Every finding on record at Arbor Post Acute

Based on record review and interview, the facility failed to ensure the individual designated as the Dietary Manager met the qualifications required to direct food and nutrition services, including certification as a Dietary Manager or other qualifying credentials for one of one dietary managers.This failure had the potential to result in all residents receiving food and nutrition services that were not provided in accordance with professional standards.Findings:California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. The Health and Safety Code describe, in the absence of a full-time Registered Dietitian with supervisory responsibilities for dietetic services, the licensed facility shall employ a full-time qualified dietary services supervisor. There are 7 recognized pathways, all of which are based on a variety of educational experiences.During a review of the facility Dietary Supervisor (referred to as Dietary Manager [DM]) employee file, signed by the DM and dated 1/26/24, the Job Description: Dietary Supervisor, indicated the position required graduation from an approved dietary manager course that meets state and federal regulations, maintenance of all required continuing education, and remaining in good standing with the Department of Public Health Licensing and Certification Division (CDPH), at all times.During a review of the DM's employee file, signed by the DM and the Registered Dietitian (RD), dated 1/12/26, the Food Service Supervisor CDM, DM Competencies, indicated that maintaining her Certified Dietary Manager (CDM) had not been met.During a review of the DM's employee file, signed by the DM and the RD, dated 5/29/26, the Performance Evaluation, indicated that completion of the CDM certification was identified as an opportunity for improvement, and the DM listed completing the CDM certification as a current work goal in the self-evaluation.During the initial tour of the kitchen on 7/6/26 at 6:05 am, and a concurrent interviews with the DM and the RD, the DM stated that they were not currently a CDM, were enrolled in a certification program, and had not yet completed it. The RD indicated they were the facilities only RD for the 144-bed facility and were responsible for daily clinical rounds, staff and services, new admissions (approximately 5 to 11 per week), weight meetings, and quarterly and annual assessments. The RD indicated they spend 50 percent (%) of their time performing clinical duties and 50% of their time in the kitchen, equating to 20 hours per week providing kitchen oversight.During an interview on 7/8/26 at 9:21 am, with the DM, the DM indicated they had served in the position since 2023. The DM stated their responsibilities included overseeing the day-to-day kitchen operations, ordering supplies, labeling and dating food, maintaining inventory and cleaning logs, managing resident food preferences, and completing meal rounds with residents. The DM indicated all job duties were overseen by the RD. The DM further indicated they were informed upon accepting the position that obtaining this CDM credential was required to qualify for the position, that no timeline was established for completing the certification, and that the expectation was that the CDM certification would be completed.During an interview on 7/8/26 at 9:55 am, with the facility Administrator (Admin), the Admin indicated that the DM job description requires the DM to hold a CDM credential and that the expectation is for the DM to complete the CDM certification by the end of this month.

Based on observation, interview, and record review, the facility failed to maintain refuse (garbage) and debris (bits of trash) in a manner that minimized pests harborage (safe shelter, protection and suitable conditions to live, breed and thrive), by allowing trash receptacles to overflow, remain uncovered, and become soiled with food debris, and by permitting discarded remodeling materials and equipment to accumulate on the premises.This failure increased the risk of pest harborage and contamination, affecting all residents, staff, and visitors within the facility.Findings:A review of the United States Department of Agriculture (USDA) food code S 5-501.113, Covering Receptacles, indicated that refuse, recyclable, and returnable receptacles and waste handling units kept outside the food service establishment must be maintained with tight fitting lids and doors.A review of the USDA food code S 5-501.115, maintaining refuse areas and enclosures indicated that, refuse storage areas and enclosures must be kept clean and free of unnecessary items.During a review of the facility's policy and procedure titled, Miscellaneous Area, dated 2023, indicated, that food waste must be disposed of to prevent a nuisance; garbage and rubbish must be stored in clean, vermin proof areas; trash receptacles and surrounding areas must be inspected daily to ensure lids are closed in the area as free of debris; trash collection areas must be kept clean to prevent vermin and rodents; trash bins must be exchanged periodically for cleanliness when serviced by a commercial waste provider; and that flies are recognized as carriers of disease and a threat to sanitation standards.During a concurrent observation and interview on 7/6/26 at 9:30 am, with the Maintenance Director (MAIN) outside at the facility waste storage area, observed were two overflowing trash dumpsters with lids unable to fully close, an organic waste bin with excessive dried food debris and flies, discarded toilets, nightstands, and beds. The MAIN indicated the discarded remodeling materials had remained in the area for more than a month, acknowledged that they had remained there longer than considered timely (a couple of weeks), and confirmed the overflowing refuse, flies and accumulated debris, and flies created the potential for pest harborage.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen when:1. Proper hand hygiene was not performed.2. Cross contamination was observed during food prep.3. Plastic plate covers were worn with rough, uncleanable surfaces.These failures posed a risk for foodborne illness in 118 residents who received food prepared in the kitchen.Findings:During a review of the facility Diet Order Tally Report, dated 7/7/26, the report indicated that 118 residents received food prepared in the kitchen.1.During a review of the facility's policy and procedure (P&P) titled, Glove Use Policy, dated 2023, indicated, that hands must be washed before applying gloves and before donning a new pair. Gloves must be changed between tasks, after handling raw meat, when torn or soiled, after potential contamination, and at least every four hours during continual use.During a review of the facility's P&P titled, Hand Washing Procedure, dated 10/2026, indicated, that hand washing is essential to prevent he spread of infection and should be performed using soap and warm water before beginning work in the kitchen, before and after handing food, after handling soiled dishes and utensils, and after touching a trash can or its lid.During an observation on 7/7/26 at 10:05 am, in the kitchen during food preparation, the Facility [NAME] (FC) was observed removing gloves and donning (putting on) a new pair on four separate occasions without washing his hands between glove changes.During an observation on 7/7/26 at 10:33 am, and again at 11:55 am, in the kitchen during food preparation, the Dietary Aide (DA) was observed removing gloves, touching the trash can, and donning a new pair of gloves without washing her hands between glove changes.2. During a review of the facility's P&P titled, Food Handling, dated 2023, indicated, that food must be prepared and served in a safe and sanitary manner, personnel must wash their hands before handling food and before and after handling raw meat, bare-hand contact with food is prohibited, gloves must be changed before handling washed or ready to eat food items, and suitable utensils or single use gloves must be used when handling food.During an observation on 7/7/26 at 10:15 am, in the kitchen during food preparation, the FC was observed preparing food on a countertop that appeared unclean, was cluttered, and had the presence of food crumbs. On two occasions the FC was observed returning cooked meat to the cutting board after touching the meat to a portion guide mounted on the wall. During food preparation, the FC was observed flipping the cutting board over and continuing food preparation after the opposite side of the cutting board had been in contact with the countertop surface. The FC was observed going to the dish machine (dishwasher) and returning to the food preparation area without performing proper hand hygiene. The FC was observed pulling aluminum foil from the box, folding it against his clothing before using it to cover vegetables, and touching the scale controls before handling cooked zucchini with the same gloved hand.During an observation on 7/7/26 at 11:45 am, in the kitchen during tray line, the FC was observed touching his face and continuing to serve food without changing gloves or performing hand hygiene.3. During a review of the facility purchase documentation, dated 5/26/26, indicated three sets of 24 plastic plate covers were ordered on 5/20/26 and received on 5/29/26. During a concurrent observation and interview on 7/6/26 at 6:37 am, with the Dietary Manager (DM) in the kitchen, observed were six plastic plate covers that were heavily marred with thick white residue, creating rough, uncleanable surfaces. The DM confirmed the plate covers had rough surfaces, acknowledged they needed to be replaced, and stated new plate covers had been ordered but not all old covers had been removed from use yet.During an interview on 7/8/26 at 9:21 am, with the Registered Dietician (RD), the RD confirmed kitchen staff are expected to perform proper hand hygiene between glove changes and after touching contaminants, such as trash or the face. The RD further confirmed that using a cluttered food preparation service, flipping a cutting board after it had contacted the soiled countertop and continuing food preparation, and returning food to the cutting board after it had contacted a size reference guide posted on the wall were all examples of cross contamination. The RD indicated employee competency is evaluated following in-services through verbal responses or direct observation of task performance.

Based on observations, interviews, and record review the facility failed to ensure menus and portions sizes were followed for 21 of 118 residents when pureed foods were not prepared according to the menu instructions and the wrong portion size was served for soft and bite sized vegetables. This failure placed residents at risk of receiving meals that did not meet the planned nutritional standards, potentially affecting nutritional intake and dietary consistency.Findings:During a review of the facility Diet Order Tally Report, dated 7/7/26, the report indicated that 118 residents received food prepared in the kitchen, including four residents receiving puree diets. During a review of the facility's policy and procedure (P&P) titled, Portion Control, dated 2025, indicated, that food must be portioned according to the menu using the appropriate portion-control equipment. The policy specified that scoop sizes are identified by number and listed in the menu recipe books and menu spreadsheet, and that staff are to use the designated portion-control equipment when serving food.During review of the facility recipe titled, Recipe: Pureed (IDDSI Level #4) Vegetables, dated 2025, indicated, food was to be pureed to a paste consistency before adding liquid. Warm low-sodium broth or milk was to be added gradually only if needed, and thickener was to be added after pureeing to achieve the appropriate consistency.During review of the facility recipe titled, Recipe: Pureed (IDDSI Level #4) Casserole (which was used for the chicken), dated 2025, indicated, vegetables are to be pureed to a paste consistency before adding liquid. Warm low-sodium broth or milk was to be added gradually only if needed, and thickener was to be added after pureeing to achieve the appropriate consistency.During a review of the facility document titled Food and Nutrition Service In-Service - Topic - IDDSI, Diets, Liquid, Texture testing methods, dated 9/15/25, indicated the Facility [NAME] (FC) did not attend the in-service.During review of the facility menu titled, Summer Menus, dated 7/7/26, indicated, the soft and bite size baked zucchini was to be served as a 1/2 cup (#8 scoop) portion for the regular diet.During an observation on 7/7/26 at 10:05 am, in the kitchen during food preparation, the FC was observed preparing pureed Italian chicken using broth that was not low-sodium. The FC added an unmeasured amount of the broth until it reached puree consistency.During an observation on 7/7/26 at 10:15 am, in the kitchen during food preparation, the FC was observed preparing pureed zucchini using broth that was not low-sodium. The FC added the broth before blending the vegetables, after which thickener was added to achieve the appropriate consistency.During an observation on 7/7/26 at 11:50 am, in the kitchen during tray line, the FC was observed using a 1/3 cup (#12 scoop) to serve the soft and bite size baked zucchini for the regular diet instead of the 1/2 cup (#8 scoop) specified on the menu.During an interview on 7/8/26 at 9:21 am, with the Registered Dietician (RD), the RD confirmed recipes are expected to be followed, including using low-sodium broth as specified and adding liquid to pureed vegetables only after the vegetables have been pureed, if needed. The RD stated employee competency is evaluated following in-services through verbal responses or direct observation of task performance.During an interview 7/9/26 at 11:06 am, with the facility Dietary Manager (DM), the DM confirmed that the bite size zucchini for the regular diet was served using a 1/3 cup (#12 scoop) instead of the 1/2 cup (#8 scoop) specified on the menu.

Based on interview and record review, the facility failed to ensure a routinely prescribed medication was available and administered as ordered for one of seven sampled residents (Resident 102). This failure placed the resident at risk for worsening gastrointestinal symptoms and pain.Findings:A review of the facility policy titled, Administering Medication, reviewed 10/2025, indicated Policy Interpretation and Implementation 2. Medications are administered in accordance with prescriber orders, including any required time frame.A review of Resident 102's admission Record indicated that she was admitted to the facility on [DATE] with diagnoses that included acute gastritis (stomach lining has suddenly become irritated or inflamed), gastro-esophageal reflux disease without esophagitis (GERD, stomach acid regularly flows back up the tube that carries food from the mouth to the stomach), and chronic pain.A review of Resident 102's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/12/26, indicated that Resident 102 had a brief interview for mental status (BIMS) score of 12 out of 15, at section C Cognitive Patterns indicating she was moderately cognitively impaired.During an interview on 7/6/26 at 12:20 pm, with Resident 102, Resident 102 indicated two days ago she was unable to eat lunch or dinner because her stomach medication wasn't available. Resident 102 indicated the facility was out of Sucralfate (medication that coats and protects the stomach from ulcers and gastric acids), but had not informed her. A review of Resident 102's Physician Order Summary dated 6/5/26, indicated Resident 102 was prescribed Sucralfate, 1 tablet, 1 gram (gm, a unit of measure), give 1 tablet by mouth four times a day for acute gastritis (inflammation of stomach lining), and give on an empty stomach.A review of Resident 102's Medication Administration Record (MAR), from 7/1/26 to 7/7/26, indicated on 7/4/26 that Sucralfate 1 gm, had not been administered at 11 am and 4 pm.A review of Resident 102's Documentation Survey Report, dated 7/1/26 to 7/7/26, indicated that on 7/4/26, Resident 102 had refused breakfast, lunch and supper.During a concurrent interview and record review on 7/8/26 at 1:43 pm, with Licensed Nurse (LN) L, LN L indicated if Sucralfate was administered late then Resident 102 will refuse to eat due to stomach discomfort. LN L indicated Resident 102 has told LN L that she can't eat if she does not have her Sucralfate given to her on an empty stomach before meals. LN L confirmed that on 7/4/26 the 11 am and 4 pm doses of Sucralfate were not given to Resident 102, because the medication was not available. LN L stated when the facility has ran out of a resident's medication the nurse was to call the pharmacy and reorder the medication and notify the resident and their physician. LN L confirmed that on 7/4/26, Resident 102's Sucralfate was reordered late. LN L indicated the standard practice would have been to reorder Resident 102's Sucralfate when there were about five left.

Based on interview, facility policy, and record review, the facility failed to ensure the procedures for reporting alleged abuse were implemented when Licensed Nurse (LN) O did not report an allegation of abuse for one of 29 Residents (Resident 63), immediately or within 2 hours to the California Department of Public Health (CDPH), Ombudsman (resident advocacy group), local law enforcement and the facility Administrator.This resulted in a delay in protecting Resident 29 from further abuse and had the potential to delay investigations and protection of all residents from ongoing abuse and mistreatment.Findings:A review of the facility's policy and procedure titled, Abuse Investigation and Reporting , dated 10/2024, indicated under Reporting Line 1 Alleged violations involving abuse . will be reported to the facility Administrator, or his/her designee, and may be reported to the following persons or agencies, as required by regulation/law: a. the State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; d. Adult Protective Services; e. Law Enforcement. Line 2 indicated, An alleged violation of abuse. will be reported immediately, but not later than, Line A two hours if the alleged violator involves abuse.A record review of Resident 63's admission Report dated 7/9/26, indicated Resident 63 was admitted on [DATE] with diagnoses that included amyotrophic lateral sclerosis (ALS, a progressive, disorder affecting the brain, spinal cord, and nerves throughout the body), hemiplegia (muscle and sensory loss on one side of the body), and neuropathy (nerve damage).A record review of Resident 63's admission Minimum Data Set (MDS, comprehensive assessment) dated 6/29/26, indicated Resident 63 had a Brief Interview for Mental Status (BIMS, an assessment of memory and recall ability scored from 00-15), indicated Resident 63 had no memory or recall problems with a score of 15.During an interview on 7/6/26 at 10:10 am, with Resident 63, Resident 63 indicated that, Five days ago one Certified Nursing Assistant [CNA] was rough when getting him up out of bed to the wheelchair. Resident 63 was unable to identify the CNA by name. During an interview on 7/7/26 at 2:28 pm, with Resident 63, Resident 63 was able to describe the alleged rough CNA's hair color and what they wore. Resident 63 expressed concern about receiving care from that CNA. Resident 63 stated he had reported this rough treatment to LN O at the time it happened. Resident 63 indicated that no one followed up with him after he reported the incident. Resident 63 indicated he would be able to identify the alleged CNA, if he saw them again. During an interview on 7/7/26 at 4:03 pm, with the Administrator (ADM), ADM indicated that she was not aware of any reports where Resident 63 had made an abuse allegation of rough treatment by a CNA. During an interview on 7/8/26 at 7:45 am, with LN O, LN O confirmed Resident 63 told him a CNA Was kind of rough when caring for him. LN O indicated he thought he knew who this CNA was, however, Resident 63 did not identify them by name. LN O indicated he did not think this was abuse or suspect abuse because the resident stated, kind of rough. LN O indicated on 7/4/26 at 4:10 pm, he called the Director of Staff Development (DSD) to request the resident be reassigned to another CNA but could not reach them and did not leave a message. LN O indicated he was off for a couple days following the allegation and reporting it slipped his mind. LN O confirmed he did not follow up and should have. During an interview on 7/8/26 at 1:37 pm, with ADM, ADM indicated Resident 63 identified CNA I by a photograph and said they were rough during his care. During an interview on 7/8/26 at 2:41 pm, with the Director of Nursing (DON), DON stated she was notified by the ADM on 7/7/26 of Resident 63's alleged abuse report. DON indicated nurses must report any allegations of abuse within two hours of receiving an allegation. DON indicated LN O should have reported the alleged abuse on the day Resident 63 reported it to him to the ADM, CDPH, Ombudsman and local law enforcement immediately or within 2 hours in accordance with the facility's policy.

Based on observations, interviews, and record review, the facility failed to ensure two of 19 kitchen employees demonstrated the competency and skills necessary to safely perform daily kitchen duties when:1. Proper hand hygiene was not performed.2. Cross contamination was observed during food prep.3. Resident menus and recipes were not followed.4. Temperatures were not properly taken for tray line.This failure had the potential to result in unsafe food handling practices, increasing the risk of food contamination and foodborne illness for 118 residents who received food prepared in the kitchen.Findings:During a review of the facility Diet Order Tally Report, dated 7/7/26, the report indicated that 118 residents received food prepared in the kitchen, including four residents receiving puree diets.During a review of the facility cook's (FC) employee file, signed by the FC , undated, the [NAME] Job Description, indicated, the cook is responsible for maintaining a safe, clean, and sanitary kitchen; preparing meals according to the menu and portion control guidelines; recording meal temperatures; preparing puree foods; and cleaning cooking and serving areas.During a review of the FC's employee file, signed by the Registered Dietician (RD) and FC, dated 2/3/26, indicated the FC met the standard for hand washing, glove use, use of recipes, cutting board use, and recording temperature for tray line.During a review of the FC's employee file, signed by the FC, dated 4/30/26, the Employee Disciplinary Action Form, indicated, the FC had received disciplinary action for failing to follow a resident specific diet. The corrective action plan required 0 discrepancies related to diet and liquid consistency orders, less than 5 percent (%) error for food preferences, and 100% tray line compliance for 90 consecutive days.During a review of the Dietary Aide's (DA) employee file, signed by the DA, dated 9/25/25, the Dietary Aide Job Description, indicated, the dietary aid is responsible for learning food service procedures, setting up meal trays, preparing snacks and nourishments, maintaining a clean and sanitary kitchen, and assisting the cook or dietary supervisor as needed.During a review of the DA's employee file, signed by the RD and DA, dated 2026, titled, Food and Nutrition Competency Checklist - Food Service Worker indicated the DA met the standard for safety precautions, infection control practices, hand washing, glove use, and knowledge of food practices.1. During a review of the facility's policy and procedure (P&P) titled, Glove Use Policy, dated 2023, indicated, that hands must be washed before applying gloves and before donning a new pair. Gloves must be changed between tasks, after handling raw meat, when torn or soiled, after potential contamination, and at least every four hours during continual use.During a review of the facility's P&P titled, Hand Washing Procedure, dated 10/2026, indicated, that hand washing is essential to prevent he spread of infection and should be performed using soap and warm water before beginning work in the kitchen, before and after handing food, after handling soiled dishes and utensils, and after touching a trash can or its lid.During a review of the facility document titled, Food and Nutrition Service In-Service - Topic - Norovirus, Hand washing/Glove Use, dated 1/13/26, indicated the FC attendrd the in-service, but the DA did not.During an observation on 7/7/26 at 10:05 am, in the kitchen during food preparation, the FC was observed removing gloves and donning a new pair on four separate occasions, without washing his hands between glove changes.During an observation on 7/7/26 at 10:33 am, and again at 11:55 am, in the kitchen during food preparation, the DA was observed removing gloves, touching the trash can, and donning a new pair of gloves, without washing her hands between glove changes.2. During a review of the facility's P&P titled, Food Handling, dated 2023, indicated, that food must be prepared and served in a safe and sanitary manner, personnel must wash their hands before handling food and before and after handling raw meat, bare-hand contact with food is prohibited, gloves must be changed before handling washed or ready to eat food items, and suitable utensils or single use gloves must be used when handling food.During a review of the facility document titled, Food and Nutrition Service In-Service - Topic - Food Preferences, Allergies, Mock Survey, dated 4/10/26, indicated the in-service included prevention of cross contamination during food preparation and food service. Documentation indicated FC attended the in-service.During an observation on 7/7/26 at 10:15 am, in the kitchen during food preparation, the FC was observed preparing food on a countertop that appeared unclean, was cluttered, and had the presence of food crumbs. On two occasions the FC was observed returning cooked meat to the cutting board after touching the meat to a portion guide mounted on the wall. During food preparation, the FC was observed flipping the cutting board over and continuing food preparation after the opposite side of the cutting board had been in contact with the countertop surface. The FC was observed going to the dish machine (dishwasher) and returning to the food preparation area without washing their hands. The FC was observed pulling aluminum foil from the box, folding it against his clothing before using it to cover vegetables, and touching the scale controls before handling cooked zucchini with the same gloved hand.During an observation on 7/7/26 at 11:45 am, in the kitchen during tray line, the FC was observed touching his face and continuing to serve food without changing gloves or performing hand hygiene.3. During a review of the facility's P&P titled, Portion Control, dated 2025, indicated, that food must be portioned according to the menu using the appropriate portion-control equipment. The policy specified that scoop sizes are identified by number and listed in the menu recipe books and menu spreadsheet, and that staff are to use the designated portion-control equipment when serving food.During review of the facility recipe titled, Recipe: Pureed (IDDSI Level #4) Vegetables, dated 2025, indicated, Vegetables were to be pureed to a paste consistency before adding liquid. Warm low-sodium (salt) broth or milk was to be added gradually only if needed, and thickener was to be added after pureeing to achieve the appropriate consistency.During review of the facility recipe titled, Recipe: Pureed (IDDSI Level #4) Casserole (which was used for the chicken), dated 2025, indicated, vegetables are to be pureed to a paste consistency before adding liquid. Warm low-sodium broth or milk was to be added gradually only if needed, and thickener was to be added after pureeing to achieve the appropriate consistency.During a review of the facility document titled, Food and Nutrition Service In-Service - Topic - IDDSI, Diets, Liquid, Texture testing methods, dated 9/15/25, indicated the FC did not attend the in-service.During an observation on 7/7/26 at 10:05 am, in the kitchen during food preparation, the FC was observed preparing pureed Italian chicken using broth that was not low-sodium. The FC added an unmeasured amount of the broth until it reached puree consistency.During an observation on 7/7/26 at 10:15 am, in the kitchen during food preparation, the FC was observed preparing pureed zucchini using broth that was not low-sodium. The FC added the broth before blending the vegetables, after which thickener was added to achieve the appropriate consistency.During review of the facility menu titled, Summer Menus, dated 7/7/26, indicated, the soft and bite size baked zucchini was to be served as a 1/2 cup (#8 scoop) portion for the regular diet.During an observation on 7/7/26 at 11:50 am, in the kitchen during tray line, the FC was observed using a 1/3 cup (#12 scoop) to serve the soft and bite size baked zucchini for the regular diet, instead of the 1/2 cup (#8 scoop) specified on the menu.During an interview 7/9/26 at 11:06 am, with the facility Dietary Manager (DM), the DM confirmed that the bite size zucchini for the regular diet was served using a 1/3 cup (#12 scoop), instead of the 1/2 cup (#8 scoop) specified on the menu. 4. According to the USDA Food Code 2022, Section 4-302.12 Food Temperature Measuring Devices, the presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded.Review of a professional reference article titled, CDPH Reminds Californians about Safe Food Handling During Summer Season, dated 6/29/17, indicated, safety tips for properly preparing and handling food: Measure the temperature in the thickest part of the food, ensuring the thermometer does not touch bone or the cooking pan which can give you an inaccurate reading. https://www.cdph.ca.gov/Programs/OPA/Pages/NR17-056.aspxDuring a review of the facility's P&P titled, Meal Service, dated 2023, indicated, that meals are to be served at the appropriate temperature and that food and nutrition services staff are to verify food temperatures prior to meal service using a cleaned and sanitized thermometer inserted into the thickest part of the food to ensure an accurate temperature reading.During a review of the facility document titled, Food and Nutrition Service In-Service - Topic - Handwashing, Survey Prep, and Temperatures, dated 7/1/26, indicated the FC did attend the in-service.During an observation on 7/7/26 at 11:37 am, in the kitchen during tray line, the FC was observed taking the temperature of food prepared for serving with the thermometer probe inserted until the tip contacted the hot bottom and side of the food container rather than positioned within the food.During an interview on 7/8/26 at 9:21 am, with the Registered Dietician (RD), the RD confirmed recipes are expected to be followed, including using low-sodium broth as specified and adding liquid to pureed vegetables only after the vegetables have been pureed, if needed. The RD confirmed kitchen staff are expected to perform proper hand hygiene between glove changes and after touching contaminants, such as trash or the face. The RD further confirmed that using a cluttered food preparation service, flipping a cutting board after it had contacted the soiled countertop and continuing food preparation, and returning food to the cutting board after it had contacted a size reference guide posted on the wall were are all examples of cross contamination. The RD indicated employee competency is evaluated following in-services through verbal responses or direct observation of task performance. The RD also confirmed that a thermometer probe should be inserted into the thickest part of the food and should not contact the hot bottom or sides of the food container while obtaining a food temperature.

