfer, Sit to Stand: moderate asisstance Transfer, Stand to Sit: moderate assistance The facility's policy and procedure titled, Falls and Fall Risk, Managing, dated (MONTH) 2007, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Monitoring Subsequent Falls and Fall Risks 1. The staff will monitor and document each resident's response to interventions intended to reduce failling or the risks of falling.

Based on observation, interview and document review, the facility failed to provide comfortable and safe temperature for 2 of 6 sampled residents (Resident 1 and 2), when the facility heating system failed. This failure resulted in the residents complaining of being freezing cold and uncomfortable. This failure also had the potential to jeopardize and adversely affect the residents' health and safety for a universe of 82 residents, by placing them at risk for hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat) and serious harm. Immediate Jeopardy was called on November 4, 2014 at 6:40 PM in the presence of the facility's Administrator, due to the facility's inoperable heating system. Findings: On November 4, 2014 at 3:15 PM, an unannounced on site visit was conducted to the facility to investigate a complaint regarding heating system failure. During a tour of the facility on November 4, 2014 at 3:30 PM, accompanied by the Administrator, the hallway temperature felt cold. During a concurrent interview with the Administrator, he stated, "The heaters are not working. I have a guy coming to fix it." During an observation of the residents' rooms and different hallways on November 4, 2014 at approximately 4 PM, accompanied by the Administrator and the Maintenance Supervisor (MS), the measurement of the residents' rooms/ the residents' common areas temperature was conducted. The following residents' rooms/ the residents' common areas had temperature readings of: room [ROOM NUMBER] was at 65.0 degree Fahrenheit. room [ROOM NUMBER] was 68.0 degrees Fahrenheit. room [ROOM NUMBER] was 69.0 degrees Fahrenheit. room [ROOM NUMBER] was 67.0 degrees Fahrenheit. room [ROOM NUMBER] was 67.0 degrees Fahrenheit. room [ROOM NUMBER] was 66.0 degrees Fahrenheit. room [ROOM NUMBER] was 66.0 degrees Fahrenheit. room [ROOM NUMBER] was 69.0 degrees Fahrenheit. room [ROOM NUMBER] was 69.0 degrees Fahrenheit. Dining Room was 67.0 degrees Fahrenheit. room [ROOM NUMBER] was 70.0 degrees Fahrenheit. Front hallway 100's was 70.0 degrees Fahrenheit. Back hallway 200's was 67.0 degrees Fahrenheit. During an interview with Licensed Vocational Nurse (LVN) 1 on November 4, 2014 at 4:20 PM, LVN 1 stated the temperature in the facility is too cold. During an interview with Resident 1 on November 4, 2014 at 4:45 PM, Resident 1 was observed curled up in bed with blankets pulled tightly up to her chin. She complained that the heating system was not working for about a week. Resident 1 stated that she had complained about it to the facility staff; however, her room temperature remained too cold for her. She further stated, "It is a torture chamber here. It is ridiculously cold here." A concurrent observation of Resident 1's room, noted the temperature was 65 degrees Fahrenheit. This was verified with the MS at the time of the observation and he stated "The room is too cold." During an interview with Resident 2 on November 4, 2014 at 5:15 PM, Resident 2 was observed in bed with two blankets. Resident 2 stated, "It's too cold here. It has been like this since last Monday. I am not comfortable. The whole facility is too cold." She further stated, "My daughter brought me a warmer blanket from home." A concurrent observation of Resident 2's room, noted the temperature was 66 degrees Fahrenheit. This was verified with the MS at the time of the observation and he stated "The room is too cold." The MS stated the room temperature should be between 71 to 81 degrees Fahrenheit. A review of the facility document for a work order estimate, dated August 20, 2014 indicated the 2 (two) heating boilers for the heaters needed repair. The recommendations included "Shut down and isolate system, perform complete annual maintenance on both boilers ...perform combustion analysis, check all safety and controls ..." During an interview with the MS on November 4, 2014 at approximately 5 PM, he stated the work repair had not been done due to waiting for the approval from the company. The MS stated he was aware the 2 heating boilers needed maintenance and he admitted the repair was not done. He stated the facility had no system for monitoring the residents' room temperature since the two boilers identified malfunction on August 20, 2014. A review of the Accuweather for the weather temperature at the facility location, dated November 4, 2014 indicated the forecast at 12 AM, the temperature was 48 degrees Fahrenheit, at 2 AM was 46 degrees Fahrenheit and at 4 AM was 43 