Based on observations, interviews, and record reviews the facility did not ensure Physician ordered services were provided to one out of two sampled residents (Resident 1) when specialized rehabilitative services (expert led therapy program to help individuals improve on daily function and return to normal life) were not provided. This had the potential for Resident 1 not to attain or maintain their highest practicable level of physical, mental, functional, and psychosocial well-being.Findings: A review of the facility's policies and procedures (P&P) titled, Physician Orders, dated 10/1/24, indicated, treatment orders would be carried out in accordance with the Physician's order. A review of the facility's P&P titled, Speech Therapy, dated, 5/1/13, indicated, The purpose of this procedure is to identify, assess, and treat speech and language problems, including swallowing disorders (the specialist who performed this procedure was a Speech Therapist, ST). A review of Resident 1's admission Record, dated 1/13/26, indicated, admission to the facility on 1/13/26 with the diagnoses of essential tremor (involuntary shaking, most commonly in the hands), dysphagia oropharyngeal phase (swallowing problem that occurred in the mouth or throat), and cognitive communication deficit (an impairment in communication). Resident 1 was their own responsible party (made own decisions). A review of the admission Minimum Data Set (MDS, an assessment tool), Section C, dated 1/19/26, indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was conducted. Resident 1 scored 12 out of 15, indicating intact memory. A review of the admission MDS, Section K, dated 1/20/26, indicated that Resident 2 had difficulty or pain when swallowing. During a concurrent interview and record review on 1/29/26 at 3:06 pm, with Director of Rehab (DOR), Resident 1's Physician's Order, dated 1/14/26 was reviewed. DOR confirmed the order indicated that ST performed an evaluation and Resident 1 required ST services, three times a week for four weeks. DOR reviewed Resident 1's Speech Therapy Evaluation and Plan of Treatment (the evaluation was the first visit and was utilized to develop a plan of care and treatment schedule), dated 1/14/26 and stated, we have not had him on the ordered schedule, he has only been seen that one time. A review of Resident 1's care plan (a detailed plan that included resident goals and facility staff care instructions) titled, Cognitive Communication Deficit, dated 1/14/26, indicated, ST would provide skilled treatments, three times a week for 4 weeks that included voice exercises, breathing exercises, group treatment, speech and hearing. The care plan indicated, Resident 1's goal was to improve functional skills to return home safely. During a concurrent observation and interview on 2/4/26 at 9:48 am, Resident 1 was observed laying in bed and their hands were shaking. Resident 1 was asked if the facility's ST had been providing treatments and Resident 1 stated, I thought she was going to work with me on speech and confirmed ST had performed the evaluation and no other visits were provided. Resident 1 spoke slowly and stopped speaking in between words with a look on his face that indicated he was thinking. During a concurrent interview and record review on 2/4/26 at 11:13 am, with Regional Director of Therapy Services (RDTS), Resident 1's Speech Therapy Evaluation and Plan of Treatment, dated 1/14/26 was reviewed. RDTS stated the ST evaluation indicated that Resident 1 required more assistance with speech therapy for speech function than with swallowing. RDTS confirmed, ST had performed an evaluation, ordered a visit frequency of three times a week for four weeks and did not provide any visits per the Physician's ordered visit frequency.

Based on observations, interviews, and record reviews, the facility failed to accommodate the needs for one out of two sampled residents (Resident 1) when bed canes (a device that was like a grab bar, attached to the bed, and designed to help residents move, reposition, or transfer out of bed) were recommended and not provided in a timely manner. This failure caused Resident 1 to depend upon staff for bed mobility (movement) and had the potential to cause a decline in maintaining and/or achieving independent functioning, dignity, and well-being.Findings: A review of the facility's policies and procedures titled, Assistive Devices and Equipment, dated 2/1/21, indicated it provided assistive devices to help residents with mobility and independence. A review of Resident 1's admission Record, dated 1/13/26, indicated, admission to the facility on 1/13/26 with the diagnoses of Parkinson's Disease (incurable brain disorder that affected movement of the body), essential tremor (involuntary shaking, most commonly in the hands), and muscle weakness. Resident 1 was their own responsible party (made own decisions). A review of the admission Minimum Data Set (MDS, an assessment tool), Section C, dated 1/19/26, indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was conducted. Resident 1 scored 12 out of 15, indicating intact memory. A review of the admission MDS, Section GG, dated 1/20/26, indicated that Resident 1 had limited function of both legs, required touching assistance to roll over in bed, and required moderate assistance to sit up in bed. A review of Resident 1's care plan (a written document that contained resident goals and care instructions for staff) titled, ADL/Mobility (activities of daily living, dressing, showering, getting in and out of bed), dated 1/13/26, indicated that Resident 1 was at risk for a decline with ADLs and mobility and facility staff would encourage Resident 1 to participate in ADLs to promote independence. During an observation on 1/29/26 at 2:25 pm, Resident 1's bed was observed. There were no bed canes or bed rails present. During an observation on 2/4/26 at 9:28 am, Resident 1's bed was observed. There were no bed canes or bed rails present. During a concurrent observation and interview on 2/4/26 at 9:29 am, with Certified Nurse Assistant (CNA) A, Resident 1's bed was observed. CNA A confirmed, there were no bed canes present and stated, Resident 1 can turn in bed with one person assistance. During a concurrent observation and interview on 2/4/26 at 9:48 am, Resident 1 stated, We've talked a lot about the bed rails [bed canes]. I need the bed rails to hold to help pull myself around. Resident 1 was asked if he was dependent upon staff for bed mobility due to not having bed canes or bed rails and stated, quite a bit. During the interview, Resident 1 utilized the call light and requested assistance from CNA A to use the bathroom. CNA A was observed asking Resident 1 to roll in bed towards CNA A. Resident 1 stated, I can't, I have nothing to hold on to. CNA A was observed assisting Resident 1 to roll from a back laying position to a side laying position. During a concurrent interview and record review on 2/4/26 at 10:06 am, with Licensed Nurse (LN) B, Resident 1's Bed Rail and Entrapment Risk Observation/Assessment (bedrail consent form), dated 1/13/26 was reviewed. LN B confirmed the bedrail consent indicated that a recommendation had been made for Resident 1 to have bed canes due to mobility limitations. LN B confirmed Resident 1 was dependent upon staff for bed mobility and Resident 1's bed did not have bed canes. LN B stated, there are a few beds in the facility that don't accommodate bed rails or bed canes. During a concurrent interview and record review on 2/4/26 at 10:49 am, with Maintenance Director (MD), a work order, dated 1/31/26 was reviewed. MD confirmed the work order indicated a request for Resident 1 to have bed rails was made on 1/31/26 (18 days after the facility assessed Resident 1's need for bed canes). MD stated, Resident 1's bed doesn't accommodate bed canes, and a work order was submitted for bed canes. MD confirmed, there was no available bed in the facility to accommodate the use of bed canes and stated, the facility was at max capacity (the facility had reached maximum capacity for residents and there were no more beds). During an interview on 2/4/26 at 11:58 am, LN C indicated, when a resident was assessed upon admission, it included an assessment for bed canes. LN C stated, if they have a need, it goes to maintenance, we ask maintenance for the bed to be assessed. LN C indicated the bed assessment was to determine if the bed was compatible with the use of bed canes. LN C confirmed, Resident 1's bed did not have bed canes and was not able to verbalize why. During an interview on 2/4/26 at 12:28 pm, Director of Nursing (DON) stated, the admission nurse (LN C) does the assessment (Bed Rail and Entrapment Risk Observation/Assessment), if LN C feels it's appropriate, LN C puts in the work order. DON confirmed, the assessment occurred on 1/13/26, the work order for Resident 1's bed canes was entered 1/31/26, and Resident 1 did not have bed canes attached to the bed. DON stated, Resident 1's bed doesn't accommodate [the use of bed canes], we are full [facility was at maximum resident capacity], it's an equipment issue, we don't have a bed to swap it out for. DON confirmed, Resident 1 needed bed canes and they were not provided.

Based on interview and record review, the facility failed to ensure one of three residents sampled for falls with injury was provided with the necessary care to prevent an avoidable fall with injury (Resident 1) when the facility failed to;1.Take Resident 1 to the bathroom on 3/9/25, after her family member (FM) told staff that she needed to go. Subsequently, Resident 1 got up on her own to use the bathroom and fell. This failure to toilet Resident 1 resulted in Resident 1 falling and sustaining a broken right ankle, foot and toes which caused her severe pain, a transfer to the hospital, and delayed her discharge back home by 6 weeks. (Refer to F600 and F697)2.Ensure Resident 1 was assigned a Certified Nursing Assistant (CNA) to take care of her on the PM shift (2:30 pm to 11 pm), on 3/9/25.This failure resulted in Resident 1 having no CNA assigned to her care and help her to the bathroom and Resident 1 fell and sustained a broken ankle, foot and toes.3.Review and revise Resident 1's care plan with new interventions to prevent further falls and injuries on 3/6/25.This failure resulted in Resident 1 having another fall three days later. Findings:1.The facility's policy titled, Falls and Fall Risk, Managing revised March 2018, was reviewed and 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 to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] to nursing unit three (rooms 300 thru 317), with diagnoses which included surgery to the right hip from a broken hip (due to a fall at home), dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), Alzheimer's (a progressive disease that destroys memory and other important mental functions), osteoporosis (bones are weak and brittle), muscle weakness, and diabetes (high sugar in the blood).A review of Resident 1's January 2025 Physician's Orders indicated:a An order, dated 1/30/25, indicated Resident 1 did not have capacity to understand choices, to make health care decisions and/or participate in a treatment plan. Resident 1's Family Member (FM) was Resident 1's decision maker. b An order, dated 1/15/25, for Norco (narcotic pain pill) tablet 5-325 mg (milligram a unit of measurement), give one tablet by mouth every four hours as needed (PRN) for pain level 4-6 (moderate pain) and a Norco tablet 10-325 mg, give one tablet by mouth every four hours as needed for pain level 7-10 (severe pain).A review of Resident 1's admission Minimum Data Set (MDS, a complete clinical assessment), dated 1/17/25, section C- Cognitive Patterns (determines residents attention, orientation, and ability to register and recall information) indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to evaluate memory and decision making skills on a scale of 0 to 15, with 0 being highly impaired and 15 being no impairment), and Resident 1 scored 0, which indicated Resident 1's cognition was severely impaired. Section GG- Functional Abilities and Goals indicated Resident 1 required maximal assistance (Staff does most of the work) from staff for bed mobility (to turn and reposition in bed), transferring from chair to bed and bed to chair, and was dependent (staff does all of the work) on staff for toileting (going to the bathroom). Section H- Bladder and Bowel indicated Resident 1 had occasional urinary incontinence (some loss of bladder control) episodes and was always continent (had full control) of her bowels.A review of Resident 1's admission Fall Risk Assessment, dated 1/14/25, indicated that Resident 1 was at high risk for falls with a score of 22 based on Resident 1's cognition, previous history of falls, bowel and bladder continence (control), and medications she was taking.A review of Resident 1's care plans was conducted and indicated the following: a Musculoskeletal Care Plan, dated 1/14/25, included interventions to Anticipate and meet needs.respond promptly to all requests for assistance.b High Risk for Fall Care Plan, revised 2/11/25, included interventions to anticipate and meet needs, keep within supervised view as much as possible, keep bed in low position with brakes locked, keep call light within reach.c. Bladder Incontinence Care Plan, dated 1/14/25, included interventions to offer toileting on rounds (an every two hour check done by the CNAs), upon request, and as needed.During a phone interview with FM on 6/10/25 at 9:44 am, FM stated, Right before I left [the facility] that day [3/9/25] at about 6:15 pm, I told the nurse [Licensed Nurse A] that [Resident 1] was laying down to go to sleep but you will have to get her up and take her to the bathroom or she would try to go to the bathroom by herself. [LN A] responded okay. FM stated that around 6:50 pm, (40 minutes later), that same evening (3/9/25), FM received a call from the facility that Resident 1 had fallen trying to go to the bathroom. FM stated that 6:30 pm was Resident 1's usual time to go to the bathroom and get ready for bed.A review of Resident 1's Bladder Continence documentation dated 3/9/25, was conducted and indicated that Resident 1 was last taken to the bathroom at 4:27 pm, over 2 hours before she fell.A review of Resident 1's progress notes titled, Alert Charting dated 3/10/25 at 3:46 am, indicated LN B documented on 3/9/25 at 6:45 pm, that LN B found Resident 1 in her room between the bed and her room door, lying on her left side sitting halfway up with her hands holding her up on the floor, and indicated it appeared as though she (Resident 1) was trying to walk to the restroom. LN B documented, [Resident 1's] lateral [outside] ankle was swollen and tender to touch. This nurse called MD [Medical Doctor] he ordered x-ray [to right ankle] to be done in the facility, Asper-creme [a cream that provides relief to joint pain and helps to reduce swelling] to be applied topically [on the skin of Resident 1's right ankle], ace bandage wrap [a stretchy bandage to help reduce swelling], ice [to right ankle], and a foot cradle [a frame that goes on the foot of the bed to lift sheets and blankets off of the and feet] to keep the blankets off the [right] foot since there is so much swelling and discoloration.A review of Resident 1's progress notes titled, Nurse's Notes dated 3/10/25 at 1:27 pm, LN A documented that Resident 1's right ankle was swollen, purple, and wrapped in an ace wrap. Resident 1 had an X-ray taken on 3/10/25 at 10:00 am, in the facility. Resident 1's FM was concerned and did not want to wait for X-ray results. Resident 1's FM insisted that Resident 1 be sent to the hospital. EMS (Emergency Medical Services 911) was called at 11:20 am and arrived to the facility at 11:35 am. Resident 1 then left by ambulance at 11:45 am, to go to the hospital. Resident 1 returned to the facility after her evaluation in the emergency department at the hospital.A review of Resident 1's Emergency Department (ED) provider notes on 3/10/25 at 12:00 pm, documented by the Emergency Department Physician (EDP), indicated, examination of the right foot and ankle does show tenderness and swelling both to the dorsal [top] and lateral [outer side] of foot as well as the right ankle. Resident 1's ED X-ray results of her right ankle indicated Resident 1 had a broken ankle, a broken pinky toe, a broken big toe, and a broken bone on the top of her right foot. Resident 1 received Norco 5-325 mg 1 tablet at 1:34 pm, in the ED. EDP wrote new orders for Resident 1's right foot to be immobilized (not able to be moved) and to see orthopedics (Physician that specializes in bones). Resident 1 was then taken back to the facility.Resident 1's March 2025's Medication Administration Record (MAR) was reviewed for Resident 1's documented pain complaints and pain levels (0 - 10, 0 was no pain and 10 was extreme, severe pain). The following was documented on Resident 1's MAR:a. On 3/9/25 at 7:17 pm, LN B documented Resident 1's pain level as a 6 (moderate pain) and LN B gave Resident 1 one Norco 10- 325 mg tablet. b. On 3/9/25 at 11:30 pm, LN B documented Resident 1's pain level as a 7 (severe pain) and LN B gave Resident 1 one Norco 10- 325 mg tablet.c. On 3/10/25 at 3:30 am, LN B documented Resident 1's pain level as a 5 (moderate pain), and LN B had not given Resident 1 pain medication. d. On 3/10/25 at 8:00 am, LN A documented Resident 1's pain level as a 5 (moderate pain), and LN A had not given Resident 1 pain medication. e. On 3/10/25 at 9:00 am, LN A documented Resident 1's pain level as a 5 (moderate pain), and LN A had not given Resident 1 pain medication. f. On 3/10/25 at 5:05 pm, LN A documented Resident 1's pain level as an 8 (severe pain). LN A gave Resident 1 one Norco 5-325 mg tablet. A review of Resident 1's Social Service Note dated 3/17/25 at 10:32 am, Social Service (SS) documented Resident 1 was scheduled to discharge home on 3/12/25 with her FM, but due to Resident 1's recent falls that occurred on 3/6/25 where Resident 1 sustained a hematoma (large bump) on her forehead, then on 3/9/25 where Resident 1 sustained a fracture to the right ankle, foot and toes, Resident 1 was now not able to stand on her right foot. SS documented that Resident 1 required a Hoyer lift (a mechanical lift that transfers a resident without the resident touching the ground), and Resident 1 was not able to go home and required extended physical therapy.During a concurrent interview and record review on 7/8/25 at 1:41 pm, the Director of Rehab (DOR) stated that Resident 1 was preparing to discharge home on 3/12/25, but then Resident 1 had a fall on 3/9/25 and subsequently became dependent on staff for transfers and had to stay longer at the facility due to a broken right ankle. DOR indicated Resident 1 discharged home on 4/24/25, six weeks after she had initially planned to go home.During an interview on 7/8/25 at 2:23 pm, LN A stated that on 3/9/25 at around 6:20 pm, FM told her that she (FM) was leaving and to have a CNA take Resident 1 to the bathroom. LN A indicated Resident 1 required help to go to the bathroom, was confused, and was always getting out of bed without help. LN A said she asked CNA E to take Resident 1 to the bathroom. LN A stated she also asked LN B (the oncoming nurse) to get a CNA to take Resident 1 to the bathroom. LN A stated, I was worried that she [Resident 1] might get out of bed. I should have checked on her, but I thought the CNA was going to help her.During a phone interview on 7/9/25 at 10:39 am, LN B indicated on the night of 3/9/25 around 6:45 pm, Resident 1 was found on the floor in her room. LN B indicated Resident 1 had fallen right after LN B had started her night shift (6:30 pm to 7 am) and she remembered Resident 1 being in a lot of pain after the fall. LN B stated that Resident 1 had dementia and when she sat up on the side of the bed, that meant she needed to go to the bathroom or was hungry. LN B stated that 6:30 pm was Resident 1's normal time to go to the bathroom and since Resident 1 had dementia, she was unable to always answer accurately to whether or not she needed to use the bathroom. LN B stated LN A had not reported to her that Resident 1 needed to go to the bathroom.During a phone interview on 7/10/25 at 2:33 pm, CNA H stated she worked on 3/9/25 from 6:30 pm to 11:00 pm, on nursing unit three and was never asked to take Resident 1 to the bathroom and confirmed she never took Resident 1 to the bathroom.During a phone interview on 7/10/25 at 3:10 pm, CNA G stated that on 3/9/25 from 2:30 pm through 7:00 pm, she was assigned to float (a CNA that was not assigned to specific rooms or residents, but helps where help was needed) on unit three. CNA G stated she was never asked to take Resident 1 to the bathroom on 3/9/25, however around 6:35 pm, she had walked by Resident 1's room and saw Resident 1 sitting on the edge of her bed. CNA G stated she asked Resident 1 if she needed to use the bathroom and Resident 1 responded no. CNA G then assisted Resident 1 to lie back down and had not taken her to the bathroom. CNA G stated she then left Resident 1's room and within minutes she heard help me, help me and saw Resident 1 on the floor in her room. During a phone interview on 7/10/25 at 3:15 pm, CNA E confirmed she was assigned to care for Resident 1 on 3/9/25 from 2:30 pm to 11:00 pm, but never took care of her, and has not taken care of Resident 1 since February 2025, because Resident 1's FM requested her to no longer care for Resident 1. CNA E stated LN A never asked her to take Resident 1 to the bathroom.2. Nursing Staff Assignment and Sign-In Sheet, dated 3/9/25, for PM shift 2:30 pm to 11 pm, on nursing unit three (rooms 300-317), was reviewed and indicated that CNA E was scheduled to work 2:30 pm to 11 pm, and assigned to Resident 1's room, CNA G was scheduled to work from 2:30 pm to 7 pm, CNA H was scheduled to work 6:30 pm to 11 pm, CNA J was scheduled to work from 2:30 pm to 7 pm, and CNA K was scheduled to work from 2:30 pm to 11 pm, were all assigned to nursing unit three. During a phone interview on 7/10/25 at 2:33 pm, CNA H stated she worked on 3/9/25 from 6:30 pm to 11:00 pm, on nursing unit three and confirmed she was not assigned to Resident 1. During a phone interview on 7/10/25 at 3:10 pm, CNA G stated that on 3/9/25, she was assigned as a float on unit three from 2:30 pm to 7 pm and confirmed she was not assigned to care for Resident 1. During a phone interview on 7/10/25 at 3:15 pm, CNA E confirmed she was assigned to care for Resident 1 on 3/9/25 from 2:30 pm to 11:00 pm, and had not taken care of her. CNA E explained that she was not allowed to care for Resident 1 because since February 2025, Resident 1's FM did not want her taking care of Resident 1. Surveyor asked CNA E if this had been communicated to a nurse or another CNA and if CNA E knew who ended up taking care of Resident 1. CNA E replied that it was not her job to find someone to replace her, it was the nurses job. CNA E stated she never cared for Resident 1 on 3/9/25, and does not know who did. 3. The facility's policy titled, Assessing Falls and their Causes dated March 2018, was reviewed and indicated, Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. When a resident falls, the following information should be recorded in the resident's medical record: 6. Appropriate interventions taken to prevent future falls.A review of Resident 1's progress note titled, Change in Condition (CIC) dated 3/6/25, LN D indicated Resident 1 had a fall on 3/6/25 at 3:32 pm, documentation included [LN D] found res [Resident 1] sitting on floor to right side of bed. Res [Resident 1] sitting on her buttocks on floor mat. Res wearing socks, no incontinence at time of fall, brief [adult diaper] was dry. Bed below knee height. Hematoma [bump or goose egg] to top of head measuring approx. [approximately] 3 cm [centimeters, 2.5 centimeters equal about one inch] X [by] 3.2 cm. Resident 1's nursing progress note documentation from 3/6/25 through 3/9/25 was reviewed and indicated that there was no nursing documentation which identified possible or likely causes of Resident 1's fall on 3/6/25, as the facility's policy indicated there should have been.A review of Resident 1's Fall Care Plan, created on 3/6/25, indicated that no revisions or new interventions had been made after Resident 1's fall with injury on 3/6/25. A concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON) on 7/8/25 at 3:19 pm. Resident 1's CIC note from 3/6/25, nursing documentation notes from 3/6/25 through 3/9/25, and Fall Care Plan dated 3/6/25, were reviewed with the ADON. The ADON confirmed Resident 1 had a fall and hit her head on 3/6/25, and there was no CIC nursing documentation or revisions to her Fall Care plan, and there should have been.

Based on interview and record review the facility failed to ensure pain management was provided for one of three residents sampled for pain management (Resident 1) when Resident 1 had pain in her right ankle rated at a 5 (on a pain scale from 0-10 with 0 being no pain and 10 being severe pain) and was not medicated with pain medication as indicated in her physician's orders consistent with her pain level.This resulted in Resident 1 experiencing unrelieved moderate pain and tenderness to right ankle and had the potential to negatively impact her physical and emotional well-being.Findings:A review of the facility's policy titled, Pain Assessment and Management dated April 2025, indicated, The purpose of this procedure is to help the staff identify pain in the residents, and to develop interventions that are consistent with resident needs. Possible Behavioral Signs of pain: Facial Expression such as grimacing, frowning, clenching of jaw. Implement the medication regimen per Physician orders.A review of the facility's policy titled, Pain-Clinical Protocol Revised April 2025, indicated, The physician and staff will identify individuals who have pain or who are at risk for having pain.A review of the facility's policy titled, Administering Pain Medications revised April 2025, indicated, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary process that includes the following: a. identifying signs and symptoms of and assessing existing pain; b. recognizing situation and conditions with the potential for pain.f. monitoring for the effectiveness of interventions; and g. modifying approaches as necessary.A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with diagnoses which included surgery to the right hip from a broken hip (due to a fall at home), dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), Alzheimer's (a progressive disease that destroys memory and other important mental functions), osteoporosis (bones are weak and brittle), muscle weakness, and diabetes (high sugar in the blood). The admission record indicated Resident 1 did not have mental capacity to make healthcare decisions. A review of Resident 1's admission Minimum Data Set (MDS, a complete clinical assessment), dated 1/17/25, section C- Cognitive Patterns (determines residents attention, orientation, and ability to register and recall information) indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to evaluate memory and decision making skills on a scale of 0 to 15, with 0 being highly impaired and 15 being no impairment), Resident 1 scored 0 which indicated Resident 1's cognition was severely impaired. A review of Resident 1's progress notes dated 3/10/25 at 3:46 am, was conducted. Licensed Nurse (LN) B, documented that at 6:45 pm she found Resident 1 in her room between the bed and her room door, lying on her left side sitting halfway up with her hands holding her up on the floor, and indicated that it appeared as though Resident 1 may be have been trying to walk to the restroom. LN B documented, her [Resident 1's] lateral [outside] [right] ankle was swollen and tender to touch. This nurse called MD [Medical Doctor] he ordered x-ray [to right ankle] to be done in the facility, Asper-creme (a cream that helps relieve joint pain and reduce swelling] to be applied topically [on top of the right foot], ace bandage wrap [an elastic bandage that reduces swelling], ice [to the right foot], and a foot cradle [a metal frame that goes on the foot of the bed to keep blankets and sheets from touching the feet] to keep the blanket off the foot since there is so much swelling and discoloration. FM also stated she wanted [Resident 1] to have consistent pain management with this COC [Change of Condition] this was endorsed [told to] to oncoming nurse. During an interview with Resident 1's family member (FM) on 6/10/25 at 9:44 am, FM stated she got a call from LN B on 3/9/25 in the evening, telling her that Resident 1 had fell and hurt her right ankle. FM stated she came to the facility the next day, on 3/10/25 before lunch, and found that Resident 1's right ankle was causing her so much pain. Resident 1's right foot and ankle were black and blue, swollen, and hurt when it was touched. FM stated she asked LN A if she had given Resident 1 any pain medication. LN A replied that she had not given Resident 1 any pain medication since she had come on shift at 6:30 am. FM stated that she asked the LN A to send Resident 1 to the hospital at that point, so her right foot could be evaluated and x-rayed. A review of Resident 1's progress notes dated 3/10/25 at 1:27 pm, was conducted. LN A documented Resident's right ankle was swollen, purple, and wrapped in an ace wrap. LN A documented that Resident 1 had an X-ray taken of her right ankle and foot on 3/10/25 at 10:00 am, in the facility and that Resident 1's FM was concerned and did not want to wait for those X-ray results. LN A documented that Resident 1's FM insisted that she (Resident 1) be sent to hospital. EMS (Emergency Medical Services-911) was called at 11:20 am and arrived at 11:35 am. Resident transferred safely onto gurney and into ambulance at 11:45 am. A review of Resident 1's January 2025 Physician's Orders indicated: An order, dated 1/15/25, for Norco (narcotic pain pill) tablet 5-325 mg (milligrams a unit of measurement), give one tablet by mouth every four hours as needed for pain level 4-6 (moderate pain) and a Norco tablet 10-325 mg, give one tablet by mouth every four hours as needed for pain level 7-10 (severe pain). Resident 1's March 2025's Medication Administration Record (MAR) was reviewed for Resident 1's documented pain complaints and pain levels (0 - 10, 0 was no pain and 10 was extreme, severe pain) were as follows:On 3/10/25 at 3:30 am, Resident 1's pain level was documented as level 5 by LN B. No pain medication was given.On 3/10/25 at 8:00 am, Resident 1's pain level was documented as a level 5 by LN A. No pain medication was given. On 3/10/25 at 9:00 am, Resident 1's pain level was documented as a level 5 by LN A . No pain medication was given. On 3/10/25 at 5:05 pm, LN A documented Resident 1's pain level as an 8 (severe pain). LN A gave Resident 1 one Norco 5- 325 mg tablet, which was the wrong dose of Norco for a pain level of 8. Norco 10-325 was ordered for a pain level of 7-10 severe pain. A review of Resident 1's Emergency Department (ED) provider notes on 3/10/25 at 12:00 pm, written by the emergency room Doctor, indicated examination of the right foot and ankle does show tenderness and swelling both to the dorsal [top] and lateral [outer side] of foot as well as the right ankle. Resident 1's ED X-Ray results of her right ankle indicated Resident 1 had a broken shin bone that extended into the ankle, broken pinky toe, broken big toe, and a broken bone on the top of her foot. Resident 1 received Hydrocodone-Acetaminophen 5-325 mg 1 tablet at 1:34 pm, in the ED. During a concurrent interview with Physical Therapist and record review on 7/11/25 at 2:51 pm, Resident 1's therapy notes were reviewed for a session dated 3/10/25 at around 11:00 am. PT notes indicated, Response to Session interventions: the patient recently suffered a ground level fall last night and her R [right] lower leg was involved. The patient was approached in bed and the patient was very lethargic [drowsy]. The patient endorses [states] large amounts of pain in her RLE [right lower extremity] and is very tender to palpation [touching] on the outside of the ankle and displays large area of bruising and diffuse swelling throughout. PT stated that when he went in to do Resident 1's therapy on 3/10/25 around 11:00 am, he remembered Resident 1 being in pain. Resident 1 had a purple, swollen and tender right ankle. PT stated that Resident 1 grimaced, clenched her jaw and pulled away when he would reach for the foot and was noted to be in pain. PT stated that Resident 1 was then sent to the ED for evaluation. During a concurrent interview with LN A and record review on 7/14/25 at 2:05 pm, Resident 1's March 2025's MAR was reviewed. LN A confirmed that she did not medicate Resident 1 with Norco 5-325 mg for a pain level of 5 at 8:00 am and 9:00 am, on 3/10/25, as per physician orders, and she should have.

Based on interview and record review, the facility failed to protect one of three residents, sampled for abuse, (Resident 1) the right to be free from neglect due to the deprivation of goods and services by Licensed Nurse (LN) A when Resident 1 had pain in her broken right ankle and LN A indicated she was too busy to dispense Resident 1 pain medication. This resulted in Resident 1 experiencing unnecessary unrelieved pain and discomfort to right ankle and had the potential to negatively impact her physical and emotional well-being.FindingsA review of the facility's policy titled Identifying Types of Abuse revised 9/22, indicated abuse of any kind against residents is strictly prohibited. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain mental anguish or emotional distress.A review of the facility's policy titled Resident Rights revised 2/20/21, indicated employees shall treat all resident with kindness, respect, and dignity and be free from abuse, neglect.A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with diagnoses which included surgery to the right hip from a broken hip (due to a fall at home), dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), Alzheimer's (a progressive disease that destroys memory and other important mental functions), osteoporosis (bones are weak and brittle), muscle weakness, and diabetes (high sugar in the blood). The admission record indicated Resident 1 did not have mental capacity to make healthcare decisions. A review of Resident 1's admission Minimum Data Set (MDS, a complete clinical assessment), dated 1/17/25, section C- Cognitive Patterns (determines residents attention, orientation, and ability to register and recall information) indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to evaluate memory and decision making skills on a scale of 0 to 15, with 0 being highly impaired and 15 being no impairment), Resident 1 scored 0 which indicated Resident 1's cognition was severely impaired. A review of Resident 1's progress notes dated 3/10/25 at 3:46 am, was conducted. Licensed Nurse (LN) B, documented that at 6:45 pm she found Resident 1 in her room between the bed and her room door, lying on her left side sitting halfway up with her hands holding her up on the floor, and indicated that it appeared as though Resident 1 may have been trying to walk to the restroom. LN B documented, her [Resident 1's] lateral [outside] [right] ankle was swollen and tender to touch. This nurse called MD [Medical Doctor] he ordered x-ray [to right ankle] to be done in the facility, Asper-creme (a cream that helps relieve joint pain and reduce swelling] to be applied topically [on top of the right foot], ace bandage wrap [an elastic bandage that reduces swelling], ice [to the right foot], and a foot cradle [a metal frame that goes on the foot of the bed to keep blankets and sheets from touching the feet] to keep the blanket off the foot since there is so much swelling and discoloration. FM also stated she wanted [Resident 1] to have consistent pain management with this COC [Change of Condition] this was endorsed [told to] to oncoming nurse. During an interview with Resident 1's family member (FM) on 6/10/25 at 9:44 am, FM stated she got a call from LN B on 3/9/25 in the evening, telling her that Resident 1 had fallen and hurt her right ankle. FM stated she came to the facility the next day, on 3/10/25 before lunch, and found that Resident 1's right ankle was causing her so much pain and that Resident 1 was crying. Resident 1's right foot and ankle were black and blue, swollen, and hurt when it was touched. FM stated she asked LN A if she had given Resident 1 any pain medication. LN A replied that she had not given Resident 1 any pain medication since she had come on shift at 6:30 am. FM stated that she asked the LN A to send Resident 1 to the hospital so her right foot could be evaluated and x-rayed. During a concurrent interview with Physical Therapist and record review on 7/11/25 at 2:51 pm, Resident 1's therapy notes were reviewed for a session dated 3/10/25 at around 11:00 am. PT notes indicated Response to Session interventions: the patient recently suffered a ground level fall last night and her R [right] lower leg was involved. The patient was approached in bed and the patient was very lethargic. The patient endorses [states] large amounts of pain in her RLE [right lower extremity] and is very tender to palpation on the outside of the ankle and displays large area of bruising and diffuse swelling throughout. PT stated that when he went in to do Resident 1's therapy on 3/10/25 around 11:00 am, he remembered Resident 1 being in pain. Resident 1 had a purple, swollen and tender right ankle. PT stated that Resident 1 grimaced, clenched her jaw and jerked away when PT would reach for Resident 1's right foot. PT stated that Resident 1 was then sent to the ED for evaluation of her right ankle. A review of Resident 1's Emergency Department (ED) provider notes dated 3/10/25 at 12:00 pm, written by the emergency room Doctor, indicated examination of the right foot and ankle does show tenderness and swelling both to the dorsal [top] and lateral [outer side] of foot as well as the right ankle. Resident 1's ED X-Ray results of her right ankle indicated Resident 1 had a broken shin bone that extended into the ankle, broken pinky toe, broken big toe, and a broken bone on the top of her foot.A review of Resident 1's January 2025 Physician's Orders indicated an order, dated 1/15/25, for Norco (narcotic pain pill) tablet 5-325 mg (milligrams a unit of measurement), give one tablet by mouth every four hours as needed for pain level 4-6 (moderate pain) and a Norco tablet 10-325 mg give one tablet by mouth every four hours as needed for pain level 7-10 (severe pain).Resident 1's March 2025's Medication Administration Record (MAR) was reviewed for Resident 1's documented pain complaints and pain levels (0-10, 0 was no pain and 10 was extreme, severe pain) were as follows: On 3/10/25 at 8:00 am, Resident 1's pain level was documented as a level 5 by LN A and no pain medication was documented as given. On 3/10/25 at 9:00 am, Resident 1's pain level was documented as a level 5 by LN A and no pain medication was documented as given.During a concurrent interview with LN A and record review on 7/14/25 at 2:05 pm, Resident 1's March 2025's MAR was reviewed. LN A confirmed that Resident 1 was having moderate pain at a level 5 on 3/10/25 at 8 am and 9 am, and that LN A documented that on Resident 1's MAR. LN A confirmed she was aware that Resident 1 had a physician's order for one Norco 5-325 mg tablet for moderate pain. During the interview LN A stated, Her [Resident 1's] ankle was swollen and purple and [Resident 1] was just lying in bed and not wanting to do any activities. I [LN A] did not give her pain medication until 5:00 pm that evening when she [Resident 1] complained of severe pain. I should have given her [Resident 1] pain medication in the morning when she was having moderate pain in her right ankle, but I did not because I was really busy that day.

Based on observation, interview, and record review, the facility failed to ensure the safety and security of seven of seven residents (Residents 1, 2, 3, 4, 5, 6 and 7) sampled as those who had been identified as high risk for wandering and/or elopement (when a resident unsafely leaves the facility undetected) when: 1. The Touchpad Exit Controller (TEC, a system located on exit doors that alarms when resident wearing a Wanderguard (a wrist or ankle bracelet that alarms), passes through any of those exits), alarm system did not alarm and Resident 1 eloped from the facility without staffs knowledge, and Resident 1 was found across the street from the facility by a person who was driving by, with his wheelchair stuck in a sidewalk crack. 2. The monitoring check-off log of the TEC system and exit door alarms had not identified which doors were being tested , had not included all of the facility exit doors, and had days where there was no documentation that reflected that the doors had been checked. 3. The TEC system on Station 3 ' s exit door was not functioning and had not alarmed when tested by the surveyor. 4. The physician ' s orders for Residents 2, 3, 4, 5, 6, and 7, indicated the resident's wanderguards would be checked once daily which was not in accordance with the facility's policy that indicated the checks would be done every shift (three times a day). 5. Registered Nurse (RN) A and Licensed Vocational Nurse (LVN) B were not checking the functionality (whether they would alarm or not if they went through the TEC system) of the wanderguards as ordered. The facility's lack of oversight of ensuring their TEC and Wanderguard systems were fully functional, resulted in Resident 1 eloping from the facility and endangered the safety and welfare of six other residents who were known to wander. Findings: A review of the facility ' s policy titled, Safety and Supervision of Residents revised [DATE], indicated, Our facility strives to make the environment as free from accident hazards as possible. Residents ' safety and supervision and assistance to prevent accidents are facility-wide priorities. These risk factors and environmental hazards include the following: e. unsafe wandering. 1. A review of Resident 1 ' s admission record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, dementia (a group of symptoms that affecting memory, thinking and social abilities), depression, history of falling, muscle weakness, heart failure and a stroke (the brain goes without blood and causes damage to that certain area affected). Resident 1 was unable to make his own health care decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a data driven clinical assessment) dated [DATE], section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS, evaluation of cognition, thinking, memory recall and decision making with a score from 00 to15) score of 7, severely impaired cognition. Section E indicated Resident 1 had wandering behaviors one to three times a week. A review of Resident 1 ' s Physician's Order, revised [DATE], reflected an order for, Wandergard (wanderguard) to right ankle due to elopement risk. A review of Resident 1 ' s nurses Progress Notes written by LVN D, dated [DATE] at 8:29 pm, indicated at approximately 6:10 pm, A member of the community came into the facility and informed this nurse that there was a man in a w/c (wheelchair) stuck on the sidewalk. This nurse walked outside with the community member where she proceeded to point out where the man was, stating he was across the street and stuck by the fence. This nurse walked out to the sidewalk and saw a man in a w/c across the street facing a fence and seemingly stuck. This nurse went across the street and spoke with the man, asked his name, he identified himself, this nurse recognized him as a resident of this facility. A report by the facility to the California Department of Public Health on [DATE] at 3:01 pm, indicated Resident 1 had a wanderguard placed on his left ankle that failed to alarm when he went out of one of the facility exit doors. The facility indicated that their wanderguard system (TEC) was assessed by the facility and found to have an unconnected wire and was not working. During an interview on [DATE] at 11:30 am, LVN C indicated Resident 1 ' s room was next to the North door on Station 1 and the TEC system which was mounted next to the door on the wall, Was missing a screw, was loose and unplugged behind the cover the day [Resident 1] got out. LVN C indicated that after she plugged in the TEC and replaced the screws the alarm was working again. During an interview with the Administrator (Admin) on [DATE] at 11:30 am, the Admin confirmed the TEC system on the North door on Station 1 was not working when Resident 1 eloped on [DATE]. 2. During an observation and interview with the Maintenance Director (MD) on [DATE] at 11:49 am, the exit doors of the facility were observed. There were nine exit doors identified to exit the building. Station 1 ' s North exit door, Station 1 ' s East exit door, Station 2 ' s East exit door, Station 2 ' s South exit door, Station 3 ' s exit door, Station 4 ' s exit door, the Dining Room exit door, the Lobby exit door, and the Laundry Hall exit door. The MD indicated the door alarms and locks are checked every morning on all nine doors. The MD indicated that on the morning of [DATE], the nine exit doors were check for the sound of the alarm, but it was not noticed if the TEC cover was loose, were missing screws or unplugged. The MD indicated they just checked to see if the alarms were working. During a concurrent interview with the Admin and record review on [DATE] at 11:30 am, a facility ' s door monitoring check-off log titled, Logbook document . for Doors, Locks, Gates and Alarms: Test operation of doors and locks for dates [DATE] thru [DATE] were reviewed. The check-off log had no documentation that any of the alarms had been checked on Sunday February 16th, Saturday February 22nd, and Sunday February 23, 2025. The check-off log only listed seven of the nine exit doors in the facility. The Admin confirmed there were nine exit doors, but the log only identified seven and had not included one door on Station 1 and one door on Station 2. The Admin confirmed that all nine doors should be checked daily to ensure all alarms and locks were functioning for the safety of the residents. 3. During a concurrent observation and interview with the MD on [DATE] at 11:49 am, the TEC system for the exit door on Station 3 was tested . This surveyor held onto a wanderguard (the device that the resident wears which signals the TEC to alarm), with her right hand and walked out Station 3 ' s door and the TEC alarm did not go off. MD was previously unaware that alarm was not working. 4. During a review of the facility policy titled, WanderGaurd Process Guide Revised [DATE], the policy indicated, 7. Monitor placement and functioning of the device per order. Order should include: b. Every shift monitoring of WanderGaurd device functioning. During a concurrent interview with the Admin and record review on [DATE] at 11:30 am, physician's orders for Residents 1, 2, 3, 4, 5, 6, and 7 who the facility had identified as wanderers with the potential to elope, were reviewed. Residents 2, 3, 4, 5, 6, and 7 had an order to check functionality (of the wanderguard) . every day shift. The Admin confirmed the facility had not followed their policy by checking the functionality of the wanderguards every day instead of every shift. 5. A review of the facility's,Wander Management Transmitters user guide dated 2018, the guide instructions reviewed testing and care of the transmitter (wanderguard), which included: Visual Inspection 1.Verify that the warranty expirations date that is stamped on the transmitter is not expired. 2. Visually inspect the transmitter for damage or loose parts. Operation 1. Place the transmitter tester directly on the transmitter (wanderguard). 2. Press and hold the button on the left side of the transmitter tester. 3 The device beeps once when you initially press the button. 3. While holding the button in, the indicator light flashes and a tone sounds once per second. 5. Wait for at least 3 flashes of the indicator light and 3 tones from the transmitter tester to verify that the transmitter is functioning correctly. During an interview on [DATE] at 12:28 pm, Registered Nurse (RN) A indicated that she would look at the residents wanderguards daily to make sure they were physically on the residents, but she did not check functionality with a tester. RN A indicated, About every four days or so she would place a resident next to an exit door to see if it would alarm and that was how she checked it. During an interview on [DATE] at 12:38 pm, LVN B indicated he checked that the residents were wearing their wanderguards every day, but did not check to see if they worked. LVN B indicated he had not used a transmitter tester to test the wanderguards. During an interview on [DATE] at 12:45 pm, Director of Nursing (DON) indicated that there was a tool available to staff to check the functionality of the wanderguards and the staff should be using that.