degrees Fahrenheit. On November 4, 2014 at approximately 3 PM Administrator reported to California Department of Public Health the temperature in the facility last night was around 40 degrees Fahrenheit. The Administrator stated there was no heating system in the facility since last night. A review of the facility's policy and procedure, titled "Inspection of Heat/Air- Conditioning Systems", dated August 2008, indicated "Prior to the beginning of each heating/cooling season ...facility's heating and air conditioning systems shall be inspected ...functionality of equipment ..." During an interview with the Administrator on November 4, 2014 at approximately 5:30 PM, he confirmed the low temperatures in the facility due to heating system failure. He stated the residents' rooms temperature should be between 71 to 81 degrees Fahrenheit. The immediate jeopardy was abated on November 4, 2014 at 10:17 PM, with the Administrator upon receipt of an acceptable corrective action plan as follows: Offer all residents blankets and jacket. Offer warm beverages. Provide extra staff to monitor residents frequently. Maintenance will monitor ambient temperatures and functionality of all heating equipment. Boilers valve will be repaired upon receipt of parts from air conditioning and heating company.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 20 residents (Resident 2), in a universe of 85, did not receive unnecessary drugs. This failure resulted in Resident 2 receiving an excessive dose of a [MEDICAL CONDITION] (a medication that alters the chemical levels in the brain which impact mood and behavior) drug ([MEDICATION NAME]) without an allowable [DIAGNOSES REDACTED]. This failure also had the potential to contribute to Resident 2's decline in activities of daily living (ADLs) and the potential to contribute to falls. Findings: An observation of Resident 2, on March 4, 2013 at 12:30 PM, revealed that the resident was sitting in the bed, eating lunch and had tremors (involuntary trembling) of the arms which were evident as she was feeding herself. Resident 2 was alert and oriented to person and place. An observation and a concurrent interview of Resident 2, on March 5, 2013 at 1 PM, revealed that the resident was in her room sitting on the bed. When asked by the surveyor if she participated in activities, the resident stated that sometimes she does but most of the time she just stays in the room. Resident 2 also stated that she had "bad tremors" and did not know why. A medical record review of Resident 2 on March 5, 2013 at 1:30 PM, revealed that the resident was [AGE] years of age, originally admitted to the facility on [DATE]. According to a licensed vocation nurse (LVN 1), the resident had been transferred to the acute hospital multiple times as a result of difficulty breathing and the last readmitted to this facility was on February 18, 2013. Resident 2's medical diagnoses were, obstructive chronic [MEDICAL CONDITION] with exacerbation ([MEDICAL CONDITION] - a lung disease with episodes of difficulty breathing), difficulty in walking, lack of coordination, unspecified essential hypertension (a sustained elevation in blood pressure that is not due to some other cause), unspecified [MEDICAL CONDITION] (An underproduction of the [MEDICAL CONDITION], which is located near the Adams apple and is responsible for producing hormones for regulating the body's metabolism. [MEDICAL CONDITION] contributes to the body systems slowing down), [MEDICAL CONDITION] not elsewhere classified (Depression that is usually of moderate or marked intensity.), [MEDICAL CONDITION] (A [MEDICAL CONDITION] brain disease that can cause impaired thinking, disorientation and mood changes.), and anxiety (A feeling of worry, nervousness or unease). A record review of Resident 2 on March 5, 2013 at approximately 1:30 PM, of the "Initial Psychiatric Evaluation" dated January 24, 2013, revealed that the psychiatrist assessed the resident and diagnosed her with "Dementia with depression and agitation." She documented the following, mood was appropriate, no [MEDICAL CONDITION], no obsession or compulsiveness, no auditory or visual hallucinations (hearing or seeing objects that are not real or present) and no [MEDICAL CONDITION] (thoughts of killing herself). A record review on March 5, 2013 at 1:30 PM, of Resident 2's medication regimen revealed the following: On February 18, 2013, Resident 2 had also been prescribed [MEDICATION NAME] 100 milligrams by mouth at bedtime as needed for [MEDICAL CONDITION] (difficulty sleeping). Except for February 23, 2013, Resident 2 received the [MEDICATION NAME] every night from February 18 to February 25, 2013 (7 nights). According to the "Medication Administration Record" (MAR - a document nurses use to document the medication administered to a resident), the resident complained of 2 episodes of [MEDICAL CONDITION]. [MEDICATION