Based on observation, interview, and record review, the facility violated a request for refusal of treatment for one of two residents sampled for resident rights (Resident 1) when, Resident 1 requested no artificial means of nutrition, including feeding tubes (Gastrointestinal Tube(G-tube)), a flexible tube that is placed through the abdominal wall and into the stomach for feeding liquid nutrition), because he wanted to eat and drink regular food and liquids, and the facility continued to feed Resident 1 by G-tube for 24 days after he had signed a Physician Order for Life Sustaining Treatment (POLST, a document of resident wishes). This failure caused Resident 1 distress, frustration and pain and negatively impacted his quality of life. Findings: A review of the facility ' s admission agreement titled, California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities revised 5/11, the agreement indicated .you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. A review of the facility ' s, POLST form indicated, First follow these orders then contact Physician .A copy of the signed POLST form is a legally valid physician order. A review of Resident 1 ' s Admission Record indicated Resident 1 was originally admitted on [DATE] with diagnoses that included diabetes, obesity, heart failure, and major depression. On 1/18/25 Resident 1 was readmitted to the facility after a short hospital stay with new diagnoses that included placement of a G-tube due to dysphagia (difficulty swallowing certain foods or liquids which causes coughing and choking), and aspiration (when food or fluids are accidentally inhaled into the lungs, instead of the stomach). Resident 1 made his own health care decisions. A review of Resident 1 ' s Admission Minimum Data Set (a data driven clinical assessment), dated 1/21/25, section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS, evaluation of cognition, thinking, memory recall and decision making that scores from 00 to15), reflected that Resident 1's BIMS score was a 15. A review of Resident 1 ' s POLST dated 1/31/25, indicated Resident 1 ' s wishes were, Do not attempt Resuscitation [DNR, allow natural death], and, No artificial means of nutrition, including feeding tubes. Resident 1 and the Medical Director both signed the form on 1/31/25. A review of Resident ' 1 ' s Physician's Orders for February 2025, indicated an Enteral (the administration of nutrition through a G-Tube) feeding order was started 1/18/25 and discontinued on 2/24/25, twenty-four days after Resident 1 made his wishes clear. A review of Resident 1 ' s nursing Progress Notes were reviewed and reflected the following: On 2/2/25 at 4:15 pm, a nurse documented, Resident on alert charting r/t [related to] monitoring for noncompliance with NPO [nothing by mouth] diet. Fluids and meals given via [by way of] G-Tube as scheduled On 2/3/25 at 4:07 pm, a nurse documented, Resident on alert charting r/t monitoring for noncompliance with NPO diet. Fluids and meals given via (by the way of) G-Tube as scheduled On 2/4/25 at 10:48 pm, a nurse documented, At approx. 10:20 [pm] CNA [Certified Nursing Assistant] approached nurse and said residents G-Tube was no longer intact, the nurse went in room to find resident holding g-tube. When asked what happened he states, it was an accident it got caught on my blankets. EMS [Emergency Medical System, an ambulance] called. On 2/5/25 at 9:45 am, a nurse documented, Resident return from acute on 2/5/25 with new G-tube in place. On 2/6/25 at 10:45 pm, a nurse documented, Weekly Summary notes .Resident is NPO and receives 2500 mL [milliliters] daily via g-tube, also some flushes too as tolerated. Resident has been non-compliant at times with new diet by consuming oral snacks and beverages. On 2/7/25 at 10:45 am, a nurse documented, Attempted to speak with resident regarding TF [tube feeding] and weight refusal. Resident continues to be upset about feeding tube. Writer offered sympathetic listening. He then stated, ' I am either going to commit suicide or take this thing out [the G-tube] ' He went on to state he is mad how big the tube out of his stomach is and stated, ' I want this F* thing out ' . During an observation and interview with Resident 1 on 3/11/25 at 11:30 am, Resident 1 was observed in bed with no shirt on and a sheet covering the lower half of his body, a G-tube was visible coming from his stomach. Resident 1 stated, They said I was aspirating. I had pneumonia and I failed the swallowing test. I want to get it [the G-tube] out .I want to eat regular food. Resident 1 indicated the G-tube caused him pain and discomfort. During a concurrent interview with Director of Nursing (DON) and record review on 3/11/25 at 4:31 pm, Resident 1 ' s POLST and physician orders were reviewed. DON confirmed that Resident 1 indicated he did not want feeding through a tube on his POLST and the Medical Director signed it on 1/31/25. The DON confirmed Resident 1 had received feedings through his G-tube after he had signed his POLST, requesting not to have this treatment. The DON confirmed the facility should have followed Resident 1 ' s wishes beginning on 1/31/25, but instead continued to feed Resident 1 against his will, for another 24 days. Resident 1 ' s nursing progress notes were reviewed and the DON who confirmed that nursing documentation reflected Resident 1 was distraught over being fed by a G-tube.

Based on interview, record and facility policy review, the facility failed to recognize and report a change in condition to the physician, conduct weekly skin wound evaluations as their policy directed, and carry out physician's orders for antibiotic (medication for treating infections), for one of three residents sampled for wound care (Resident 1) when: 1. Resident 1 had a surgical wound to her upper left leg that had worsened on 3/29/24, and her physician was not notified. 2. Resident 1's weekly skin evaluations of her wounds, were not performed weekly. 3. Resident 1 had orders from her vascular surgeon (a doctor who specializes in treatment of blocked arteries and veins), to begin taking an antibiotic on 4/10/24, that were never carried out. These failures had the potential to delay the healing process of Resident 1's wounds and contribute to Resident 1's hospital readmission. Findings: 1. A review of the facility's policy titled, Change in a Resident's Condition or Status revised October 2024, indicated, The nurse will notify the resident's Attending Physician .when there has been .d. significant change in the resident's condition. A review of the Centers for Disease Control and Prevention (CDC) newsletter titled, Know the Signs and Symptoms of Infection dated 11/4/24, indicated, call the doctor right away if you notice any of the following signs and symptoms of an infection; redness, soreness, or swelling in any area including surgical wounds A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare following surgical amputation (removal of toes), diabetes, kidney disease stage 3 (kidneys have moderate damage and decreased ability to filter waste products), heart failure, chronic obstructive pulmonary disease (COPD, a lung disease), peripheral vascular disease (impaired or blocked blood flow to arms and legs), non-pressure chronic ulcer of left heel and midfoot (a wound), dementia, bipolar disorder (form of depression and anxiety), and lung cancer. Resident 1 was made her own healthcare decisions. A review of Resident 1's Admission Minimum Data Set (MDS, a data driven clinical assessment) dated 3/28/24, indicated Resident 1's Brief Interview of Mental Status (BIMS, an evaluation of cognition level, thinking, reasoning and memory recall with range 00 to 15), score was 15 out of 15, which indicated no problems. A review of Resident 1's hospital, Discharge Summary dated 3/25/24, indicated Resident 1's hospital course included left lower extremity (left leg) peripheral vascular disease (blockage of blood vessels) complicated by osteomyelitis (bone infection) of the left great toe, second left toe ulceration which were amputated, left heel wound, and cellulitis (an infection and swelling caused by bacteria) of the left foot. On 3/21/24, Resident 1 had a surgical procedure called a Fem-Pop Bypass (a surgery that creates a new pathway for blood to flow through the lower leg), and the surgical incisions were intact. A review of Resident 1's, Nursing-Admission/Readmission Evaluation/assessment dated [DATE], indicated Resident 1 was admitted to the facility with three surgical incisions on her left leg; a. Left inner upper thigh which measured 2.5 centimeters long (cm- 2.5 cm equals approximately one inch). b. A mid-thigh incision which measured 2.8 cm long by 0.5 cm wide, and described the wound as beefy red. c. A third incision that was near the bottom of the thigh above the knee. This incision was not measured, but indicated the incision wound was covered with steri-strips (a form of wound closure strips), and had a small amount of bloody drainage, but no signs of infection. A review of Resident 1's, Physician's Orders dated 3/25/24, indicated, Left Anterior [front] Leg Surgical Incisions: Cleanse with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), cover with dry dressing and wrap. Monitor for s/sx [signs and symptoms] of infection every day shift for 14 days. A review of Resident 1's Physician's Orders dated 3/26/24, included an order to, Monitor redness and swelling to LLE [left lower extremity], for increase in redness and pain notify MD [doctor] and an appointment with [the vascular surgeon] on 4/10/24 to recheck the left inner leg incisions status. A review of Resident 1's, Impaired Skin Integrity Care Plan, initiated on 3/25/24, reflected interventions to administer treatments as ordered and monitor for effectiveness. A review of Resident 1's, Skin Breakdown Care Plan, initiated on 3/25/24, reflected interventions, Check skin during daily care provisions. Notify physician of abnormal findings. A review of Resident 1's nursing Progress Notes titled, Skin/Wound Note reflected the following: On 3/27/24 at 2:07 pm, a nurse documented, No signs or symptoms of infection to the left leg. On 3/29/24 at 4:29 pm, a nurse documented, LLE edematous [swollen], hard to touch and red. There was no documentation that Resident 1's physician was notified of this change. On 3/30/24 at 2:53 pm, a nurse documented, Resident complained of pain to left medial [middle] leg surgical incision sites. Incision sites red/inflammed and warm to the touch doctor contacted and new order was received for Keflex [an antibiotic] 500 mg (milligrams a unit of measure), three times a day and topical Bactroban (antibiotic ointment) two times a day, for 7 days. During a concurrent interview and record review of Resident 1's nursing Progress Notes, with the Director of Nursing (DON) on 3/11/25 at 1:50 pm, Resident 1's progress note dated 3/29/24 at 4:29 pm, was reviewed. DON confirmed Resident 1 had a change in the condition of her wound and her physician was not notified and should have been. 2. A review of the facility's policy titled, Skin Assessment: Best Practice revised 9/8/22, indicated, A weekly skin assessment is completed once a week and describes the current condition of the patients skin. A review of the facility's policy titled, Pressure Injuries/Skin Breakdown-Clinical Protocol revised April 2018, indicated, If a skin issue is noted the nurse should describe and document/report the following: Anatomical [where on the body] location stage, size, (length, width and depth), sinus tracts (tunneling under the skin), undermining (wound edges separate from the wound), presence of drainage, necrotic tissue (dead tissue) A review of three weeks of Resident 1's, Weekly Skin and Wound Evaluations V7.0 from admission on 3/25/24 to discharge on 4/13/24, reflected one of three weeks of the Weekly Skin and Wound Evaluations had not been completed; On 3/25/24, documentation included descriptions and measurements for the three surgical sites on the left upper leg. The week of 4/1/24, had no documentation that Resident 1's surgical wounds had been evaluated. The week of 4/8/24, the evaluation was done on 4/11/24, and reflected that one of the incisions, left mid-thigh surgical site, had dehisced (broke open), the left leg was red, hard, swollen and warm to the touch. During a concurrent interview with the DON and record review on 3/11/25 at 1:50 pm, Resident 1's, Weekly Skin and Wound Evaluations V7.0 were reviewed. DON confirmed Resident 1's surgical wounds were not evaluated on 4/1/24, and should have been. 3. A review of the facility's policy titled, Physician Orders revised October 2023, indicated Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. A review of Resident 1's Vascular Surgeon's VS), Physician's Visit Summary note, dated 4/10/24, indicated Resident 1 had seen her vascular surgeon that day for a follow-up visit. The vascular surgeon documented, I obtained a culture from one of the incisions that had dehisced. I started her [Resident 1] on Augmentin [an antibiotic] 500 mg 3 times daily. One of the small incisions in the medial thigh where I ligated a tributary [rerouted a blood vessel] has dehisced. There is no pus drainage, but I went ahead and cultured the wound. [Resident 1] has a lot of swelling and cellulitis appearance along the medial aspect of her thigh. She also has swelling of the leg. She needs to keep it elevated. A review of Resident 1's nursing Progress Notes dated 4/10/24, indicated there was no documentation to reflect that Resident 1 had left the facility to go to her appointment with her VS on 4/10/24. There was no documentation that Resident 1 returned from her appointment or whether or not she had new orders from the VS. A review of Resident 1's, Physician's Orders for the month of April 2024, reflected no order for the Augmentin that her vascular surgeon had ordered on 4/10/24. During a concurrent interview with the Administrator (Admin) and record review on 3/12/25 at 4:14 pm, Resident 1's Physician Visit Summary for the Vascular Surgery Clinic office visit on 4/10/24 was reviewed. Admin confirmed that Resident 1's VS had ordered Augmentin for Resident 1, and that was never started, nor was there any documentation by the facility that Resident 1 had left for, or returned from this appointment on 4/10/24, and there should have been documentation and follow-up by the nurses for any new orders.

Based on observation, interview, and record review, the facility failed to follow their pain management policy and identify causes of pain, implement pain management strategies, and monitor or modify approaches to ensure pain was adequately controlled for one out of 4 sampled residents (Resident 76) when: Resident 76 screamed out in pain when staff changed her brief (adult diaper), because staff forced her contractured legs (a permanent and irreversible deformity of a joint caused by the muscles and tendons shortening and stiffens the joint and causes an inability to move. Forcing a contractured body part such as arms, legs or neck, to move farther than the position it is fixed in, causes severe pain, muscle damage and broken bones). This failure resulted in severe pain and anxiety during brief changes for Resident 76 and had a negative affect on her physical, mental, and emotional well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 4/1/24, indicated, facility staff would identify causes of pain, implement pain management strategies, and monitor or modify approaches to ensure pain was adequately controlled. The P&P indicated, possible behavioral signs of pain were Verbal expressions of pain, and Facial expressions such as grimacing, frowning, clenching of the jaw, etc. The P&P indicated, an increase in breathing was a possible response to pain. A review of the undated, Admission Record, indicated, Resident 76 was admitted to the facility on [DATE] and had the diagnoses of anxiety (feelings of dread or fear), unilateral primary osteoarthritis (a disease that caused a breakdown of the joints over time and often caused pain), left hip, dorsalgia (back pain), and dementia (memory loss). The Admission Record, indicated, Resident 76 received hospice care and was not her own responsible party (did not make own decisions). A review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 10/15/24, Section C, indicated, Resident 76 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident's ability to recall information and memory, also known as cognition). Resident 76 scored a 1 out of 15, which indicated poor cognition. The MDS indicated, Resident 76 was dependent (staff did all of the work) on facility staff for toileting hygiene, rolling from left to right in bed, and had impairments to both lower extremities (hip, knee, ankle, foot). The MDS indicated, Resident 76 had pain and was incontinent (had no control of her bowel and bladder). During a concurrent observation and interview on 1/22/25 at 2:15 pm in Resident 76's room, Certified Nurse Assistant (CNA) D and CNA M were observed changing Resident 76's brief. Resident 76's left leg was observed to be fixed and bent at the knee and was over her chest, and tilted inwards against the right leg. CNA D confirmed, Resident 76's left leg could not move very far because she had a contracture. CNA D stated, when Resident 76's left leg was touched it was painful to her and she would scream, and cry. When CNA D and CNA M assisted Resident 76 to roll over onto her right side, Resident 76 made a moaning sound. When Resident 76 was assisted to roll onto her left side, Resident 76 had a frown on her face and said ooooooo multiple times. CNA D and CNA M then assisted Resident 76 to lying on her back. CNA D was observed forcing Resident 76's legs apart while CNA M slid the brief through the small tight opening of the legs. Resident 76 was observed screaming ow multiple times, had tears in her eyes, was breathing fast, was holding on to the bed rails tightly, and Resident 76's knuckles turned white. CNA D asked if Resident 76 was in pain. Resident 76 confirmed being in pain. CNA D and CNA M confirmed every time they changed Resident 76's brief and pulled her legs apart, it caused her pain. During an interview on 1/22/25 at 2:44 pm, Licensed Nurse (LN) R confirmed, when Resident 76 needed her brief changed it was always a painful experience for her because of her contractured legs. LN R confirmed that Resident 76 had not been evaluated for a less painful way to manage her incontinence. During an interview on 1/22/25 at 2:59 pm, CNA N confirmed anytime Resident 76's left leg was touched, Resident 76 would scream out in pain. CNA N stated, CNA N would talk to Resident 76 about deep breathing during pain, and she tolerates it. During an interview on 1/22/25 at 3:42 pm, Registered Nurse (RN) A confirmed anytime Resident 76's legs were moved, it caused her pain. RN A indicated there had been no reevaluations considered for an alternative to using briefs to manage Resident 76's incontinence. During an interview on 1/23/25 at 11:35 am, Resident 76's roommate stated every time facility staff changed Resident 76, Resident 76 would scream out in pain. The roommate added, It is heart breaking to hear and it makes me want to cry. During a concurrent observation and interview on 1/23/25 at 9:08 am in Resident 76's room, with Hospice Licensed Nurse (HLN). Resident 76 was lying on her back in bed. HLN asked Resident 76 if she could describe her pain on a scale of 0 to 10 (where zero meant no pain, and 10 meant the worst pain), Resident 76 yelled, it's a 20! HLN confirmed that he was not informed by facility staff that changing Resident 76's brief was painful and stated he was not aware that Resident 76's pain was, at this level. During an interview on 1/23/25 at 11:41 am in Resident 76's room, Resident 76 stated, It's very painful when the CNAs change her brief. During a concurrent observation and interview on 1/23/25 at 12:13 pm in Resident 76's room, Resident 76 was observed laying on her back in bed, with the head of the bed elevated. CNA D and CNA M were observed lowering the head of bed down and preparing to change Resident 76's brief. Resident 76 immediately started crying and said No! Resident 76 cried out ow, ow, ow, ow, over and over until the head of the bed was down and the bed was in the flat position. CNA M was observed placing one hand on Resident 76's left knee and the other hand on Resident 76's left shoulder and physically rolled Resident 76 onto her right side. While CNA D cleaned Resident 76's peri area (private area), Resident 76 was grimacing, crying, and stated, She just hurt me. CNA D and CNA M then rolled Resident 76 on to her back. CNA D was observed placing a brief in between Resident 76's legs, but the opening was narrow because her legs were stuck bent together from contractures and CNA D pulled on the brief harder, forcing it through Resident 76's legs. Resident 76 began screaming ow, ow, ow and no, no, no. Resident 76 was breathing heavy and had a frown on her face. Both of Resident 76's hands were holding the bed rails so tight that her knuckles were white. A review of the facility's P&P titled, Care Plans, Comprehensive, dated 8/1/24, indicated, facility staff would identify .problem areas and their causes . The P&P indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. A review of Resident 76's Pain care plan, dated 2/20/24, indicated, Resident 76 was at an increased risk to experience pain during ADL (Activities of Daily Living) care. The care plan included interventions, revised on 2/23/24 that included; assessing factors that contributed to pain, notifying the physician if there was an increase in pain, and that staff would handle Resident 76 gently when providing care. The care plan had not addressed how to manage brief changes with Resident 76's contractured legs, without causing her pain, anxiety and fear. A review of Resident 76's Bladder Incontinence and Bowel Incontinence care plan, revised on 2/23/23, had not identified that brief changes were painful to Resident 76. There were no alternative methods for managing her incontinence. During a concurrent interview and record review on 1/24/25 at 6:56 am, the Director of Staff Development (DSD) confirmed she knew Resident 76 had pain with brief changes because of the left leg being moved. DSD confirmed staff should not force Resident 76's legs apart as that caused severe pain. DSD indicated that CNAs were expected to handle Resident 76 gently, stop providing care when she expressed pain, and notify the nurse. DSD stated, by forcing the brief between Resident 76's legs could also cause skin breakdown by sheering (a wound caused by the friction of something rubbing against the skin). DSD stated, CNAs should not use their hands to reposition a resident. DSD stated staff were trained to use a draw sheet (a sheet under the resident to roll them side to side). DSD was unable to provide evidence that LN and CNA staff had received training on care of residents with contractures and pain. During a concurrent interview and record review on 1/24/25 at 8:09 am, with the DON she confirmed that she knew changing Resident 76's brief was an uncomfortable and painful experience for Resident 76. DON stated she expected the CNAs to notify the LNs when Resident 76 had pain, and for the LNs to notify the physician and DON, if the pain was not controlled. DON stated, she had not provided LNs with training regarding care of residents with contractures. During an interview on 1/24/25 at 11:16 am, the facility's Medical Director (MD) indicated that HLN had just notified him about Resident 76's pain during brief changes. MD stated, I can talk to the hospice team about problem solving. MD indicated that communication between the facility and hospice had not been effective in regard to managing Resident 76's pain and stated, it should be better.

Based on observation, interview, and record review, the facility failed to ensure resident's plan of care met their needs and provided supervision required to keep them free from accidents and hazards for two of five sampled residents (Resident 250 and 303) when: 1. Resident 250 was known to the facility to have restless/aggressive behaviors, active infection and had been evaluated to be at a high risk for falls. The facility failed to re-evaluate past interventions, identify the root cause of Resident 250's falls and develop resident specific individualized interventions to prevent accidents. This resulted in repeated falls for Resident 250 and subsequently, a bilateral head injury that required a 12-day hospitalization . 2. Resident 303 a) Was not identified as a smoker on admission but was seen smoking on the sidewalk. b) Smoked off campus without facility knowledge. c) Kept his cigarettes and lighters in his room unsecured. d) Was not evaluated for smoking safety on admission but 14 days later was evaluated to need a smoking apron and did not wear one while smoking. e) The path provided for Resident 303 to go off the facility property to smoke, had a large pothole along the path. The facility's lack of safety interventions for Resident 303 had the potential for injury related to smoking. Findings: A review of facility's policy titled, Assessing Falls and Their causes, revised August 2024, indicated the purpose of the policy is to provide guidelines for investigation and assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident's care plan to assess for any special needs of the resident. The policy indicated residents must be assessed in a timely manner for potential causes of falls and relevant environmental issues should be addressed promptly. Investigation of a Fall or Fall Risk included time of day, time of last meal, what the resident was doing, was resident going to toilet, and whether there is a pattern of falls for this resident. Nursing staff will collect and evaluate information until they either identify the cause or determine cause cannot be found. A review of Resident 250's Admission record indicated Resident 250 was admitted on [DATE], with diagnoses of urinary tract infection requiring intravenous (IV, way to deliver fluids, medicine, or blood directly into a vein) antibiotics (treats infection) treatment, dementia, muscle weakness, difficulty walking, and unsteadiness on feet. A review of Resident 250's Nursing Admission Evaluation Assessment date 10/7/24 at 3:53 pm, indicated under orientation the acute hospital report indicated Resident 250 had confusion and episodes of agitation. Resident 250 was admitted to the skilled nursing facility with a urinary catheter (a tube that drains urine from bladder) and a midline central IV to right upper arm, placed on 10/6/24. A review of Resident 250's Baseline Care Plan dated 10/7/24, indicated Resident 250 was alert and oriented to self with increased confusion at night. Care plan indicated Resident 250 was a high fall risk due to dementia, being confused and had a urinary tract infection which can cause increased confusion. A review of a Minimum Data Set (MDS, resident assessment) dated 10/10/24, indicated Resident 250 had a Brief Interview for Mental Status (BIMS, resident memory and decision making abilities) score was of 4 out of 15, indicating a severe impairment. Resident 250 was an extensive (dependent on one to two staff to help him) assist for all activities of daily living and transfers. A review of a Nursing Fall Risk assessment dated [DATE], 10/10/24, and 10/12/24 indicated Resident 250 was a high risk for falls. A review of an Alert Charting Progress note dated 10/7/24 at 6:24 pm, shortly after admission, indicated Resident 250 was agitated not getting along with his roommate. Resident 250 had thrown a cup of water onto his bed and was moved to another room in the facility. A review of an Alert Charting Progress note dated 10/7/24 at 11:55 pm, indicated Resident 250 had a new roommate and he was not get along with him either. Resident 250 was very confused and pulling/dragging on his urinary catheter. A message was left for the Medical Director (MD), requesting a medication for anxiety. A review of an Alert Charting Progress note dated 10/8/24 at 6:17 pm, indicated Resident 250 frequently gets up and walks around without calling for assistance. Resident 250 had removed all of his clothing and pulled at the urinary catheter multiple times. A review of a Fall Care Plan dated 10/8/24, indicated a goal that Resident 250 would not experience a fall related to risk factors. Interventions included; Keep call light in reach, anticipate needs, keep personal items within reach, monitor for changes in condition and notify physician, proper footwear non-skid socks, and safety devices. Fall #1: A review of an Alert Charting Progress note dated 10/8/24 at 8:30 pm, indicated Resident 250 had an unwitnessed fall with no injuries. He was found sitting on the floor next to his bed. Resident 250 was very confused, restless, and agitated. MD was notified and new orders were given for Ativan (anxiety medication produces a calming effect on the brain and nerves), for restlessness. Documentation reflected that Resident 250 wandered and could not stay in bed. A review of an online resource from National Library of Medicine, Daily Med, indicated in a sample of about 3500 patients treated for anxiety, the most frequent adverse reaction to Ativan (lorazepam) was sedation (15.9%), followed by dizziness (6.9%), weakness (4.2%), and unsteadiness (3.4%). The incidence of sedation and unsteadiness increased with age. Paradoxical (opposite) reactions, including anxiety, excitation, agitation, hostility, aggression, rage, sleep disturbances/insomnia, sexual arousal, and hallucinations may occur. A review of a Infection Control Interdisciplinary Team (IDT, where facility managers meet to discuss plans of care for residents) note dated 10/8/24 at 2:35 pm, indicated Resident 250 had a change of condition related to increased confusion and other symptoms or signs of delirium (a temporary condition with an inability to pay attention and thoughts are disorganized). A licensed nurse got an order for Ativan 0.5 milligrams (mg, a unit of measure) every 6 hours, for restlessness. According to the IDT note, the Ativan was of little help and documented, He needs stronger meds and a sitter (1:1, a caregiver sits with resident and available to assist). The IDT note indicated that Resident 250 was currently on antibiotics for an infection and, maybe he will get better once infection gone. A review of an IDT note dated 10/9/24 at 10:19 am, indicated Resident 250 had an unwitnessed fall on 10/8/24 at 8:30 pm. Certified Nurse Assistant (CNA) notified the nurse that Resident 250 was sitting on the floor next to his bed. The note indicated that Resident 250 had poor safety awareness, was impulsive, and unable to be redirected when provided with education with his urinary catheter. Resident 250 continued to wander the facility and running over his urinary catheter bag (the bag that collects the urine) and dragging it across the floor. New interventions following this fall were for Resident 250 to use a leg bag a device that attaches to the upper thigh and does not get in the way of walking, and Ativan for his restlessness. A review of a Resident 250's physician order dated 10/8/24 at 11:30 pm, indicated Ativan 0.5 mg tablet every 6 hours was ordered as needed for restlessness. Another physician ordered on the same day, to monitor the antianxiety medication for adverse side effects such as; drowsiness, slurred speech, dizziness, nausea, and aggressive impulsive behavior. A review of Resident 250's Medication Administration Record (MAR) dated October 2024, indicated Ativan 0.5 mg had been administered five times for restlessness, on 10/8/24 at 11:45 pm, 10/10/24 at 12:35 am, 10/11/24 at 8:35 am and again at 8:47pm, and on 10/12/24 at 5:23 am. A review of an Alert Charting Progress note dated 10/9/24 at 2:48 pm, indicated Resident 250 continued not to use his call light or ask for staff assistance and continued to pull at his urinary catheter. The note indicated Resident 250 walked with an assistive device and the help of staff. A review of an Alert Charting Progress note dated 10/10/24 at 4:44 am, indicated Resident 250 continued to get up and walk by himself and refused t use call light despite unsteady balance. Fall #2: A review of an Alert Charting Progress note dated 10/10/24 at 9:30 pm, indicated Resident 250 refused to wear non-skid socks, was confused and frustrated with his urinary catheter. He had a laceration (cut) to the back of his head. The progress note indicated that staff were unable to check his pupils (to check neurological [brain] function), and Resident 250 was transferred out to the acute care hospital for evaluation. A review of an IDT note dated 10/11/24 at 10:17 am, indicated Resident 250 had an unwitnessed fall on 10/10/24 at approximately 6:33 pm. Resident 250 was found lying on his back on the floor. His wheelchair was found next to him with wheelchair unlocked. A laceration (a cut or tear in the skin caused by an injury) was found to the back of his head and staff were unable to see his pupils due to resident rolling his eyes upward. Resident 250 was sent to the emergency department for a post fall evaluation. At the hospital a Computed Tomography (CT scan, an X-ray to create detailed pictures of the inside of the body) scan was completed with no remarkable findings and he was sent back to the facility. The IDT recommended that therapy to evaluate for proper wheelchair. The IDT note did not address or evaluate the effectiveness of the administration of Ativan in reducing Resident 250's restlessness and impulsive/wandering behaviors. A review of an Alert Charting Progress note dated 10/11/24 at 4:31 pm, indicated Resident 250 was confused at his baseline, had no safety awareness, and that staff continued to redirect him to sit in a chair which made him agitated, and he continued to self-transfer and not ask for assistance. A review of an Alert Charting Progress note dated 10/12/24 at 2:46 am, indicated Resident 250 was observed walking down hallway with unsteady balance and continued to have no safety awareness. Fall #3: A review of a SBAR (Situation, Background, Assessment and Recommendation) note dated 10/12/24 at 9:27 am, indicated Resident 250 was in his wheelchair by the nursing medication cart. He tried to stand to get a spoon from the cart and fell hitting the right side of his head on the bottom of the cart. Resident 250 sustained a skin tear to his right forearm. Neurological (checks brain function) checks were started but staff were unable to complete the assessment because his eyes were rolling upward when trying to check. There was no IDT post fall note for Fall #3, it was included in the Fall #4 IDT note dated 10/14/24, two days later. There was no documented evaluation of the effectiveness of the past fall prevention interventions and no changes were made to his fall care plan. Fall #4: A review of a Nursing Progress Note dated 10/12/24 at 1:37 pm, indicated a second fall had occurred after fall #3, on the same day, but had not included the time of the fall. The note indicated that Resident 250 tried to pull out his IV and fell and hit his head on the floor. LN documented Resident 250 was assessed to be confused, drowsy, and was unable to stay awake, and he was transferred out to the acute care hospital for evaluation. A review of an IDT note dated 10/14/24 at 2:58 pm, indicated Resident 250 has suffered from four falls during a stay of seven days in the facility. The final, 4th fall, at approximately 9:45 am, Resident 250 was assisted to bed so the Registered Nurse (RN) could administer his antibiotic medication in his IV. Resident 250 was witnessed trying to remove the IV while the antibiotics were being administered. An LN tried to redirect him and left the room, once he had calmed down. Then at approximately 10:05 am, Resident 250 was found on the ground near his bed. The note indicated that Resident 250 had increased confusion and difficulty staying awake. Resident 250 was sent to the hospital emergency room and was found to have a subdural hematoma (where the blood pools in the brain from hitting the head strong enough to burst the blood vessels). A review of an online resource NationalInstituteofHealth.gov dated 8/1/24, indicated confusion will last in the elderly with a urinary tract infections as follows: Mild UTIs: Confusion often improves within 24 to 48 hours, with full recovery in 3 to 5 days. Severe or Complicated UTIs: Symptoms may last 1 to 3 weeks, especially if the infection involves the kidneys or catheters. During a concurrent interview and record review on 1/23/25 2:54 pm, Licensed Nurse (LN) AH stated she remembered Resident 250 to be very confused and needed to be monitored closely by staff for safety. LN AH stated he would sit in hallway so staff could provide close supervision, but still fell near medication cart and hit his head. LN AH stated the last fall (Fall #4), she found Resident 250 later in his room lying on the floor on the fall mat next to his bed tangled in his IV tubing. LN AH stated Resident 250 should have not been left alone especially when having antibiotics administered. LN AH stated the Ativan did not really help Resident 250, He may have needed a different medication for his restlessness and aggression. During an interview on 1/24/25 at 9:04 am, CNA Q stated she remembered Resident 250, after seeing a picture of him. CNA Q stated he was confused, agitated, and did get aggressive at times. CNA Q indicated that Resident 250 would have benefited from 1:1 supervision (caregiver always has eyes on resident and available to assist resident) due to safety concerns, but also indicated that the facility was not always able to provide 1:1 supervision due to not having enough staff to provide this. During a concurrent interview and record review on 1/24/25 at 12:30 pm, with Director of Nursing (DON) and Assistant Director of Nursing (ADON), they both confirmed Resident 250 had behaviors and falls. ADON stated she participated in the IDT meetings and was unaware that Resident 250 had a total of four falls. DON and ADON confirmed direct care staff such as CNAs and LNs were not included in the fall IDT meetings and contribute to identifying root causes of of Resident 250's confusion and multiple falls. DON and ADON confirmed that redirection, the reminder to use call light, with a BIMS of 4, and reminders to use wheelchair brakes when Resident 250 transferred himself, were not effective interventions to prevent further falls. DON and ADON indicated that Resident 250 was impulsive, restless, and had dementia (memory problems), which contributed to his poor safety awareness and inability to follow directions. DON and ADON confirmed that 1:1 supervision had not been considered until after Fall #4. DON and ADON confirmed the IDT meeting documentation had not included a review or discussion of Resident 250's behaviors if the Ativan use had been beneficial. ADON confirmed Ativan could also have the opposite desired affect and cause aggressive impulsive behaviors. DON and ADON confirmed the IDT meetings did not evaluate the risks of leaving Resident 250 alone while IV antibiotics were infusing. DON and ADON agreed that Resident 250's UTI could have contributed to his restlessness and confusion, thereby placing him at a higher risk for falls with injuries. A review of the acute care hospital discharge summary record dated 10/24/24, indicated Resident 250 was admitted to the hospital for treatment of right and left subdural hematomas. Resident 250 required treatment for respiratory failure that required intubation (a medical procedure that involves inserting a tube into the windpipe when someone cannot breathe on their own), and a feeding tube (a tube surgically placed into the stomach when food cannot be taken by mouth), because of the severity of his head injuries. Resident 250 spent 12 days in the hospital. 43755 2. a) A review of the facility's policy titled, Non-Smoking Policy-Residents dated January 2024, the policy indicated, This facility is a non-smoking facility but has grandfathered (a resident who was allowed to smoke before the new policy was put into practice was still allowed to smoke on the facility property under the new policy). 1. Prior to, and upon admission, residents are informed of the facility non-smoking policy. 2. Smoking is only permitted by residents (other than the one individual grandfathered into prior smoking policy) off property. On 1/21/25 at 8:08 am, during the entrance conference, the Administrator (Admin) indicated that the facility was a non-smoking facility except for one resident (Resident 17) that was grandfathered and allowed to smoke in designated smoking areas on the facility property. Admin indicated that anyone admitted , after smoking on the property ended in January 2024, had to sign themselves out of the facility and smoke off the facility property. The Admin indicated she did not know who smoked off the property and that there was no list of residents who smoked off the property. A review of Resident 303's Admission Record (undated), indicated Resident 303 was admitted on [DATE] with diagnoses that include osteomyelitis (bone infection) of right leg, diabetes (high sugar in the blood), right below the knee amputation (a surgical procedure where a limb (arm or leg) is removed), muscle weakness, lack of coordination, high blood pressure and nicotine dependence. Resident 303 was his own responsible party. A review of Resident 303's Admission Minimum Data Set (MDS, a clinical assessment tool), dated 1/11/25, indicated a Brief Interview of Mental Status (BIMS, an evaluation of cognition: thinking and reasoning) was conducted and Resident 303 scored a 15 out of 15 indicating he had an intact cognition. Section GG of the MDS indicated Resident 303 used a wheelchair (w/c) for locomotion and required set up and clean up assistance from staff for locomotion. During an interview and observation on 1/21/25 at 8:44 am, Resident 303 was sitting in his wheelchair (w/c) in the facility hallway. Resident 303 indicated that he was a smoker and since this was a non-smoking facility, he was supposed to sign himself out of the facility and wheel out to the curb to smoke. A review of Resident 303's Nursing-Admission/Readmission Evaluation/Assessment (NAREA) dated 1/8/25, indicated Licensed Nurse (LN) V documented Resident 303 as a non-smoker. A review of Resident 303's Comprehensive Care Plans identified that there was no documented smoking care plan. A review of Resident 303's medical record identified that Resident 303 had no documented Admission Smoking Evaluation (an evaluation that identified if a resident was safe with smoking and/or required equipment needed to be safe to smoke). During an interview on 1/21/25 at 9:00 am, LN W indicated Resident 303 was a smoker and went outside to the curb to smoke. During a concurrent interview with LN V and record review on 1/24/25 at 11:50 am, Resident 303's NAREA was reviewed. LN V indicated that Resident 303 was a smoker, but she documented on the assessment that he was not a smoker because she thought since this was a non-smoking facility, she should identify residents as non-smokers. After reviewing the medical record LN V indicated she marked it wrong, and she should have indicated that Resident 303 was a smoker. During an interview with the Administrator (Admin) on 1/24/25 at 12:45 pm, Admin indicated that Resident 303 should have been identified as a smoker so the facility could provide the appropriate safety and care needed. 2. b) During an observation and interview on 1/24/25 at 12:02 pm, Resident 303 was observed sitting in his w/c outside the facility on the facility property and listening to music. Resident 303 indicated that he liked to come outside to listen to music and that he would go back and forth to the curb to smoke and did not always sign himself out. During an observation and interview on 1/24/25 at 12:09 pm, Resident 303 indicated he was going to smoke by the curb and was observed wheeling himself down the sidewalk to the curb. Resident 303 indicated he had not signed out, so the facility would not know he was off the facility property. During an interview with the Admin on 1/24/25 at 12:45 pm, Admin indicated that it was important for the facility to know when a resident was off the facility property, and the residents should be signing out. 2. c) During an interview on 1/24/25 at 11:59 am, LN U indicated she did not know where Resident 303 kept his cigarettes or lighters. LN U indicated since they were a non-smoking facility she did not monitor the smoking equipment. During an observation and interview on 1/24/25 at 12:09 pm, Resident 303 was observed outside on the curb and pulled his lighter and cigarettes from his coat pocket and lit his cigarette. Resident 303 indicated that he kept his cigarettes and lighter with him in his room, sometimes in his coat pocket and sometimes in his pants pockets. Resident 303 indicated his friends bring him lighters and cigarettes and sometimes he goes to the store and buys them. During an interview with the Administrator (Admin) on 1/24/25 at 12:45 pm, indicated that the facility did not manage the residents smoking equipment. But indicated that they should. 2. d) On 1/24/25 a review of Resident 303's medical record identified a Smoking Evaluation (an evaluation that identified if a resident was safe with smoking and/or required equipment needed to be safe to smoke) dated 1/22/25, (14 days after admission). The document indicated Resident 303 required a smoking apron for safety when smoking. During a concurrent interview with LN V and record review on 1/24/25 at 11:50 am, LN V indicated she did not know if she should have done a smoking evaluation on admission for Resident 303, since he smoked off the facility property. During an interview with Medical Director (MD) on 1/24/25 at 11:56 am, MD indicated that this was a non-smoking facility and if a resident wanted to go off the facility grounds to smoke then we should have done a smoking evaluation on admission to see if they were safe to smoke. During an observation and interview on 1/24/25 at 12:09 pm, Resident 303 was observed by the curb and lit his cigarette and smoked. Resident 303 had a round hole in his sweatpants, and he indicated he had burned it with his cigarette a few months ago at home. Resident 303 was not wearing a smoking apron and indicated that he had never worn one. 2. e) During an observation and interview on 1/24/25 at 12:09 pm, Resident 303 indicated he was going to smoke by the curb and was observed wheeling himself down the sidewalk. As Resident 303 went rapidly down a sidewalk ramp, he took his hands off the w/c wheels and let the w/c roll forward, uncontrolled, into the facility parking lot within inches of a large pothole that was in the crosswalk lines. Resident 303 continued across another short section of facility sidewalk, through another facility parking lot, then onto the last stretch of facility sidewalk to the curb. Resident 303 indicated that sometimes the pathway to the curb was blocked by cars and he was unable to get to the curb. During an observation and interview with the Maintenance Director (MTD) on 1/24/25 at 12:40 pm, the pothole in the parking lot crosswalk was observed. MTD indicated that it was unsafe for Resident 303 to wheel close to this pothole and it should be fixed. During an interview with the Admin on 1/24/25 at 12:45 pm, Admin indicated she was unaware that Resident 303 wheeled past the pothole. Admin indicated they had been reviewing bids from different contractors to get the parking lot repaved and to fix the potholes.

Based on observation, interview, and record review, the facility failed to ensure the safe and effective use of medications when: 1. Resident 302 found a pain pill at her bedside when she woke up. This failure caused anxiety for Resident 302 and the potential for a decline in her psychosocial and physical well-being. 2. The policy for medication storage was not implemented for two out five sampled medication carts. This failure resulted in putting residents at risk for harm from receiving expired and potentially contaminated or ineffective medications. 3. Narcotic disposal logs were inaccurately maintained, as there were missing names and signatures of licensed nurses in four out of 125 instances of narcotic disposal between 11/13/24 to 1/6/25. This failure had the potential to allow for drug diversion (when medication is taken for use by someone other than whom it is prescribed for). Findings: A review of the facility policy titled, Administering Medications revised August 2024, the policy indicated Medications are administered in a safe and timely manner, and as prescribed. 1. A review of Resident 302's Admission Record (undated), indicated Resident 302 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty in swallowing), aphasia (difficulty with expressing or understanding written and spoken language), difficulty in walking, weakness, anxiety disorder, esophagus (tube from mouth to stomach) disease, and stroke. Resident 302 was discharged on [DATE]. A review of Resident 302's Physician's Orders, dated 1/6/25, indicated Resident 302 was on a pureed (foods that have been blended or mashed until they are smooth and easy to swallow) diet. During an interview on 1/22/25 at 9:11 am, Licensed Nurse (LN) S indicated that on 1/12/25 at 11:00 am, Resident 302 showed her a medicine cup with a pill in it and stated, someone left it by her bedside during the night. LN S indicated that Resident 302 was angry and said, no one woke me up and left the pill there. LN S confirmed the pill found had been a Norco (a narcotic pain pill), 5-325 mg (milligrams, a unit of measure). LN S confirmed that Resident 302 received Norco every 4 hours for pain at 2:15 am, 6:15 am, 10:15 am, 2:15 pm, 6:15 pm, and 10:15 pm. During an interview on 1/22/25 at 11:01 am, Speech Therapist (ST) indicted that Resident 302 had a lot of anxiety about swallowing due to her diagnoses. ST relayed the conversation she had with Resident 302 on 1/12/25, I went in [Resident 302's room] about mid-morning. She [Resident 302] told me an incident about a night med [medication] nurse. The nurse came in about 2:00 am and handed her a Norco pill, Here is your pill then left. She would sleep sitting up due to her swallowing condition. She said she was still half asleep and fell asleep with the pill in her hand. She woke up and found the pill in her hand and said, 'I cannot take this on my own.' She [Resident 302] was concerned that the nurse did not stay with her, The med nurse should stay with me. During an interview on 1/23/25 at 9:33 am, Director of Nursing (DON) confirmed that LN T had taken a Norco 5-325 mg tablet into Resident 302's room during the night and had not verified that Resident 302 had taken the pill. The DON indicated that LN T should have stayed with Resident 302 until she swallowed the pill and LN T had not done that. DON and LN S identified the pill together and destroyed it as per facility policy. 50363 During an observation of Station I's medication cart on 1/21/2025 at 11:34 am, a Toujeo Solo (Insulin Pen, a device for insulin administration; insulin is injected to control blood sugar for patients with uncontrolled blood sugar), remained available for use after the expiration date 12/14/2022. Refresh P.M. ophthalmic ointment (ointment used at night to help treat dry eyes), remained available for use after the expiration date 11/25/2024. During an observation of Station 4's medication cart on 1/21/2025 at 11:34 am, Aspirin 325 milligrams (mg), remained available for use after the expiration date 12/31/2024 on a station 4 medication cart. During a review of the facility's policy titled, Storage of Medications revised August 2024, indicated, Discontinued, outdated, or deteriorated drugs or biologicals are placed in designated appropriate bins for destructions. During a review of facility's policy titled, Administering Medications revised August 2024, indicated, The expiration/beyond use date on the medication label is checked prior to administration. During an interview on 1/21/2025 at 10:30 am, Licensed Nurse (LN) S confirmed there were expired medications available for use in the medication carts and stated, I'm not sure why expired medications are in the cart. During an interview on 1/21/2025 at 2:04 pm, LN W indicated she did not know how often medication carts were supposed to be checked for expired medications. During a review of the facility's policy titled, Discarding and Destroying Medications revised October 2024, indicated, The medication disposition record will contain the following .signature of witnesses. During a concurrent interview and record review of document titled, Master Narcotic Inventory Sheet, on 1/24/2025 at 2:30 pm, DON confirmed there were four licensed nurse signatures missing on the master narcotic (highly controlled substances such as narcotic pain pills) inventory sheets in either, signature of nurse receiving medication or nurse giving to DON under disposition information. DON stated facility would do better.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention program was maintained to prevent the spread of infection when: 1. The wheelchairs (W/Cs) for Residents 1, 2, 13, 46, and Resident 133 were visibly unclean and soiled. 2. The oxygen tubing for Resident 72 was not stored appropriately while not in use. 3. Personal hygiene products were not stored properly for Resident 62 and Resident 133. 4. An unkept and worn elevated bedside commode was used for Resident 87. 5. Certified Nursing Assistant (CNA) B did not perform hand hygeine after touching self during a dining observation. These failures had the potential for the spread of infection throughout the facility to each client which could lead to negative clinical outcomes including transmission of food borne illness. Findings: 1. A review of the facility's policy revised 8/2024, titled, Cleaning and Disinfection of Environmental Services, indicated resident-care equipment, including reusable items, and durable medical equipment (DME) will be cleaned, according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards. Reusable items, including environmental surfaces will be cleaned and disinfected between residents and when surfaces are visibly soiled. DME must be cleaned before reuse by another resident. During an observation on 1/21/25 at 8:55 am, the W/C for Resident 1 including the footrests were unclean, with dried yellow and tan colored food substances, dried food crumbs and cumulative dust and grime. The W/C cushion was visibly soiled with tan colored food substances, and food crumbs. During an observation on 1/21/25 at 9:13 am, the W/C for Resident 46 was unclean with dried, tan colored food substances, dried food crumbs and cumulative dust and grime. The W/C cushion was visibly soiled with tan colored food substances, and food crumbs. During an observation on 1/21/25 at 9:33 am, the W/C including both arm rests for Resident 133 was unclean with dried, cumulative dust and grime. The W/C footrests were covered in dark dried black spots, and cumulative dust and dried food particles. During an observation on 1/21/25 at 9:49 am, the W/C including the arm rests, footrests, and wheels for Resident 13 was unclean with dried, cumulative dust and grime. The W/C cushion was visibly soiled with dried food particles. During an interview on 1/21/25 at 3:18 pm, the Housekeeping Supervisor (HS) confirmed the W/Cs and cushions need to remain clean for all residents for infection control. HS stated, Sometimes we have to wait until the residents are back in bed to clean, but I confirm the W/Cs are dirty and need to be cleaned for all residents. During an interview on 1/22/25 at 2:42 pm, the Director of Nursing (DON) confirmed the W/Cs and cushions were not clean on the long-term hall for Residents 1, 13, 46, and Resident 133. During an interview on 1/22/25 at 2:45 pm, the Administrator (Admin) confirmed the W/Cs and cushions were not clean for Residents 1, 13, 46, and Resident 133. During an observation on 1/24/25 at 8:30 am, the W/C and cushion for Resident 2 were visibly soiled with dried food particles and a yellow-colored dried substances. During a concurrent observation and interview on 1/24/25 at 8:46 am, Licensed Nursed (LN) R confirmed the W/C and cushion for Resident 2 had dried food particles and needed to be cleaned. LN R stated, Yes, I confirm all the W/Cs and cushions need to be cleaned on a regular basis for all the residents because they need to sit in a clean chair for infection control. During a record review dated December 2024, titled, Wheelchair Wash Log and Inspection, indicated the W/C and cushion cleanings for all residents in the facility documented. The last date the W/C and cushions were cleaned for Residents 1, 2, and Resident 46 was 12/3/2024. The last date the W/Cs and cushions were cleaned for Resident 13 and Resident 133 was 12/4/2024. During this wheelchair log review, it was indicated there were no logs for October 2024, November 2024, and January 2025. 2. A review of the facility's policy revised 10/2024, titled, Oxygen Administration, indicated to verify there is a physician order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Oxygen therapy is administered by way of an oxygen mask (device held in place by an elastic band around the resident's head), nasal cannula (n/c, an oxygen tube placed in the resident's nose). The oxygen tubing is changed at least weekly and stored in anti-microbial bag which is changed at least every 30 days. During a review of Resident 72's medical record, the Admission Record, indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstruction Pulmonary Disease (COPD, a progressive lung disease), chronic respiratory failure with hypoxia (low oxygen levels in the blood), dysphagia (difficulty swallowing), and heart disease. During a review of Resident 72's medical record, a document dated January 2025, titled, Order Summary Report, indicated oxygen was ordered at 2 liters/minute via n/c routine to maintain oxygen levels greater than 90%. Oxygen at 2 liters via n/c every shift for COPD. During an observation on 1/21/25 at 12:00 pm, the oxygen tubing was lying on the floor for Resident 87 when he was in the dining room. Certified Nursing Assistant (CNA) D confirmed the oxygen tubing should be stored in an anti-microbial bag on the bedside table when Resident 87 is not in bed. During an observation on 1/24/25 at 7:15 am, the oxygen tubing for Resident 87 was lying on the floor, not stored in the anti-microbial bag. During a concurrent observation and interview on 1/24/25 at 7:30 am, the Director of Nursing (DON) removed the dirty oxygen tubing on the floor for Resident 87 and confirmed the oxygen tubing should be placed in the anti-microbial bag when not in use. 3. A review of the facility's policy revised 6/2023, titled, Infection Prevention and Control Program, indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable (contagious illnesses) diseases and infections. The IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. The program is based on accepted national infection prevention and control standards. During an observation on 1/21/25 at 11:04 am, the incontinent pads for Resident 62 were out of the package, not covered and lying inside the dresser shelves. During an interview on 1/22/25 at 3:25 pm, CNA L confirmed the incontinent pads for Resident 62 should be stored in a plastic bag and should be inside a dresser, not lying on the shelves. CNA L stated, Sometimes noc shift leaves them out if they are in a hurry, but that is not how we were trained. During an observation on 1/21/25 at 3:01 pm, personal hygiene wipes were sitting beside Resident 133's glass of water on the bedside table. During an interview on 1/21/25 at 3:10 pm, CNA L confirmed the personal hygiene products should never be stored on a bedside table for any resident and sitting beside any food or water. During an interview on 1/22/25 at 3:00 pm, the DON confirmed all personal hygiene products should be stored separately from any food or water, and all incontinent pads should be covered and stored inside the furniture. 4. During an observation on 1/21/25 at 3:16 pm, the elevated commode in Resident 87's bathroom was covered in unremovable rust-colored areas including the legs, arm rests and had chipped white paint. During an interview on 1/21/25 at 3:30 pm, the HS confirmed there was multiple areas of unremovable rust, and the elevated commode used by Resident 87 needed to be replaced. HS stated, I will change that out right now, I did not know it was rusty, we have more elevated commodes in storage. 45315 5. During an observation on 1/21/25 at 12:22 pm, CNA B was observed passing out lunch trays in the main dining room. CNA B was assisting multiple residents prepare to eat their lunch by opening milk cartons, taking lids off bowls and plates, and opening packets of salt and pepper. CNA B was observed touching her face, in between assisting residents without washing her hands. During an observation on 1/21/25 at 12:28 pm, CNA B was observed touching her face, reaching into the tray cart (where resident meals were stored), and removing a lunch tray. CNA B assisted a resident prepare to eat lunch without washing her hands after touching her face. During an interview on 1/21/25 at 12:36 pm, CNA B stated, CNA B was unaware that she had touched her face during the dining observation. CNA B stated, hand hygiene should be performed in between each meal tray that was passed and after touching self. During an interview on 1/24/25 at 9:19 am, Infection Preventist (IP) stated, facility staff were expected to sanitize hands after touching their face, prior to serving residents their meals.