NAME] is an antipsychotic medication that is used to treat [MEDICAL CONDITION] (a thought disorder marked by disorganized speech and behavior), [MEDICAL CONDITION] disorder (a condition in which people go back and forth between a very good or irritable mood and depression ) with major depressive episodes and other psychiatric [DIAGNOSES REDACTED]. [MEDICATION NAME] should also be used with caution in the elderly population. According to 2012, AstraZeneca (registered trademark for [MEDICATION NAME]), [MEDICATION NAME] is not approved for treating elderly patients with dementia-related [MEDICAL CONDITION] (having lost touch with reality due to confusion or memory loss) because of the increased risk of death. Side effects include tremors, confusion, and dizziness among others. A facility Pharmacist Consultant reviewed Resident 2's medications during the week of February 21, 2013 and made the following recommendation: "This resident is receiving the antipsychotic agent [MEDICATION NAME] but lacks an allowable [DIAGNOSES REDACTED]. On February 26, 2013 (5 days after the pharmacist made the recommendation), the [MEDICATION NAME] was discontinued and [MEDICATION NAME] 2 milligrams at bedtime and 1 milligram in the morning was prescribed ([MEDICATION NAME] is an antipsychotic medication which has a maximum daily dose of 2 milligrams per day. A telephone order obtained by a nurse (RN Supervisor) indicated that Resident 2 was prescribed the medication for [MEDICAL CONDITION], combativeness and aggressive behavior towards staff however there was no documented evidence from a physician or psychiatrist that the resident had been diagnosed with [REDACTED]. From February 26, 2013 to March 7, 2013, Resident 2 received a total of 3 milligrams of [MEDICATION NAME] every day (11 days). The nurses documented a total of 8 episodes on various shifts and days that the resident was yelling out and was combative. On March 7, 2013 at approximately 1:30 PM, the RN Supervisor was interviewed. He stated that he called the physician who ordered the [MEDICATION NAME] to ask him if there was an indication for the use of the [MEDICATION NAME]. The RN Supervisor stated that the physician told him, "Well, how does [MEDICAL CONDITION] NOS (not otherwise specified) sound, is that good?" The surveyor asked the RN Supervisor, if the physician's assessment and [DIAGNOSES REDACTED]." The RN Supervisor also informed the physician that the order for the [MEDICATION NAME] was an excessive dose and he stated that the physician remained silent and provided no new orders. On February 18, 2013, physician orders [REDACTED]. Nurses documented on the MAR, from February 20, 2013 to February 28, 2013, Resident 2 received [MEDICATION NAME], 40 milligrams every day (9 days). According to the drug manufacturer, [MEDICATION NAME] is used for depression but should be used with caution to treat elderly depression and patients who have severely decreased kidney function and are on a diuretic (a medication, such as [MEDICATION NAME], which Resident 2 was administered to remove excess fluid from the body) . According to Resident 2's Medication Administration Record (MAR - a document that nurses use to document the medications administered and the reasons why), Resident 2 had 3 episodes of depression during this time frame. From March 1, 2013 to March 7, 2013 Resident 2 received 40 milligrams of [MEDICATION NAME] every day (7 days) although, nurses documented that the resident had no episodes of depression. Resident 2 was also given [MEDICATION NAME] 20 milligrams every day from February 2, 2013 to March 7, 2013 for [MEDICAL CONDITION] (excess fluid within the body). From March 3, 2013 to March 6, 2013 Resident 2 received [MEDICATION NAME] 5/325 milligrams ([MEDICATION NAME] - a narcotic used to treat moderate to severe pain and should be used with caution with people who have [MEDICAL CONDITIONS], mental illness and the elderly.) According to Watson Pharmacology Inc. 1/2011 guidelines, they indicated to use the medication with caution in the elderly and those with severe impairment of the liver or kidney function and [MEDICAL CONDITION]. Warnings and side effects included respiratory depression, impaired thinking, and decrease in mental and physical performance, anxiety, and mood changes. The guidelines also indicated that the medication is excreted (removed) by the kidneys and therefore the risk of toxic reactions could be greater in patients with impaired kidney function and that the elderly population is more likely to have decreased kidney function. From March 2, 2013 to March 6, 2013, Resident 2 had an order for [REDACTED]. Resident 2 was given one Klonopin everyday and two on March 5, 2013 (In 4 days, 5 doses were given). The telephone order obtained by the nurse indicated that the physician ordered that the resident obtain the medication as needed however