Based on observation, interview and record review the facility failed to ensure the environment was maintained in a safe, clean, comfortable and homelike manner when: 1. Resident 5's mattress was uncomfortable. 2. Resident shower rooms had broken tiles, the showers and dining room was cold, and room [ROOM NUMBER]'s heater/AC unit had metal tape around it with exposed wall and insulation. This had the potential for residents to feel uncomfortable in their home. Findings: 1. During a concurrent observation and interview on 1/21/25 at 9:51 am, Resident 5, admitted [DATE], in room [ROOM NUMBER] B explained her mattress has hole in the middle of it. Resident 51 stated, I have told everyone I can think of since I have been here. Resident 51 stated if, I get stuck in the hole too long it's just uncomfortable. Resident stated that mattresses have been ordered and they have not come in yet. During an interview on 1/23/25 at 10:15 am, Central Supply (CS) stated they ordered four mattresses on 1/8/25, they arrived last week, and there are three still available. 2. A review of a facility policy titled, Comfortable and Safe Room Temperature Level Policy reviewed October 2024, indicated the purpose was to provide safe and comfortable room temperatures to assure optimal health and comfort of residents. The facility room temperatures should be between 71-81 degrees Fahrenheit (F). During a concurrent observation and interview on 1/22/25 at 8:45 am, Housekeeper (HSK) confirmed that in Shower room [ROOM NUMBER] near Station 1 and 2, was 69 degrees F. There was one heater at the entry of the shower room in the ceiling that was not connected to a thermostat. HSK explained CNAs have to turn it on to warm all the shower rooms. HSK confirmed at 8:50 am, Shower room [ROOM NUMBER] between Station 2 and 3 the temperature was 70 degrees F. During a concurrent observation and interview on 1/22/25 at 9:25 am, Activity Assistant (AA) confirmed the temperature in the main dining room was 67 degrees F. AA stated they have to turn it on, it is not automatically programmed. During a concurrent observation and interview on 1/24/25 at 8:10 am, the Maintenance Director (MND) and Maintenance Assistants (MDA and MDB) explained they do not have a facility log for checking temperatures in the shower rooms on Station 1, 2 and 3. MND, MDA, and MDB were all aware that the main dining room main was cold, 67 degrees F, and explained the thermostat was not programmable. They all confirmed that facility staff have to adjust the temperatures when entering the dining room and showers, no way to keep a consistent temperature. MND stated it the quality committee was planning to redo all the shower rooms due to the broken tiles on the floors, which they tried to paint and now was peeling off. MDB took the temperatures in all Shower rooms [ROOM NUMBER], all rooms were between 62-64 degrees F, and confirmed that had not met the regulation. MDB confirmed room [ROOM NUMBER] air conditioner/heater split unit was replaced, and they did not finish to cover the exposed wall and insulation. MDA and MDB stated they do environmental rounds weekly, and confirmed they have projects that are not finished in the facility and are working on a better system of tracking maintenance work.

Based on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for one out of four sampled Residents (Resident 1), when Resident 1 was slapped on the face by Resident 2. As a result, Resident 1 had redness and swelling on her face, and she was crying. Findings: During a review of the facility's policy titled, Abuse and Neglect -Clinical Protocol , no revised date provided, the policy indicated: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . 2. Willful as defined as used in the definition of abuse , means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses which included cognitive functions problem (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), lung problem and diabetes (high blood sugar). Resident 1 ' s primary language was Spanish. She was not her own healthcare decision maker. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 8/29/2023, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 5, at section C Cognitive Patterns indicating that her cognition was severely impaired. During a review of Resident 2's clinical record, indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses which included liver problem, alcohol use, and stomach problem. He is not his own health care decision maker. During a review of Resident 2's MDS, dated [DATE], the MDS indicated that Resident 2 had a BIMS score of 13, at section C Cognitive Patterns indicating that his cognition was intact. During a review of Resident 1's Nurse's Note by Licensed Nurse (LN) 1, dated 9/28/2023 at 11:30 pm, the Nurse's Note indicated that at approximately 8:45 pm, a Certified Nursing Assistant (CNA) approached LN 1 and told her that Resident 1 is claiming Resident 2 walked into her room and made contact to her face with his hand. LN 1 went into Resident 1's room and spoke with her, LN 1 brought the CNA with her to translate. Resident 1 states he came into my room and yelled at me to shut up, took my call light out of my hand and slapped me in the face . Resident 1 then pointed to the left side of her face. Resident 1 appeared in distress and was crying. Upon examining Resident 1's left side of her face, it had slight redness and swelling . LN 1 then went into Resident 2's room and interviewed him what happened. Resident 2 admitted that he went into Resident 1's room, he said yeah, I did. To tell her to shut up . LN 1 was later called into a room which was next to Resident 2's room, the resident resided in the room told LN 1 that she witnessed the entire thing. She stated, I saw Resident 2 walked into Resident 1's room, yelled at her to shut up, took something out of her hand and I saw hm slap her across her face. During a review of Resident 1's Nurse's Note by LN 1 with the indication of late entry , dated 9/28/2023 at 11:30 pm, the Nurse Note indicated that Resident 1's roommate asked to speak with LN 1 about the alleged incident. The roommate stats she heard Resident 2 enter the room and yell at Resident 1 to shut up and then the roommate heard some commotion . During a review of Resident 1's Interdisciplinary Team (IDT - a team of health care professionals who work in a coordinated fashion toward a common goal for the patient, the team member here included the Assistant Director of Nursing (ADON), the administrator (ADMIN), the Director of Staff Development (DSD) and the Social Service Assistant (SSA)) note , dated 9/29/2023 at 12:23 pm, the IDT note indicated that the IDT team had DSD translated and interviewed Resident 1 on 9/29/2023. Resident 1 stated that she was sitting in her room talking to her roommate when the man (Resident 2) from next door walked in and told her to shut up, Resident 1 then stated that she told Resident 2 that he couldn't tell anything to her and that was when he came up to her and slapped her across the face and left the room . During a review of Resident 2's IDT note , dated 9/29/2023 at 11:26 am, the IDT note indicated that Resident 2 was interviewed by the team. Resident 2 stated that Resident 1 next door was yelling and banging her call light on her bedside table, and he went in and started yelling at her to shut up. He said when she did not shup up, he walked up to her and pushed her back by her head. He quickly stated to IDT that he understands that what he did was wrong and that it would never happen again . Resident 2 stated that he attempted to get a nurse to get them to stop her from yelling out, but he could not find one. LN on shift denied that Resident 2 attempted to get them to address the yelling. During a concurrent interview and observation on 10/5/2023 at 10 am, with DSD in Resident 1's room, Resident 1 was interviewed and translated by DSD. Resident 1 was asked whether she recalled the Resident-to-Resident altercation happened on 9/28/2023, Resident 1 put her hand on the left side of her face and stated that she remembered. She said She got slapped on her face, and she was sacred of Resident 2 . During an interview on 10/5/2023 at 12 p.m. with ADMIN, ADMIN stated I talked to Resident 2, and he did say that he did it .

Based on interview and record review the facility failed to maintain adequate hydration for two of two sampled residents (Residents A and B) when: 1 a. Certified Nurses Assistants (CNA's) failed to report Resident A's fluid intake of less than 1200 milliliters (ml) per daily to the licensed nurses. The licensed nurses failed to notify the physician Resident A's fluid intake was less than 1200 ml daily. b. The facility failed to update Resident A's Dehydration Risk Assessment after the following issues were identified; Resident A's family verbalized concerns regarding the amount of fluids being offered to Resident A on [DATE], and on [DATE], when the PA ordered staff to Push Fluids and Resident A's family wanted intravenous (IV, into the blood vein) fluids if necessary, when Resident A was diagnosed with [REDACTED]. c. The interdisciplinary team (IDT) failed to update Resident A's dehydration care plans to include; the current minimum fluid recommendations made by the dietitian, resident response to interventions, staff notification to the licensed nurse, dietitian and the physician when Resident A consumed less than the minimum recommendations of fluids. d. The facility failed to follow the physician's order when the Physician's Assistant (PA) ordered IV hydration on am shift [DATE], for Resident A that was not administered until pm shift [DATE], and the facility failed to notify the PA timely that staff were unable to insert an IV catheter to administer the hydration fluids. These failures resulted in Resident A's progressive decline, becoming more dehydrated and requiring transfer to acute care where she was hospitalized and ultimately expired. 2 a. The facility failed to ensure CNA's reported to the licensed nurse that Resident B's fluid intake was less than the minimum dietary recommendations and the licensed nurses failed to report the information to the dietitian and physician. b. The IDT failed to update Resident B's dehydration care plan and document interventions to be in place for decreased fluid intake. These failures resulted in Resident B's physician not being notified Resident B consumed less than the minimum recommended fluids and required transfer to acute care hospital for IV hydration and IV antibiotics. Findings: A facility policy titled Resident Hydration and Prevention of Dehydration dated [DATE], read; 2.Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments .5. Nurses will assess for signs and symptoms of dehydration during daily care. B. Aides will report intake of less than 1200 ml per day to nursing staff. 7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. b. The physician will be notified. 8. a. A specific minimum amount should be included in the order .b. Force fluids is not an appropriate order. Encourage fluids is not an adequate order. 9. The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake .12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team (IDT) will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. 1. Resident A's record was reviewed. She was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident A had a history of [REDACTED]. A Minimum Data Set (MDS-an assessment tool) dated [DATE], revealed that Resident A had severe cognitive impairment and was unable to make medical decisions. Resident A had difficulty communicating her needs and required extensive assistance from staff for consuming all food and fluids. A Nutrition Evaluation Form dated [DATE], indicated Resident A's Estimated Fluid Needs were between 1725 to 2070 ml per day. A care plan dated [DATE], revealed Resident A had a potential deficit in nutrition related to cognition deficits, functional decline . pain, swallowing issues/dysphagia . A care plan Goal read: Resident A will consume greater than 75% of each meals/fluids . Interventions included Monitor I & O (intake and output) every shift. A Physician's Assistant Progress Note dated [DATE] at 3:25 pm, indicated PA recommended changes to Resident A's regimen: Push fluids . her representative wants to have her treated with IV (A catheter inserted into a vein to administer fluids and medications .) fluids and antibiotics if necessary. a. The facility failed to ensure Certified Nurses Assistants (CNA's) reported Resident A's fluid intake of less than 1200 ml daily to the licensed nurses. The licensed nurses failed to notify the physician Resident A's fluid intake was less than 1200 ml daily. A review of the [DATE], Medication Administration Record [REDACTED].for 10 days starting [DATE] at 3:00 pm, Resident A consumed the following fluids: on [DATE] -100 ml, on ,[DATE] - 1020 ml, on ,[DATE] - 840 ml, on ,[DATE] - 530 ml, on ,[DATE] - 880 ml, on ,[DATE] - 1180 ml, on ,[DATE] - 600 ml, on ,[DATE] - 890 ml and [DATE] - 960 ml. There was no measurement of output. Output was documented as the number of times urinated. A review of the certified nurse assistants (CNA) Fluid intake documentation revealed the following; on [DATE], Resident A consumed 1,960 ml, on [DATE] - 120 ml, on [DATE] - 300 ml, on ,[DATE] - 1,140 ml, on ,[DATE] - 440 ml, on ,[DATE] - 960 ml, on ,[DATE] - 560 ml, on ,[DATE] - 320 ml, on ,[DATE] - 120 ml, on ,[DATE] was 240 ml, on ,[DATE] was 310 ml, on ,[DATE] was 420 ml, on ,[DATE] was 440 ml, on ,[DATE] was 400 ml, on ,[DATE] was 200 ml, on ,[DATE] was 60 ml, on ,[DATE] - 655 ml, on ,[DATE] - 0 ml and [DATE] - 120 ml. There was no measurement of output. Output was documented as the number of times urinated. Nursing Weekly Summaries dated [DATE] and [DATE], revealed that Resident A was not on I & O. On [DATE] at 2:20 pm, during an interview and record review with Medical Records staff (Med Recs 2) she stated there was a physician's order in the electronic record indicating Resident A was to be placed on I & O's from [DATE] through [DATE]. Med Recs 2 stated she was unable to locate documentation indicating; that the CNA's and licensed nurses monitored Resident A's I & O's between [DATE] through [DATE]. Med Recs 2 stated she was unable to find documentation that CNA's notified the licensed nurse or that the Licensed nurse notified the PA that Resident A had a fluid intake of less than 1200 ml almost daily between [DATE] and [DATE]. b. The facility failed to update Resident A's Dehydration Risk Assessment after the following issues were identified; after Resident A's family verbalized concerns regarding the amount of fluids being offered to Resident A on [DATE], and on [DATE], when the PA ordered staff to Push Fluids and Resident A's family wanted IV fluids if necessary, when Resident A was diagnosed with [REDACTED]. A review of the facility policy titled Nutritional Assessment Revised [DATE], read; The dietitian .will conduct a nutritional assessment for each resident . as indicated by a change in condition that places the resident at risk for impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .d. Dietitian (1) An estimate of .fluid needs; (2) Whether the resident's current intake is adequate to meet her nutritional needs .8. Individualized care plans . A Social Services Progress Note dated [DATE] at 3:58 am, revealed Resident B's family verbalized concerns with staff not providing liquids to (Resident B) in between meals .Ombudsman recommended to the family if they do not see progress from staff at this facility they should contact the Public Health Department. A Physician's Assistant (PA) Progress Note dated [DATE] at 3:25 pm, indicated PA recommended changes to Resident B's regimen: Push fluids . Resident A's representative wants to have her treated with IV (A catheter inserted into a vein to administer fluids and medications .) fluids and antibiotics if necessary. A Dehydration Risk Observation/assessment dated [DATE] at 11:16 am, revealed that although Resident A had Swallowing difficulty (required honey consistency) liquids. Predisposing factors including: History of urinary tract infections, fever, depression, dementia, diabetes, [MEDICAL CONDITION]/failure .her Dehydration Risk Score was 6 indicating she was Low Risk for dehydration. The assessment indicated there were no care planning needs. A Physician's Assistant Note Change in Condition Progress Note dated [DATE] at 2:33 pm, indicated Resident A sleeps most of the time for last few days and is not eating or drinking. Plan included; 1L (liter) NS (normal saline) IV . A Nurses Progress Note dated [DATE] at 12:43 am, indicated Resident A was administered IV fluids for hydration . and read This nurse spoke with the RP this evening and informed her that resident has been somnolent (sleepy or drowsy) and not able to intake fluids at this time. A Nursing Weekly Summary dated [DATE], indicated Resident A consumed less than 25% of meals and was not on I&O. Additional notes indicated she was seen by PA and given IV fluids for 24 hours for decreased oral intake (dehydration) .IV fluids finished ,[DATE] at 8 pm. An interview and record review was conducted with the MDS Coordinator (MDSC) on [DATE] at 1:15 pm, MDSC acknowledged Resident A's Dehydration Risk Assessment had not been updated since [DATE], and that Resident A had recently been diagnosed with [REDACTED]. She stated the MDS staff were responsible to update the Dehydration Assessment annually, quarterly and with a change of condition and she indicated the episodes of dehydration Resident A recently experienced were considered a change in her condition and should have been care planned. c. A facility policy titled Resident Hydration and Prevention of Dehydration dated [DATE], read; The interdisciplinary team (IDT) will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. A Social Services Progress Note dated [DATE] at 3:58 am, read, (Resident A's) family has expressed concerns with staff not providing liquids to (Resident A) in between meals . Ombudsman recommended to the family if they do not see progress from staff at this facility they should contact the Public Health Department. A dehydration Care Plan dated [DATE], titled . is at risk for dehydration and fluid imbalance related to dementia, history of infections, swallowing impairment/dysphagia .the care plan Goal indicated Resident A will not show signs/symptoms of dehydration thru next review. Interventions included: Assess for signs and symptoms (s/s) of dehydration . Document and report as needed . Monitor labs . Notify MD of signs and symptoms of dehydration. An Alert Charting Progress Note dated [DATE] at 8:06 am, read; (Resident A) on alert charting for change of condition as exhibited by poor fluid intake . An Alert Charting Progress Note dated [DATE] at 9:48 pm, read; push fluids . A Social Services Progress Note dated [DATE] at 3:41 pm, (Resident A) will not initiate needs and staff continues to attempt to anticipate needs. MD states (Resident A) does not have capacity to make health care decisions . Family expresses frustration staff is not offering liquids to (Resident A) enough which is causing (signs and symptoms) of dehydration. An Alert Charting Progress Note dated [DATE] at 1:34 am, read; fed thickened liquids from a spoon . A Weight Change Progress Note dated [DATE] at 1:15 pm, indicated; Resident A was working with speech therapy regarding diet/liquid consistency due to decline in ability to chew/swallow foods. Resident is on Honey thick liquids, Meal percentages: reflects average 1068 ml fluids consumed daily in past week. An Alert Charting Progress Note dated [DATE] at 9:58 am, read; Per PA order: Document input and output every shift x 10 days . An Alert Charting Progress Note dated [DATE] at 3:13 pm, read; Increased fluids encouraged. (Resident A) really tired and sleepy today. A Physician's Assistant Note Change in Condition Progress Note dated [DATE] at 2:33 pm, indicated Resident A sleeps most of the time for last few days and is not eating or drinking. Plan included; 1L NS (normal saline) IV . A Health Status Note dated [DATE] at 9:34 pm, read Resident family called concerned regarding resident poor PO intake, requesting IV fluids; noted tongue is dry, slightly swollen, poor skin turgor .Obtained orders for IV fluids, 2 liters NS at 75 ml per hour. A Nurses Progress Note dated [DATE] at 12:43 am, indicated an IV was inserted into Resident A's left hand. The IV drip was initiated . Purpose of the IV is hydration .This nurse spoke with the RP this evening and informed her that resident has been somnolent and not able to intake fluids at this time . d. A Notice to CMEC (physician notification group) of Patient Change of Condition dated [DATE] at 3 pm, indicated; Resident A was not eating and drinking well. Most of the time sleeping. She was hard to wake up during meals. Family requested IV fluids .labs were ordered. The request was noted on [DATE], no time indicated. A Physician's Assistant note documented [DATE] at 10:03 am, indicated Resident A had abnormal labs and was not eating or drinking. She was not arousable. She had gurgled congested respirations. The note indicated Resident A was dehydrated. The PA ordered 1 L ½ NS IV 125 ml per hour, with follow up labs. An Alert Charting Progress Note dated [DATE] at 6:37 pm, read IV attempt x 2 (two attempts to insert an IV catheter) .unsuccessful. MD made aware. A Progress Note dated [DATE] at 10:50 pm, read Resident has no water and meal intake. Has order of 1 L ½ Normal Saline. Not started yet. A Progress Note dated [DATE] at 12:56 am, read; resident is alert with confusion .new orders for 1 liter of NS at 125 ml per hour via saline lock (IV) for hydration noted .has not been started at this time .tolerates small amounts of thickened liquids when awake .noted decreased meal and fluid intake .labs ordered .CBC (complete blood count) and BMP (basic metabolic panel) for this a.m.moans with care. A Progress Note dated [DATE] at 3 pm, read: resident in decline .IV started in left arm by EMT (emergency medical technician). A Hospitalist History and Physical note dated [DATE], revealed that Resident A was admitted to the hospital for .IV fluid hydration that was initiated related to [MEDICAL CONDITION] (high sodium level) and Metabolic [MEDICAL CONDITION] (an alteration in consciousness) . In the emergency room patient was noted to have low blood pressure and a rapid heartrate .Abnormal blood work up included; Blood urea nitrogen 58 High, Sodium 158 High. A Physician's Assistant note documented [DATE] at 10:03 am, read; Chief complaint abnormal labs, not eating or drinking, sleeping or arousable, respiratory gurgling and congestion heard over lungs BL (bilaterally). Assessment including Current conditions: Dehydration . Plan; patient evaluation I personally reviewed labs, BUN 40 (blood test, the blood urea nitrogen (BUN) test measures the amount of urea nitrogen in blood. The normal range is between 7 and 21. An elevated BUN level may indicate severe dehydration), Resident A's sodium level was 152 (Normal ranges are ,[DATE]-elevated sodium may indicate [MEDICAL CONDITION] as a result of dehydration. I evaluated the patient's condition today and recommend changes to the treatment regimen, 1 L ½ NS IV 125 ml per hour .per facility policy, CBC/BMP tomorrow morning. A Lab Report document dated [DATE] at 4:20 am, had a hand written note on it that read IV fluids not started, RP in agreement (spoke w/RP at 11:30 am) send to acute for evaluation and treatment signed by PA and dated [DATE] at 11:30 am. A discharge Progress Note dated [DATE] at 9:03 pm, documented by PA read . On [DATE], I was notified she (Resident A) was again having poor intake and sleeping most of the time. I ordered BMP (Labs-Basic metabolic panel) to verify her fluid status and then ordered IV fluids to be started yesterday. The facility was unable to get them started until today. Today's labs show she has an infection, most likely aspiration pneumonia from her physical exam and history .the family desire treatment of [REDACTED]. Reason for visit included Abnormal labs WBC 16.4(white bloodcell count), blood urea nitrogen and creatinine were 56 and 1.4 (indicating dehydration), sodium 159 (elevated) . On [DATE] at 3:00 pm, an interview with Resident A's representative (Rep) was conducted. She stated that on [DATE], when she visited Resident A, she noted Residnet A was having difficulty breathing and was lethargic. Rep stated she requested an IV be started on Resident A to rehydrate her. She stated that in the morning of [DATE], she spoke with PA and was told the facility was going to transfer Resident A to the emergency room . Rep stated she was shocked Resident A was not sent out sooner. She stated she received a telephone call from a male nurse at the facility telling her they were not going to send Resident A to the ER. Rep recalled there were days of prolonged inaction from the facility and Resident A did not get to the ER until evening on [DATE]. Rep recalled facility staff did not see Resident A's condition as an emergency. Rep stated the facility gave her stories why the IV was not started. She believed it was because they were seriously understaffed. She was told the facility was unable to find someone to start the IV. Rep stated on Friday [DATE], she received a telephone call from PA. PA told her the IV had not been started and gave an order to send Resident A to the ER but that had not occurred either. After speaking with PA she received a telephone call from the nurse. The nurse told Rep that Resident A was not going to be transferred to acute care and they got the IV started. Rep stated the facility was stalling to send her out. Rep stated she knew that Resident A had to be given fluids slowly with a spoon and that was time consuming to the staff. Rep recalled when she was in the facility visiting she never saw staff offer Resident A fluids other than at mealtimes. An interview was conducted with PA on [DATE] at 1:24 pm. PA recalled writing the IV hydration order for Resident A on [DATE], after receiving abnormal Labs (Basic metabolic panel-BMP) indicating Resident A had [MEDICAL CONDITION]. She gave the order to one of the LVN's (licensed vocational nurse) on Station 1. She doesn't know what happened to the order after that. PA stated on [DATE], in the morning, she received a tiger text (a confidential text message) that had been sent on [DATE] at 7:15 pm, indicating facility staff were unable to start IV hydration for Resident A. She recalled responding to the text, early in the morning about 8 or 9 am, to please send her to the ER. When she came to work later in the morning Resident A was still in the facility so she ordered another set of labs. PA stated she gave another order to send Resident A to the emergency room (ER). The facility called EMS (emergency medical services) and they came and started the IV then left. They were supposed to take Resident A to the ER. Resident A's white count was 16 (elevated indicating she had an infection). PA recalled speaking with Rep about Resident A. On [DATE] at 2:45 pm, during an interview and record review with RCM (the resident case manager) she stated that the IV was not started and she was unable to find a Tiger Text sent to PA on [DATE] at 7:15 pm, informing them they were unable to start the IV. On [DATE] at 3 pm, an interview and record review with the facility Director of Nursing (DON) was conducted. She was unable to find documentation Resident B's IV was started when ordered or that PA was notified timely staff were unable to start it. DON stated the nurse should not have sent a text to PA. She should have picked up the phone and called. DON stated Resident A should have been transferred to theER on [DATE], when the nurses were unable to start the IV. On [DATE] at 2 pm, an interview was conducted with the facilities on call provider (OC svcs). The OC svcs stated she was unable to locate any record the facility contacted the on call services on [DATE], to alert them they were unable to start Resident A's IV. 2. A review of Resident B's record was conducted. She was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE], revealed Resident B had severe cognitive impairment and was unable to make her own medical decisions. Resident B did not ambulate and required extensive assistance from staff for; eating and personal hygiene including oral hygiene. a. An admission nutritional Risk assessment dated [DATE] at 1:04 pm, indicated a minimum fluid intake recommendation for Resident B was 1675 ml to 2010 ml daily. The Fluid Intake recorded was Consumes 1,000 - 1499 ml per day. Comments included; .inadequate oral intake . A record titled POC Response History CNA documentation, dated ,[DATE] through [DATE], revealed the following fluid intake for Resident B; On [DATE] Resident B received 240 ml of fluid, on ,[DATE]-840 ml, on ,[DATE]-720 ml, on ,[DATE]-860 ml, on ,[DATE]-360 ml, on ,[DATE]-180 ml, on ,[DATE]-480 ml, on ,[DATE]-360 ml, on ,[DATE]-480 ml, on ,[DATE]-540 ml, on ,[DATE]-480 ml, on ,[DATE]-350 ml, on ,[DATE]-360 ml, on ,[DATE]-940 ml, on ,[DATE]-760 ml, on ,[DATE]-700 ml, on ,[DATE]-170 ml, on ,[DATE]-180 ml, on ,[DATE]-600 ml, on ,[DATE]-720 ml, on ,[DATE]-780 ml, on ,[DATE]-420 ml, on [DATE]-320 ml. There was no documentation the CNA's notified the licensed nurse that Resident B received less than 1200 ml of fluid daily. On [DATE] at 11:45 am, during an interview and record review with RCM she was unable to provide documentation the CNA's notified the licensed nurse or the licensed nurse notified the physician Resident B consumed less than the minimum recommended fluid intake. A Electronic-Medication Administration Record [REDACTED]. During an interview and record review on [DATE] at 10:55 am, RD 2 acknowledged Resident B's minimum fluid requirement should have been updated to her current status and calculated that currently she should consume between 1,325 and 1,590 ml in a 24-hour period. She reviewed Resident B's licensed nurse and CNA intake documentation. RD 2 stated Resident B did not receive adequate fluid intake from [DATE] through [DATE]. On [DATE] at 1 pm, an interview and EMAR review [REDACTED]. LVN 3 stated the EMAR intake includes the CNA intake documentation. During review of Resident B's intake record LVN 3 was not aware where to find Resident B's minimum fluid intake recommendations. LVN 3 noted the care plan indicated she should consume a minimum of 1200 ml daily. LVN 3 stated had he known she consumed less than 1200 ml daily he would have notified the physician. LVN 3 further reviewed the record and stated he was unable to locate documentation Resident B's physician was notified she consumed less than 1200 ml daily. b. A dehydration care plan dated [DATE], indicated Resident B had a potential fluid deficit related to dementia. Care plan goals indicated Resident B will drink/take in a minimum of 1200 ml each 24-hour period and will be free of symptoms of dehydration . An Alert Charting note dated [DATE] at 9:34 pm, indicated Resident B needed fluids pushed on her. A ED (emergency department) Provider Note, dated [DATE], indicated Resident B Blood work was evaluated with features consistent with dehydration . Resident B was given first dose of IV fluid .Instructions were given for assistance with hydration as it seems fairly apparent that she needs to be prompted to drink appropriately while she is uncomfortable . A weekly summary on [DATE] at 1:36 am, revealed Resident B had signs and symptoms of dehydration that included; skin dry, poor skin turgor, dry mucous membranes. She complained of oral pain, she was currently on antibiotics for an abscess. Teeth in poor condition. Her average intake was 1,000 to 1,200 ml daily, she had lower extremity [MEDICAL CONDITION], she had not been eating well due to dental abscess/liquids mostly . has complained of chronic knee pain at times. Was sent to acute hospital on [DATE], for dental bleeding. Has dental appointment for [DATE]. An ED report dated [DATE] at 6:12 pm, revealed Resident B's BUN was high at 31, Sodium level was high at 150, BUN/Creatinine Ratio was high at 38.75. The physician's note read; Patient clearly appears to be dehydrated. Active Hospital Problems included; [MEDICAL CONDITION] (high sodium level), acute metabolic [MEDICAL CONDITION] (alteration in consciousness), acute [MEDICATION NAME] (inflammation of the bladder) without hematuria (blood in the urine), dementia . Plan, included; 1.[MEDICAL CONDITION]. Likely due to dehydration. Keep on IV fluids, Check sodium every 4 hours. 2. Acute Metabolic [MEDICAL CONDITION]. Likely due to UTI (urinary tract infection) with dehydration with underlying dementia. Monitor. 3. Acute [MEDICATION NAME]. Keep on IV antibiotics .6. Mild hypercalcemia (high calcium level) likely due to dehydration. Check BMP tomorrow. According to History of Present Illness She is lethargic. On [DATE] at 10:55 am, during an interview and record review with RD 2, she stated she is not familiar with Resident B. She identified Resident B's average daily fluid intake needs, according to her body weight, indicating she should consume between ,[DATE] ml. She stated she does not include the minimum fluid recommendations in the residents care plans. She indicated she does not know how the nurse would know what the recommendations are or what to do if Resident B does not consume the minimum recommended amount. During review of the record, RD 2 reviewed certified nurse's assistant and licensed nurse's documentation from ,[DATE] through [DATE], and acknowledged Resident B consumed less than the minimum recommended fluid intake for those days. Resident A's dehydration care plan dated [DATE], was not updated to include the dietitians recommended minimum amount of fluid 1,675 ml to 2,010 ml daily, or that she became dehydrated on [DATE], requiring IV hydration. Care plan Interventions did not indicate who staff were to report to if signs and symptoms of dehydration occurred or how timely they were to report the findings.

Based on observation, interview and record review the facility failed to provide an effective pain management program that included ongoing assessments and interventions over a five month period when receiving treatments for [MEDICAL TREATMENT] (removes toxins from blood) and wound care for one of 26 sampled residents (Resident 62). This failure resulted in Resident 62 to experience unrelieved moderate to severe pain causing psychological distress and interfered with his activities of daily living. Findings: A policy titled, Pain assessment and Management defined pain management as the process of alleviating the resident's pain level that is acceptable to the resident, and is based on his or her clinical condition and established treatment goals. Pain management is a care process that includes the following: a. Assessing the potential for pain b. Effectively recognizing the presence of pain c. Identifying the characteristics (pattern, frequency, impact, location), of pain d. Developing and implementing approached to pain management e. Identifying and using specific strategies for different levels and sources of pain f. Monitoring for the effectiveness of interventions and modifying approaches as necessary. Assess Resident's pain and consequences of pain each shift. Monitor the Residents response to interventions and level of comfort. Document the reported Resident's pain level with adequate detail. Report any significant changes in the level of pain, adverse effects from pain medications, prolonged unrelieved pain despite care plan interventions. A review of the Resident 62's admission record, he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 62 was able to make his own health care decisions. A review of a physician order [REDACTED]. A review of a physician order [REDACTED]. Resident 62 leaves the facility between 3:30 am-4 am and returns between 11 am-12 pm. The [MEDICAL TREATMENT] treatment days, Resident 62 was sitting in his wheelchair/treatment chair approximately seven hours. A review of a physician order [REDACTED]. A review of a physician order [REDACTED]. A review of the clinical record titled care plan initiated 09/06/18, revision on 12/05/18, indicated the pain medication therapy goals were for resident to be free of any discomfort or adverse (negative response) side effects from the pain medication. The interventions were to administer medication as ordered, ask physician to review medication, review for pain efficiency, assess whether pain intensity acceptable to resident and the therapeutic regimen followed, and if pain control not adequate, changes were required. A review of a Physician's Assistant Progress Note dated 10/29/18, indicated Resident 62 reported phantom pain (perception of pain from missing limb) in leg and was very bothersome at night. There were no new physician orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. Resident 62 required one [MEDICATION NAME] tablet at 8:20 pm, for moderate/severe generalized body pain and one hour later one [MEDICATION NAME] at 9:15 pm for moderate/severe pain. A review of the eMar dated 11/15/18, indicated Resident 62 returned from [MEDICAL TREATMENT] treatment and received one [MEDICATION NAME] 5/325 mg at 5:19 pm for severe hand, back, and neck pain. Four and half hours later he received one [MEDICATION NAME] 5/325 mg at 9:44 pm for moderate/severe pain then one minute later an additional [MEDICATION NAME] 5/325 mg at 9:45 pm for moderate/severe pain, and again 40 minutes later at 10:36 pm for moderate/severe. There was no physician notification or change in pain management plan of care found in the record. A review of the eMar dated 11/23/18, indicated Resident 62 returned from [MEDICAL TREATMENT] treatment and received one [MEDICATION NAME] 5/325 mg at 1:20 pm for moderate/severe general pain. One hour later, he received one [MEDICATION NAME] 5/325 mg at 2:22 pm, for moderate/severe pain, pain not controlled well (pain that is tolerable for the Resident). A review of a physician order [REDACTED]. A review of the Minimal Data Set (resident assessment) section J Health Conditions dated 12/04/18 at 7:14 am and 12/05/18 at 1:53 pm, indicated Resident 62's worst pain level was a 6 (moderate/severe) on a pain scale and the pain limited his abilities to perform his day-to-day activities. A review of the eMar dated 12/03/18 at 5 pm, indicated Resident 62 received one [MEDICATION NAME] 5/325 mg for severe pain to legs, neck and hands. An hour an half later at 6:47 pm, Resident 62 received one [MEDICATION NAME] 5/325 mg for moderate/severe pain, and three hours later at 10:18 pm, one [MEDICATION NAME] 5/325 mg for severe pain to legs and hands. One hour later an additional [MEDICATION NAME] 5/325mg was given at 11:14 pm for moderate/severe pain. Resident 62 received four [MEDICATION NAME] 5/325 mg in a six hour time frame due to complaints of moderate to severe pain. No physician notification found in the record and no changes to pain management interventions. A review of the eMar dated 12/05/18 indicated Resident 62 received one [MEDICATION NAME] 5/325 mg at 4:52 pm for severe pain to legs, neck and hands, again, three hours later at 8:13 pm. Hour and half later at 9:42 pm one [MEDICATION NAME] 5/325mg for moderate/severe pain, then again hour half later at 11:59 pm for moderate/severe pain, four [MEDICATION NAME] 5/325 mg in six hours. A review of a Skin/Wound note dated 12/6/18 at 2:43 pm, indicated physician removed tissue from Resident 62's Stage IV pressure injury at buttocks for testing and changed wound dressing. The eMar indicated on 12/6/18, Resident 62 was not premedicated before the testing and wound care. A review of the interdisciplinary team meeting notes (IDT, multiple health care disciplines that develop plan of care) dated from (MONTH) (YEAR) through (MONTH) (YEAR) had no evaluation of Resident 62's pain management needs. The progress note section for pain indicated Resident 62 had an ordered pain management program each meeting. An IDT dated 12/10/18 at 2:08 pm, reviewed Resident 62's plan of care. The IDT did not address his pain management needs and there was no physician notification or changes in Resident 62's plan of care for pain A review of the eMar dated 01/04/19 at 4:43 pm, indicated Resident 62 received one [MEDICATION NAME] (takes 20 minutes to take effect, peaks at 2 hours may last up to four) 5/325 mg at 2:31 pm, two and a half hours before wound treatment to coccyx. Post wound treatment, Resident 62 received, one [MEDICATION NAME] 5/325 mg tablet at 5:08 pm for moderate/severe general body pain, six hours later at 11:32 pm received [MEDICATION NAME] 5/325mg for moderate/severe general body pain, 10 minutes later at 11:42 pm received an additional [MEDICATION NAME] 5/325 mg for moderate/severe pain. A review of the eMar dated 1/5/19 at 3:18 am, indicated Resident 62 received one [MEDICATION NAME] (takes 20 minutes to take effect, peaks at 2 hours may last up to four) 5/325 mg at 3:17 am, one minute before wound treatment to buttocks. Resident 62 received, one [MEDICATION NAME]/325 mg tablet at 1:23 pm for body pain after [MEDICAL TREATMENT] treatment, one and half hours later at 2:47 pm, one [MEDICATION NAME] 5/325 mg for moderate/severe body pain. One hour and half later at 4:15 pm one [MEDICATION NAME] 5/325 mg for moderate/severe body pain he was restless and groaning with pain. Five hours later, Resident 62 received one [MEDICATION NAME] 5/325 mg tablet at 9:18 pm for moderate/severe and two hours later [MEDICATION NAME] 5/325 mg at 11:18 pm for severe pain. There was no physician notification or changes in Resident 62's plan of care for pain. A review of the eMar dated 01/05/19 at 12:07 pm, indicated Resident 62 refused the wound treatment due to severe pain, Resident 62 stated, his hands it hurts too much to move. A review of the eMar note dated 01/05/19 at 2:47 pm and 01/10/19 at 4:15 pm, both [MEDICAL TREATMENT] treatment days indicated Resident 62 complained of moderate to severe pain causing restlessness and groaning. A review of the eMar dated 1/5/19, (a Saturday post [MEDICAL TREATMENT] treatment) indicated Resident 62 received one [MEDICATION NAME] 5/325 mg at 10:50 am for moderate/severe pain. Resident 62 continued to receive [MEDICATION NAME] 5/325 mg at 5:09 pm for moderate/severe hands and leg and leg pain, two hours later at 7:01 pm for moderate/severe general body pain, two hours later at 9:18 pm for moderate to severs pain , two hours later at 11:13 pm for moderate/severe pain and again, for a total of four [MEDICATION NAME] tablet in a six hour period. There was no physician notification or changes in Resident 62's plan of care for pain. A review of the eMar dated 01/09/19, indicated Resident 62 received one [MEDICATION NAME] 5/325 mg at 10:00 am for severe back pain. Four hours later Resident 62 received, one [MEDICATION NAME] 5/325 mg tablet at 1:46 pm for moderate/severe pain. 30 minutes later, he received one [MEDICATION NAME] 5/325 mg tablet at 2:22 pm for severe back pain then eight minutes later he received one [MEDICATION NAME] 5/325 mg tablet at 2:30 pm for moderate/severe pain. There was no physician notification or changes in Resident 62's plan of care for pain. A review of the eMars dated from (MONTH) (YEAR)-January 2019, indicated Resident 62's pain was reported at a moderate to severe level consistently. The eMars indicated Resident 62's pain was not adequately controlled for 21 out of 30 days in (MONTH) (YEAR), 23 out of 31 days in (MONTH) (YEAR) and five out of nine days in (MONTH) 2019. During an concurrent observation and interview on 01/08/19 at 9:22 am, Resident 62 was sitting in wheel chair at bedside in room grimacing (nonverbal pain indication), and rubbing (pain indication) lower back and left knee. Resident 62 was at bedside in his room and stated I hurt all over and my pain is terrible. The nurses do not give me pain medication before they change the dressing on my buttocks. The pain medication I take does not help. During a concurrent interview and record review on 01/09/19 at 9 am, a for Resident 62 was conducted with Licensed nurse (LN9) confirmed Resident 62's pain is not adequately controlled and was continually at a level six on a pain scale of zero to ten before and after the daily dressing change twenty one days out of thirty days in November, twenty three days out of thirty one days in (MONTH) and five out of nine days in January. LN9 confirmed the renal physician should have been notified regarding the uncontrolled pain. During a concurrent interview and record review on 01/10/19 at 8 am, Registered Nurse (RN3) confirmed Resident 62's pain was not adequately controlled and was continually at a level six out of ten (moderate to severe), before and after the daily wound care dressing changes, 21 or of 30 days in (MONTH) (YEAR), 23 out of 31 days in (MONTH) (YEAR) and five out of nine days in (MONTH) 2019. RN3 confirmed the renal physician should have been notified regarding uncontrolled pain. During a concurrent interview and record review on 01/10/19 at 3:30 pm, for Resident 62 was conducted with Licensed Nurse (LN5). LN5 confirmed Resident 62's pain was not adequately controlled and was continually in moderate to severe pain. During a concurrent interview and record review on 01/11/19 at 1 pm, Director of Nurses confirmed that Resident 62's pain was not adequately controlled for 21 out of 30 days in (MONTH) (YEAR), 23 out of 31 days in (MONTH) (YEAR) and five out of nine days in (MONTH) 2019.