there was no documented evidence of the reason why it was ordered. According to the drug manufacturer guidelines, Klonopin is used to treat [MEDICAL CONDITION] disorders, panic disorders, anxiety disorders among others. Klonopin should be used with caution with the elderly because it can increase the chances of over-sedation and should also be used with caution with patients who have [MEDICAL CONDITION]. Other side effects include difficulty breathing, confusion and chest discomfort. During a previous admission for Resident 2 in November of 2012, a facility Pharmacist Consultant wrote the following recommendations to the ordering physician, "Please evaluate the current order for long-acting Klonopin may be changed to a shorter-acting benzodiazepine (medication used to treat anxiety) such as [MEDICATION NAME] 1 milligram every 12 hours as needed for this [AGE] year old resident. Medicare (CMS) has identified certain medications as posing an increased risk of adverse effects when given to elderly residents. Klonopin is a long-acting benzodiazepine with a half-life of 20-50 hours and may increase the risk of falls, fractures, urinary incontinence, pressure sores, and confusion..." There was no documented evidence to indicate that the physician followed the consultant's recommendations. Resident 2 had still been given Klonopin in March 2012 and there was no order for the [MEDICATION NAME]. From February 19, 2013 to February 26, 2013, Resident 2 received [MEDICATION NAME] (for anxiety) 0.25 milligrams by mouth, every day except for February 23 and 24, 2013. According to the drug manufacturer, [MEDICATION NAME] should be used with caution with the elderly because of the increased risk of over-sedation and tremors and should also be used with caution in patients with lung disease and impaired kidney disease. Side effects also include confusion, irritability, sleep disturbance, irregular heart rhythm, among others. From March 3, 2013 to March 7, 2013, according to the MAR, Resident 2 received 15 milligrams of [MEDICATION NAME] every night for [MEDICAL CONDITION]. According to the drug manufacturers guidelines, [MEDICATION NAME] should be used with caution with the elderly and patients with decreased kidney function. Some of the side effects include, confusion, falls, tremors, dizziness, shallow breathing among others. During Resident 2's initial admission to the facility, on August 24, 2012, a physician ordered 15 milligrams of [MEDICATION NAME] every night as needed for [MEDICAL CONDITION]. A facility Pharmacist Consultant, made the following recommendations in August 2012, to the physician who ordered the [MEDICATION NAME]: "Please consider reducing the current dose of [MEDICATION NAME] 15 milligrams at bedtime as needed to 7.5 milligrams when needed for this [AGE] year old resident..." There was no documented evidence to indicate that the physician followed the recommendations. Additionally, the physician re-ordered the [MEDICATION NAME] 15 milligrams during Resident 2's readmission to the facility. From February 19, 2013 to March 7, 2013, Resident 2 received 150 milligrams of [MEDICATION NAME] everyday twice a day. [MEDICATION NAME] is used to treat major [MEDICAL CONDITION] and side effects include difficulty sleeping, tremors, dizziness among others. A record review was conducted on March 6, 2013 at 12 PM, of Resident 2's labs which were obtained on March 4, 2013 at 3:15 AM to monitor the resident ' s kidney function. The "Estimated Glomerular Filtration Rate" (eGFR - a test used to determine how the kidneys are working) indicated that Resident 2's eGFR was 28 the "Interpretation of the eGFR" indicated that results from 15-29 indicated "severely reduced" kidney function. Resident 2's "Creatinine" (a test that measures kidney function) indicated that the resident's level was 1.78, a normal range is 0.60 - 1.20 (according to the lab). A record review on March 7, 2013 at approximately 1 PM, of Resident 2's history and physical performed by the physician, indicated that the physician determined that the resident "Does NOT have the capacity to understand and make decisions." A record review and a concurrent interview with the RN Supervisor, was conducted on March 7, 2013 at 1 PM of the "Facility Verification of Residents Informed Consent Psychotherapeutic Drugs or Prolonged use of a device." The document indicated that the RN Supervisor obtained the informed consent for the use of the [MEDICATION NAME] and for the Klonopin from the resident on February 26, 2013 at 11 AM. The RN Supervisor stated that he did not obtain the consent from the resident and that he made an error when he filled out the document. He stated that he obtained the consents from the resident's sister who had the power of attorney to make decisions for Resident 2. The RN Supervisor also stated that the physician gave him the orders for the medications and he explained the medication, side effects and the [DIAGNOSES REDACTED]. On March 8, 2013 at 9:40 AM, a telephone interview was conducted with a facility Pharmacy Consultant. He stated that he was not the one who conducted the medication reviews however after the surveyor read the recommendation for the antipsychotic medication to the consultant, he stated that based on the pharmacist's review, there was no [DIAGNOSES REDACTED]. The Pharmacist Consultant stated that it looked as if the physician discontinued one antipsychotic medication and ordered another one. He also stated that the Respirdal exceeded the recommended daily dose. Additionally, he stated that the Pharmacist Consultants review the medications, make the recommendations to the physicians and the facility and it is up to them to address them or not however if they choose not to, they should document that they acknowledged the recommendations. An interview was conducted on March 8, 2013 at 11:30 AM with Resident 2's sister via telephone. She stated that she did not know that her sister (Resident 2) had been diagnosed with [REDACTED]. She also stated that she had "never spoken with a male nurse only with ...(name of a female nurse) and the doctor." The resident's sister also stated that the physician did not tell her that her sister had psychiatric problems. Additionally, Resident 2's sister stated that she asked the physician to prescribe something for her tremors because according to the conversations that she had over the telephone with her sister, she had been experiencing many tremors while she was trying to eat and drink from a cup. During an interview, on March 8, 2013 at 3:45 PM, with CNA 1, she stated that Resident 2 had "more tremors now compared to before, especially while holding her cup." An Immediate Jeopardy (IJ) was called on March 8, 2013 at 4:20 PM in the presence of the facility's Administrator, Quality Assurance Nurse, and the Director of Nurses (DON). The facility failed to ensure that 1 of 20 residents (Resident 2), in a universe of 85 did not receive unnecessary drugs. This failure resulted in Resident 2 receiving an excessive dose of a [MEDICAL CONDITION] (a medication that alters the chemical levels in the brain which impact mood and behavior) drug without an allowable [DIAGNOSES REDACTED]. This failure also had the potential to contribute to Resident 2's decline in activities of daily living (ADL's) and the potential for falls. An acceptable plan of correction was received and agreed upon by the survey team on March 8, 2013 at 7:32 PM. The facility's plan included revised policy and procedures for Psychotherapeutic Medications, in- service training for all licensed staff regarding Psychotherapeutic drug use and follow up care for the sampled resident involved. The IJ was abated on March 12, 2013, at 2:25 PM in the presence of the survey team and the facility's Administrator, Quality Assurance Nurse and Director of Nurses. On March 11, 2013 at 9 AM, an observation was made of Resident 2. She was sitting in her bed, confused, slow speech, very shaky and a small bruise and bump on the right forehead. The resident stated that she fell while gardening in her backyard with a friend in Pomona. During an interview on March 11, 2013 at approximately 9:15 AM, the RN Supervisor stated that Resident 2 had an unwitnessed fall during the night and was transferred to a hospital for a CT of the head (x-rays of the head). The RN Supervisor stated that he had not been in to evaluate the resident and that an LVN (LVN 1) did the assessment after the resident returned from the hospital. On March 11, 2013 at 9:15 AM, LVN 1 was interviewed. LVN 1 stated that when the resident returned from the hospital she had more tremors but had not been confused. LVN 1 reassessed Resident 2 and stated, "She is confused and is not the same as she was when she first arrived." On March 12, 2013, at 9 AM during an observation, it was noted that Resident 2's bed was empty and had no linens. The RN Supervisor and LVN 2 stated that the resident experienced chest pain and shortness of breath during the night and was transferred to a hospital. A nurse's note dated March 11, 2013 at 11:10 PM, indicated the following, "Patient was complaining of shortness of breath, oxygen saturations 84% on 3 liters per minute. Patients pulse 94, I called Dr...(name provided) got order to send patient to...(name of hospital) for evaluation..." a normal oxygen saturation is usually greater than 91%.

Based on observation, interview and record review, the facility failed to ensure that the environment was free from accident hazards for 1 of 20 sampled residents (Residents 3) when Resident 3 fell from the bed while the bed was in a high position. This resulted in Resident 3 sustaining a laceration above the eye and a fractured toe. The facility also failed to conduct 24 hours of neurological (mental) checks per facility policy and to consistently implement the care plan to prevent further falls. On 5/16/12, the clinical record for Resident 3 was reviewed and showed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/15/12, at approximately 11:00 AM and 5/18/12, at 1:25 PM, during initial tour and a random observation, Resident 3 was observed awake, lying in bed, with a fall mat to the resident ' s left side. No mat was observed to the resident ' s right side of the bed. On 5/18/12, at 1:30 PM, during a concurrent observation and interview, CNA 3 stated that Resident 3 was at risk for falls and needed mats to both sides of her bed to prevent injury if a fall was to occur. The CNA 3 confirmed that there was no mat to the residents' right side of the bed. The mat was observed folded up in the corner of the room and placed the mat to the right side of the resident ' s bed. On 5/17/12, at 4:40 PM, during an interview with the DON, he stated that the facility investigated Resident 3's unwitnessed fall on 2/16/12, and had determined the bed was left in a high position and not returned to a low position. The DON verified that the bed should always be put back to the low position after providing resident care and before leaving a resident alone. Upon further interview with the DON, he stated that Resident 3 should have been monitored for 24 hours per facility policy to assess the resident ' s mental status and to determine if more follow up was needed. The DON also verified that the fall risk assessment was not conducted for Resident 3 at least quarterly and after the fall on 2/16/12 per facility policy. Clinical record review was conducted on 5/16/12 and 5/17/12. A document entitled, "Fall Risk Assessment", last updated 8/31/10, indicated Resident 3 scored a 12. A total score of 10 or greater are considered "High Risk" for potential falls. The "nurses notes", dated 2/16/12, at 12:45 AM, showed Resident 3 was found on the floor at the bedside, sustained a 1 & 1/2 inch laceration above the left eye and complained of soreness to the back. Resident 3 was transferred to the hospital for evaluation. The same document dated 2/16/12, at 12:00 PM, showed Resident 1 returned to the facility with 5 stitches above the left eye. And, an x-ray report, dated 2/16/12, showed Resident 3 sustained a fracture to her 2nd toe of her left foot. The "Risk for falls" care plan, revised 5/31/11, indicated the following interventions: assist with all transfers, lock bed and wheelchair when transferring, call light in reach and answered promptly and two person assist with all transfers. A review of the facility policy titled, "Fall Prevention Program", revised, 12/10, stipulated the following: 1. Residents will be assessed on admission and quarterly thereafter for risk factors for falls. 2. Licensed nurse will immediately check for the following: complete neurological checks for all head injuries including level of consciousness, orientation, changes in speech and communication, blood pressure, hand grip, dizziness, unsteady balance, pupils reaction to light. 3. A new fall risk assessment will be completed to identify any new area of concern that may need to be addressed on plan of care. 4. "FALL PREVENTION INTERVENTIONS...Interventions include, but are not limited to: a. Low Bed"

Based on observation, interview, and record review, the facility failed to ensure that 1 of 18 sampled residents (Residents 4) was free from unnecessary drugs and failed to obtain informed consent prior to the administration of psychoactive medications. This failure resulted in a significant decline in Resident 4's activities of daily living (ADLs-things normally done on a daily basis) and the inability to maintain the highest practicable well- being. Findings: During initial tour on 6/20/11, at 11:40 AM and accompanied by LVN 6 Resident 4 was observed in a low bed with fall mats and a tab alarm ( a device that has an audible alarm which detects movement when a person is rising out of bed). Resident 4's eyes were closed and when spoken to kept her eyes closed while speaking in a soft incomprehensible tone. LVN 6 stated that she thought that Resident 4 was on [MEDICATION NAME]. During an observation on 6/20/11, at 3:30 PM, Resident 4 was in bed, with eyes closed and did not respond to verbal commands. A review of Resident 4's clinical record revealed that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set / MDS (a comprehensive resident assessment), dated 3/19/11, revealed that Resident 4 had unclear speech, sometimes had the ability to express ideas and wants and sometimes had the ability to understand others. Resident 4 had short term and long-term memory problems, had moderately impaired cognitive skills for daily decision-making and disorganized thinking. The MDS also revealed that Resident 4 required extensive assistance when transferring from bed to wheelchair and to the standing position. Resident 4 also required extensive assistance with dressing, eating, and using the toilet. A review of Resident 4's MDS, dated [DATE], revealed that Resident 4 had unclear speech and sometimes had the ability to express ideas and sometimes had the ability to understand others. Resident 4 Resident 4 had short term and long-term memory problems, had moderately impaired cognitive skills for daily decision-making and disorganized thinking. The MDS also revealed that Resident 4 required total assistance when transferring from bed to wheelchair and to the standing position. Resident 4 also required total assistance with dressing, eating, and using the toilet. A review of Resident 4's physician admission orders [REDACTED]. During an observation on 6/21/11, at 8:30 AM, Resident 4 was in bed with eyes closed and did not respond to verbal commands. During an observation on 6/21/11, at 1:45 PM, Resident 4 was in bed with eyes closed. CNA 1 and CNA 4 were observed to be attempting to feed the resident. Resident 4's eyes remained closed and she clenched her lips. During an interview with CNA 1 and CNA 4, on 6/21/11, at 1:45 PM, they stated that Resident 4 kept her eyes closed, puckered up her lips and that at times Resident 4 was able to make her needs known. A review of Resident 4's nursing notes, dated 4/14/11, at 4 PM, indicated that a nurse informed the physician, via telephone, that Resident 4 had been combative and had hit staff when they attempted to provide care. The physician ordered, via telephone, [MEDICATION NAME] (an antipsychotic medication) 2.5 milligrams (mgs) twice a day for multi-infarct dementia manifested by combativeness via gastrostomy tube (GT- a tube surgically inserted into the stomach for the purpose of administering medications and to provide tube feedings). Further review the documentation showed that Resident 4 was not seen by the physician until 5/21/11. A review of Resident 4's physician progress notes [REDACTED]. During an observation of Resident 4, on 6/21/11, at 4 PM, during a dressing change done by LVN 1, Resident 4's eyes remained closed as the dressing change was being done and during the repositioning of the resident. During an observation on 6/22/11, from 8:15 to 8:30 AM, Resident 4 was alert, sitting in a wheel chair in the dining room. Resident 4 was observed to frequently keep her eyes closed and would clench her lips while staff attempted to assist with breakfast. A review of Resident 4's antipsychotic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of Resident 4's MAR for "Monitoring episodes of [MEDICAL CONDITION] manifested by combativeness every shift (day shift, PM shift and night shift" for 4/14/11 to 4/30/11, revealed that Resident 4 had 11 episodes of combativeness. A review of Resident 4's careplans, revealed no documentation to show that a careplan was developed for the use of [MEDICATION NAME]. During an interview on 6/22/11, at 1:30 PM, with the DON who reviewed Resident 4's care plans and confirmed that there was no care plan to address Resident 4's use of the antipsychotic medication, [MEDICATION NAME]. Additionally, she stated that there should have been a careplan addressing the [MEDICATION NAME]. A review of Resident 4's nursing notes, dated 5/18/11 thru 5/21/11, revealed no documented evidence that Resident 4 had combative behaviors. A review of Resident 4's physician progress notes [REDACTED]. The physician's documentation showed that Resident 4 was confused, often had her eyes closed and talked to herself, had decreased agitation and decreased combativeness. The physician's documentation also showed that the physician felt that Resident 4 required maximum assistance, was unable to stand or walk, responded to simple commands, and was not oriented to time or place but had psychotic features. A review of Resident 4's physician orders [REDACTED]. On 6/21/11, record review of Resident 4's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of Resident 4's MAR indicated Monitoring episodes of [MEDICAL CONDITION] manifested by combativeness" for 5/1/11 to 6/22/11, revealed that Resident 4 had zero episodes of combativeness. During an interview with the DON and a concurrent record review, on 6/22/11, at 1:30 PM, of Resident 4's consents revealed no documented evidence that a consent was obtained for the use of [MEDICATION NAME] 5 mgs twice a day from the surrogate decision maker. During an interview with LVN 2, on 6/22/11, at 11:30 AM, she stated that at times, Resident 4 resisted care, had increased anxiety and combativeness and that the physician had increased the [MEDICATION NAME] to 5 mg twice a day because the [MEDICATION NAME] (anti anxiety medication) was not working. However, review of physician notes dated 5/21/11 documented that Resident 4 had decreased agitation and combativeness. LVN 2 further stated that Resident 4 was still receiving the [MEDICATION NAME]. During an interview with CNA 2, on 6/22/11, at 11:35 AM, she stated that Resident 4 required a higher level of care, and usually did not participate in activities, however, she was not usually combative. During an observation on 6/22/11, at 11:40 AM, Resident 4 was in the activity room, did not participate with activities, and often kept her eyes closed. During an interview with LVN 3, on 6/22/11, at 1 PM, she stated that she took care of Resident 4 on 5/21/11, which was the day that the physician increased the [MEDICATION NAME] order. LVN 3 stated that Resident 4 was fidgety, "pulled at things but not combative and never had hallucinations or [MEDICAL CONDITION]." Additionally, LVN 3 stated that Resident 4 had declined with her ADLs since the time of her admission and while she had been on the [MEDICATION NAME]. During an observation on 6/23/11, at 9 AM, Resident 4 was sitting in a wheelchair, was lethargic, had her eyes closed. Resident 4 was non communicative when several attempts were made by the surveyor to ask questions, LVN 2 was observed to be at Resident 4's bedside. During an interview on 6/23/11, at 9 AM, with LVN 2, she attempted to wake Resident 4 up as she shook Resident 4's arm and asked her to open her eyes and acknowledge the surveyor. After four attempts, Resident 4 slowly opened her eyes, looked around her surrounding, made eye contact with the surveyor and grinned. Resident 4's speech was slurred and incomprehensible . However at times she was oriented to questions asked and then would close her eyes again. Resident 4 was observed to fidget and attempted to grab a paper from the side table. LVN 2 stated, "You see, she wakes up after a while and that's why she needs [MEDICATION NAME], she is always grabbing at things and sometimes will hit." During an interview on 6/23/11, at 10 AM, with CNA 4, she stated that when she had taken care of Resident 4, the resident was not combative, did not resist care, and did not "do much." During an interview on 6/23/11, at 1:30 PM, with the DON, and a concurrent record review of the facility's "Consultant Pharmacist's Monthly Drug Regimen Review" for 4/1/11 to 4/30/11, revealed no documentation to show that the pharmacist reviewed the [MEDICATION NAME] use by Resident 4. The findings were verified by the DON. Record review on 6/23/11, of the facility's "Consultant Pharmacist's Monthly Drug Regimen Review" for 5/1/11 to 5/31/11, showed the following documentation regarding the [MEDICATION NAME] use for Resident 4, "...discontinued on 5/21/11 in compliance with the facility' s goal to reduce the overall use of the anti-psychotic drugs." Review of Resident 4's medical record, on 6/23/11, revealed no documented evidence that the [MEDICATION NAME] was discontinued on 5/21/11 as the pharmacist consultant had documented on his monthly drug regimen review. Furthermore, on 5/21/11, Resident 4's physician, ordered to increase the [MEDICATION NAME] to 5 mgs twice a day. A review on 6/23/11, of Resident 4's records, revealed no documentation to show that the interdisciplinary team (a meeting held by various care givers such as the DON, a nurse, and social services to discuss various aspects of residents care and progress...) met to assess and monitor Resident 4's mood behavior while on she was on [MEDICATION NAME]. Further review revealed no documentation that showed that Resident 4 was assessed for the use of the [MEDICATION NAME]. During an interview, on 6/22/11, at 1:30 PM with the DON, who attends the IDT meetings stated that IDT did not discuss Resident 4's use of [MEDICATION NAME]. Record review on 6/23/11, at 10 AM, of the facility policy for "Psychotherapeutic Drug Management" effective April 2005, indicated that the purpose of the policy was "To provide a therapeutic environment using only those medications with a therapeutic value to the individual resident. Unnecessary drugs shall be avoided." Additionally, the policy indicated the following: "The psychotherapeutic medication order shall include ...informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage ....The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose or an adjustment should be made ...the nurse shall implement non-drug interventions to modify behavior according to the care plan ...nursing shall not administer the psychotherapeutic medication until informed consent has been obtained ...a monthly summary of the psychotherapeutic medication shall be completed and filed in the physician progress notes [REDACTED]. Record review on 6/23/11, at 10 AM, of the facility policy for "Drug Regimen Review" indicated that "...the Consultant Pharmacist reviews the medication regimen of each patient at least monthly...and reported to the Director of Nursing and when appropriate, to the Administrator and Medical Director."