Based on observation, interview, and record review, the facility failed to provide necessary care to maintain urinary continence for one of 26 residents (Resident 103) when no physician's order was obtained for self-catheterization (a thin, sterile tube inserted into the bladder to drain urine), and no assessment was done to assess the resident's ability to perform the procedure safely. ,This failure resulted in improper use of a foley catheter (a type of catheter that can be left in the bladder for a long time), causing extreme pain and injury to Resident 103's urethra (a duct that connects the urinary bladder to the urinary meatus (the point where urine exits the body). In males, the urethra travels through the penis. This injury required Resident 103 to be transferred to the hospital, requiring an in-dwelling foley catheter to be left in place in the bladder and follow-up care with a specialist. Findings: Resident 103's record was reviewed. Resident 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility policy titled Intermittent Catheterization, revision date (MONTH) 2007, indicated Catheterization will be done when ordered by a physician or RN (Registered Nurse) (NP) (Nurse Practitioner) .Clients are taught clean technique for ISC (Intermittent self-catheterization). A Nursing - Admission/Readmission Assessment note, dated 11/26/18 at 6:38 pm, indicated resident (Resident 103) self caths. A Progress Notes entry by Licensed Nurse (LN 15) dated 11/27/18 at 7:12 am, indicated Resident 103 does (perform) own straight caths after so many hours of not voiding (relieving bladder of urine). A Progress Notes entry by Registered Nurse (RN 4) dated 11/27/18 at 12:58 pm, indicated Resident 103 had a chronic indwelling foley catheter. RN 4 indicated that Resident 103 had a [MEDICAL CONDITION] bladder. A Progress Notes entry by LN 2 dated 11/27/18 at 6:16 pm, indicated Resident 103 self-cath to relieve bladder. A Progress Notes entry by Physician's Assistant (PA 1) dated 11/28/18 at 12:44 pm, indicated Resident 103 had a Neuromuscular dysfunction of bladder (also referred to as [MEDICAL CONDITION] bladder). PA 1 also indicated no in dwelling foley. A Progress Notes entry by LN 15 dated 11/30/18 at 12:20 am, indicated Resident 103 is able to straight cath self for urine retention r/t (related to) [MEDICAL CONDITION]. A Progress Notes entry by LN 14 dated 12/2/18 at 12:48 am, indicated Resident 103 catheterized self upon urge to urinate. A Progress Notes entry by LN 2 dated 12/2/18 at 3:48 pm, indicated Resident 103 self-cath to relieve bladder. A Progress Notes entry by LN 14 dated 12/2/18 at 11:58 pm, indicated Resident 103 notified nursing that he was retaining urine and could not void .stated he had been self catheterizing for fifteen years and he thought he had an order to self catheterize. (Nursing) went to obtain supplies to assist resident where needed. Left supplies in room out of (Resident 103's) reach to go verify order upon return (Resident 103) was in the middle of self catheterization advised resident he did not have an order to do so. (Resident 103) continued against medical (advice). In the process of inflating saline balloon (a small balloon typically filled with 10 milliliters of salt water to help keep the catheter tube from coming out of the bladder) (Resident 103) received blood return out the end of the catheter and requested to go to the ER (emergency room ) immediately. A review of ED (Emergency Department) Provider Note dated 12/3/18 indicated Resident 103 stated the facility ran out of straight catheters, so they gave him a foley to self cath with. (Resident 103 stated) he drained his own bladder, then filled the balloon, saw frank (fresh) red blood. Report indicated Patient did injure his urethra .Patient will need to follow-up with a urologist (doctor who specialized in problems with the urethra). The emergency room physician was able to insert the foley catheter past the injury and ordered Resident 103 to keep the foley catheter in until further notice, so his urethra could heal. A review of Resident 103's record revealed there was no physician's order for self-catheterization. There were no records of any care plans regarding self-catheterization. There was no record of assessments of Resident 103's bladder prior to or after any self-catheterization. During a concurrent observation and interview on 1/9/19 at 1:51 pm, Resident 103 stated he used I&O (In and Out) catheterization (the catheter is inserted into the bladder and left in only long enough to empty the bladder and then is removed) as needed. Resident 103 stated he brought 40 I&O catheters on admission and when he ran out, the facility gave him a foley catheter to use since they were out of I&O catheters. Resident 103 stated the facility wanted him to re-use it but he refused. Resident 103 stated the facility gave another foley catheter and he did not insert it far enough and filled the balloon and damaged his urethra and it bled, causing severe pain so he went to the emergency room . Resident 103 stated the foley catheter was left in, so the urethra can heal completely. Resident 103's foley catheter was still in place. During an interview on 1/11/19 at 9:10 am, LN 16 stated that if a resident requested supplies for I&O catheterization LN 16 would check to see if a care plan was initiated, complete self-administration assessment of the resident and make sure they were competent to perform catheterization. LN 16 was unaware of any residents in the facility who currently self-cath and had never had to observe a resident do so. During an interview on 1/11/19 at 9:12 am, LN 8 stated that if a resident requested supplies for I&O catheterization LN 8 would first check for an order from the physician, make sure the care plan was initiated, verify competency to complete catheterization, verify [DIAGNOSES REDACTED]. LN 8 stated there were no residents who perform self-catheterization at the facility currently. During a concurrent interview and record review on 1/11/19 at 1:28 pm, Director of Nursing (DON) acknowledged that the original nursing assessment dated [DATE], indicated Resident 103 self caths. DON stated that an order was never obtained by the physician to perform self-catheterization or for placement of a foley catheter. DON stated that if a physician determined a resident was capable to perform self-catheterizations a doctor's order would first need to be obtained, then the resident would be taught proper sterile technique then a return demonstration would be necessary to make sure the resident was able to perform it safely and ensure the facility had the proper supplies. DON stated that in this setting, it would not be appropriate for residents to perform self-catheterizations due to the resident population. DON acknowledged that six nurses charted regarding Resident 103's use of catheters prior to him injuring himself on 12/2/18 with the foley catheter. DON acknowledged that the nurse who gave Resident 103 the foley catheter on 12/2/18, charted less then 24 hours prior that Resident 103 catheterizes self upon urge. DON acknowledged that each nurse who charted regarding Resident 103 self-catheterizations should have caught there was not a doctor's order for self catheterization and intervened and Resident 103' self-harm on 12/2/18 could have been avoided. DON stated that the facility was working on ensuring the competencies of their nursing staff. DON stated that making sure the nurses do thorough assessments was the focus for 2019 and they were streamlining that process now. DON acknowledged that assessments had been identified as not being performed to nursing standards and were severely lacking. DON stated there was a ton of work to be done. DON stated it was a huge work in progress and they identified the problem in their Quality Assurance process.

Based on observation, interview, and record review, the facility failed to provide adequate and competent nursing staff to meet the needs of the residents and failed to monitor staff behaviors towards residents due to short staffing when: 1. Resident 22 received her medications late due to short staffing. 2. Resident 23 received her medications late due to short staffing. 3. Resident 25 experienced long call bell wait times, up to 25 minutes. 4. Resident 28's showers were missed for over a week. 5. Resident 30 did not have enough nursing staff to assist with the change of bed linens, resident transfers, and assistance for going to bed. 6. There were not enough staff to assist with resident care such as showers and weekly weights. 7. Resident 32 did not get a shower due to nursing staff not having enough time. 8. Resident 33 did not get a shower due to nursing staff not having enough time. 9. Resident 34 did not get a shower due to nursing staff not having enough time. 10. Resident 35 did not get a shower due to nursing staff not having enough time. 11. Resident 36 did not get any showers for over 10 days. 12. Resident 37 missed two showers in one week. 13. Resident 26 missed showers for an entire month due to lack of staff. 14. Resident 15 missed showers for the first three weeks of admission due to lack of staff. 15. Resident 16 missed 16 showers due to lack of staff. 16. Resident Council meeting minutes indicated resident concerns about staffing, call light response times, and showers. 17. A family member had concerns about the facility staffing being inadequate. 18. A nursing staff member described, due to short staffing and residents had voiced concerns of, why they are rushing with care. 19. Licensed nurses were splitting medications carts (causing an increased resident load per nurse to administer medications to) when usually they were each assigned one cart. Due to short staffing, medications were administered late with medication errors and nurses were not documenting in the resident medication administration record. Refer to F 425 20. Resident 30 was getting to bed late, and this had been reported to Resident Council many times, due to short nursing staffing. 21. Resident 10 waited on a bed pan too long (up to 2 hours) which resulted in hip/buttock bruising, signs and symptoms of constipation, dehydration and weight loss which were not identified and addressed. 22. The facility did not ensure adequate staffing to ensure residents were free from abuse and treated with dignity and respect. Refer to F 223, F 224, and F 226. 23. Resident 18 was not provided needed help with his urinal due to short staffing and the CNA did not treat him with dignity. 24. A confidential resident had to wait up to 45 minutes for a bed pan and had concerns about losing bladder function. 25. Licensed Nurse 1 treated Resident 17 disrespectfully and refused to give her pain medication. 26. There was not adequate supervision and staff to intervene to stop Resident 4 from being abused by Resident 3. These failures resulted in an Immediate Jeopardy and substandard quality of care due to neglectful and harmful care. Refer to F 223, F 224, F 226, F 241, F 254, F 309, F 323, F 312, F 325, F 327 and F 425. Findings: On 9/13/17 at 10:19 am, the facility's Executive Director (ED) was interviewed about staffing. She confirmed the facility had been experiencing a problem with staffing and had a lot of call-ins (sick calls). The ED stated the facility did not use registry staff (nurses that are provided by a private business like an employment agency). In an interview on 9/13/17 at 11:11 am, Certified Nurse Assistant (CNA) 19 stated that Licensed Nurse (LN) 6 ended up working Station 1 by herself on the weekends during the afternoon shift. On 9/13/17 at 11:20 am, CNA 16 was interviewed about staffing. She stated that on Station 1 today (9/13/17) there were 39 residents; eight residents that were 2 person transfers (2 CNAs needed to move the patient from surface to surface) and that some required the Hoyer lift (mechanical lift). CNA 16 stated they normally had four CNAs on Station 1 to assist the residents but today had they only had two and another CNA that floated between Station 1 and 2. She stated that three to four CNAs were needed to do resident care. CNA 16 stated that they had to get all of the residents up and get them to the dining room and pass the breakfast trays out, while one CNA passed out the hall trays (residents that stayed in rooms to eat). Next they had to pick up all the trays then get everyone dressed and briefs changed. CNA 16 stated that by the time these tasks were completed it was lunch time and the entire process started again. She stated that even when there were three CNAs and one floating between Station 1 and 2, it was hectic. CNA 16 stated that several CNAs were complaining and it was exhausting. 1. Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 9/7/17, described her as not having problems with short or long term memory or decision making tasks. 2. Resident 23's record was reviewed. Resident 23 was admitted on [DATE], with [DIAGNOSES REDACTED]. The facility's MDS, dated , 9/12/17, showed that her memory was intact and she was able to think and reason clearly. On 9/13/17 at 2:45 pm, Resident 22 and 23 were concurrently interviewed in their room about the facility's having enough staff to care for the residents. Resident 22 stated that the nurses were so busy this morning the morning medications were late. Resident 22 and 23 stated they did not receive their morning medications until 11 am or 12 noon today. In an interview on 9/13/17 at 3 pm, LN 3 confirmed Resident 22 and 23 both received their 8 am medications late because she had 20 residents. She stated she had to assist the CNAs because they were short staffed. LN 3 stated that this made her unable to administer her morning medications to the residents until around 11 am (3 hours late). She stated that she was answering call lights, changing residents' briefs, changing wet bed linens, getting drinking water for residents and asssiting to do the CNAs' jobs. In an interview on 9/13/17 at 2:30 pm, CNA 10 stated that one day there were 2 CNAs listed at her nurse's station to work but it was her by herself to take care of over 30 residents. CNA 10 stated that they normally had 4 CNAs on that station. She was told they were no longer able to use registry. CNA 10 stated that one of the nurses, had both Station 1 and Station 2 for a 2 hour period during the afternoon/evening shift. CNA 10 stated she had never seen the facility run so short staffed and she had worked there for several years. On 9/15/17 at 9:15 am, LN 4 was interviewed about the facility's staffing. She stated that about 2 weeks ago, they were short staffed for both CNAs and LNs and medications were administered to the residents late because of it. LN 4 stated that the residents' 8 am medications were not administered until 10:30 am. 3. Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's MDS, dated [DATE], showed that she was mentally and cognitively intact (able to reason, think clearly and make decisions for herself). On 9/13/17 at 2:15 pm, Resident 25 was interviewed. She stated that she had been timing the response to call bells (notification to nurse of residents' need for assistance) and they took one and a half hours 3 to 4 nights ago. Resident 25 stated that she ended up wetting herself because she could not get assistance for the bedpan. She stated that she felt really bad the next day and it was degrading. Resident 25 stated that she was freezing to death all night because her bed was wet also. She stated that she when she has to go, she has to go. Resident 25 stated she started the cry the next day when talking to staff about it and that she was old fashioned. Resident 25 stated that there were not enough staff at that station and it could take 20 to 25 minutes to get assistance many times because there was no one to care for the residents when the meals were getting passed out. She stated that lunch was a half an hour late every day. 4. Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS, dated [DATE], showed she was able to make health care decisions. Resident 28 was interviewed on 9/13/17 at 4 pm about whether there was enough staff in the facility to assist the residents. She stated that her showers were recently missed for a week and she felt creepy, stinky, dirty. Resident 28 stated that she had waited 45 minutes to an hour to have her briefs changed when wet or dirty. 5. On 9/14/17 at 1:45 pm, CNA 10 was interviewed. She stated that we feel like we're neglecting our residents. What are we to do? CNA 10 stated that they were short staffed since the facility had changed the ED. She stated that management told them they were spoiled and to not tell the residents that they were short staffed. CNA 10 stated that they had to skip resident showers and they were unable to get residents up and down for lunch. She stated that she would come in and find the previous night shift CNA with 40 patients to care for by themselves. CNA 11 was interviewed on 9/14/17 at 2 pm about staffing and resident care and confirmed she had worked at the facility for several years. She stated that she did not normally work the floor. CNA 11 stated it had Never been like this. She stated that Station 2 only had one CNA so she was pulled from her regular duties as a Restorative Nurse Assistant (RNA, a CNA with additional training to assist with therapies) to work the floor. CNA 11 stated she was given 16 to 17 residents to care for that she was not familiar with. She stated CNAs were normally assigned 10 to 12 residents each. CNA 11 stated that the RNA work did not get done on that day and residents were not assisted. She stated that resident weekly weights had not been done for about 2 months. CNA 11 stated that weekly weights had been reassigned to the Scheduler (SCH, Staffing Coordinator and a CNA) two months ago and had not been done since. On 9/14/17 at 3:15 pm, the Registered Dietician (RD) was interviewed and stated that for the past 2 to 3 months, residents' weekly weights were not being done. She stated that there were not enough staff here at the facility at times and thought the task had been reassigned. The RD stated the facility was not clear on who was responsible at this time for weekly weights and the task was still not being completed. The RD stated that she had observed there were not enough staff at times to assist the 9 to 12 totally dependent residents with their meals. She stated CNAs were only able to feed two at a time and many times there were only 2 to 3 CNAs and one had to pass the meal trays to the other residents. The RD stated that this left the other residents waiting as their food got cold. On 9/15/17 at 12:38 pm SCH was interviewed about the doing the residents' weekly weights and stated that she was responsible and had done the monthly weights and the RNAs were assigned the weekly weights. On 9/15/17 at 1 pm, CNA 11 was interviewed about the task for residents' weekly weights. She stated that in (MONTH) or July, the task was assigned to SCH and the RNAs had not been asked to do them. A review of SCH job description showed she was to arrange for coverage of CNAs and LNs to fill open positions (call offs/sick calls) and fill in. It showed that use of registry was to be cleared through the ED. On 9/13/17 at 3:45 pm, SCH was interviewed about the staff shortage. She stated that she had not been able to schedule today because I've been on the floor. (working as a CNA) In an interview on 9/13/17 at 4:40 pm, SCH stated that there were five CNAs scheduled to work Stations 1 and 2 because she had two call-ins (staff call in sick) and one CNA went home sick. She stated that ideally there were four CNAs scheduled for each station; Station 1 and Station 2. She stated they were not allowed to use registry anymore to fill in the schedule gaps. SCH could not explain why there were not enough staff available to work and stated there were call ins. She stated that when she could not arrange coverage for a call in, she worked the floor. In an interview during change of shift on Station 2 on 9/14/17 at 2:30 pm, CNA 12 stated that they were short staffed on every shift. She stated that they normally had four CNAs but now only had two to three for the past three months. CNA 13, 14 and 15 concurrently confirmed this. CNA 13 stated that one CNA had 4 residents that needed the Hoyer lift (mechanical device operated by two people that hoists the resident into the air for moving from surface to surface) to transfer them. 6. Resident 30's record was reviewed. Resident 30 was admitted to the facility to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS, dated [DATE], described her as cognitively intact (no problems with memory, reasoning or decision making), depressed several days each week without behaviors towards staff, unsteady yet able to stand and transfer from surface to surface without the assistance of staff, and needing the help of one person to shower. Resident 30 was interviewed on 9/15/17 at 3:10 pm about staffing at the facility. She stated that there were not enough CNAs on the night shifts and sometimes the afternoon shifts, to help transfer the residents for showers. Resident 30 stated this made her feel dirty and get her upset. She stated that she had to go days without getting her hair washed and that it Makes me embarrassed when she had visitors or friends. Resident 30 stated that sometimes there were not enough CNAs to get the residents' bed linens changed after their showers and that this was when they were to be done. She stated there were not enough CNAs for transfers and she had to wait half an hour after ringing her call bell for assistance. Resident 30 stated that sometimes she needed to be put to bed after dinner and would have to wait one to one and a half hours because there were not enough CNAs to assist. She stated this made her feel exhausted and sad and I get really upset. Resident 30 stated that this would occur three times a week. During an interview with Resident 30 on 10/3/17, the resident stated, I lost my favorite CNA. She got overworked and left. Resident 30 reported feeling frustrated and complained that there were not enough nurses or CNAs. 7. A review of Resident 32's Resident Functional Performance Record (RFPR, record of daily functional activities) for (MONTH) (YEAR) included a handwritten notation, dated 9/11/17 for the afternoon shift that read, I was unable to perform shower on this resident due to lack of time. 8. A review of Resident 33's RFPR for (MONTH) (YEAR), included a handwritten notation, dated 9/13/17 for the morning shift that read, Unable to complete shower due to lack of staff and necessary Resident care. There were no showers documented from 9/1 to 9/13/17 (four to have been done per schedule). 9. Resident 34's RFPR for (MONTH) (YEAR), was reviewed and included a handwritten notation, dated 9/13/17 for the morning shift that read, Unable to complete shower due to lack of staff and too much necessary resident care to complete. There were no showers documented from 9/1 to 9/13/17 (four to have been done per schedule). 10. Resident 35's RFPR for (MONTH) (YEAR), was reviewed and included a handwritten notation, dated 9/13/17 for the morning shift that read, Unable to give Res shower due to short staffing. There were no showers documented from 9/1 to 9/13/17 (four to have been done per schedule). 11. Resident 36's RFPR for (MONTH) (YEAR), was reviewed and showed there were no showers documented from 9/1 to 9/13/17 (four to have been done per schedule). 12. Resident 37's RFPR for (MONTH) (YEAR), was reviewed and showed there was a shower on 9/1 and 9/11/17. There was no documentation for the other twice weekly showers missed (two of four done). 13. In an interview on 9/14/17 at 2 pm, CNA 11 stated that Resident 26 was not being showered. She stated that he had moved from Station 3 to Station 2 and had not been put on the shower list. CNA 11 stated one of the nurses brought this to the attention to the Scheduler (SCH, a CNA) and stated Resident 26 had not had a shower in a month. On 9/15/17 at 11:32 am, Resident 26 was interviewed about his missed showers. He stated that he would rather have been showered but thought the facility was understaffed. 14. Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility reported that Resident 15's family lodged a complaint on 8/2/17 that Resident 15 had not received a shower and it was unfair, unkind and neglectful. During a telephone interview on 9/13/17 at 1:50 pm, FM 40 reported, It's my impression they are very understaffed. Resident 15 did not have a shower for the first three weeks. Call light response was very slow. The facility's own investigation substantiated the complaint as six out of seven residents who were questioned, reported having no regular shower or not receiving their shower on their scheduled days. 15. A review of Resident 16's record indicated that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 16 had a BIMS of 6, indicating she was unable to make healthcare decisions for herself. The MDS dated [DATE], indicated that Resident 16 required extensive assistance with all activities of daily living (ADLs) except bathing, in which she required totally dependent on assistance. A review of Resident 16's Functional Performance Records was conducted, showing how many showers or bed baths Resident 16 did not receive in June, July, (MONTH) and September. Resident 16 missed out of 36 possible showers. During an interview on 9/13/17 at 1:10 pm, CNA 13 stated that giving proper care to residents is difficult when they have so few staff to do all the work. CNA 13 felt sad and tired when asked how staff were dealing with the situation. They understaff all the time and it's scary. During a telephone interview with Family Member (FM 38) on 10/11/17 at 3 pm, FM 38 stated that care for Resident 16 at the facility had been hit and miss. He reported that no staff were providing oral care and he yelled at the staff because he was so mad. She got a sore on her gum and it hurts her. She has trouble eating anyway and now this. 16. On 9/15/17 the facility's Resident Council Minutes were reviewed. Resident Council is a monthly meeting of residents where concerns about the facility are discussed. The minutes dated 8/28/17 showed staffing as a concern under old business. The minutes dated 7/31/17, were reviewed and old business reviewed showed there were several times where no CNA was present in the main dining room and call light response was slow. New business included an introduction to the new ED. Nursing concerns reviewed were that call lights were still slow to be answered at meal and bedtimes and a resident stated she missed two showers recently because her CNA was not there. The showers for dependent residents were discussed and noted to not be thorough. Nine Grievance Forms dated 6/21, 8/08, 8/14, 8/21, 8/21, 9/6, 9/7, 9/8 and 9/11/17 regarding not having enough staff to transfer for toileting, hygiene, showering and getting in and out of bed were reviewed. These had been submitted by residents and concerned family members. Two of the nine included documentation in the Action Taken section with the remaining seven left blank. The facility's Grievance Procedure, dated (MONTH) (YEAR), read that grievances were to be resolved immediately, when possible. A Grievance Form, dated 9/5/17, for Resident 25 read, Resident put on call light waited for 1/2 hour, no response, soiled self and waited additional 1/2 hour to be changed. Felt degraded. The incident occurred on the night shift at 4 am on 9/8/17. A Grievance Form, dated 9/6/17, for Resident 25 showed it was completed by staff. It read, Resident stated last night @ (9-5-17) she had to wait over 1 and 1/2 hours to be put on the bedpan. Since no one answer her call light she ended up urinating on herself & bed. She is very upset and feels as though no one cares for her. A Grievance Form, dated 9/12/17, had a notation that it was found on 9/11/17. It listed Resident 25 as the Grievant and read, Sunday was an utter catastrophe. Room lights on like Christmas trees, while CNAs rushed to keep up. Nurses not informed of the shortage .Nurses & CNAs working to exhaustion and patients paying the price of inadequate care. A Grievance Form, dated 9/8/17 and received on 9/11/17, showed that Resident 28's family member does not feel like staff is checking in on Resident 28 as they should. On 09/8/17 in the afternoon Resident 28 was found by family saturated completely through her brief and sheets put newspapers on her bed to try to keep herself somewhat dry. On 9/15/17 at 9:25 am, CNA 17 was interviewed about staffing. She stated that the facility had previously staffed nursing at 3.5 hours PPD (per patient day, a measure used to staff healthcare facilities) when they were full. CNA 17 stated that since the arrival of the new ED around 7/1/17, they were told to drop CNAs to equate PPD to 3.4. She stated that previously the facility would staff 12 CNAs for day shift and not count the 1:1s (CNAs watching/caring for one patient only) in that total. CNA 17 stated that the facility now staffed with 10 CNAs including up to three 1:1s (that were not able to care for other patients). She stated that SCH was not calling for CNAs to work when there were call ins (sick call). CNA 17 stated that before SCH started doing scheduling, the facility was always able to get coverage for the call ins. 17. On 9/15/17 at 10:15 am, Resident 38's Family Member (FM 38) was interviewed about the facility's staffing. She stated that she had come in between 8 and 9 am on a Saturday about 3 weeks ago and all the room lights (indicates call bells activated and resident awaiting assistance) were on. FM 38 stated that this went on all day. She stated that she requested help from CNA 18 (the only CNA on the station) but that CNA 18 was talking and laughing on the phone, at the station, for an extended period of time (while the residents waited with their call lights on). FM 38 stated that when CNA 18 finally came in to change Resident 38's dirty brief, nearly an hour later, she documented the incident and reported it to the charge nurse. FM 38 stated she was told that the Director of Nurses would come in to speak with her but that had not happened. 18. During an interview on 10/10/17 at 7:30 am, CNA 21 stated they were tired of working short and having to rush with resident care. CNA 21 stated the residents have questioned why CNAs were not as available to help them. 19. During a concurrent observation, interview and record review on 10/6/17 at 3 pm, LN 6 stated Station 1 and Station 2 medication carts were being split (causing nurses to have to administer medications to more residents spread throughout the facility) and LN 6 had 26 residents to pass medications to. LN 6 stated they usually start the medication pass around 3 pm. LN 6 stated the nurses do not like to split the medication carts because it's unsafe, we are usually assigned to one cart per Station. LN 6 was holding a medication cup with medications in her hand while standing at Station 1's cart. When asked to see the Medication Administration Record (MAR) for that resident, LN 6 stated it was on Station 2's cart. LN 6 had already signed out the medication on the MAR and further explained she should not have signed it out until the medication had been administered. During a concurrent observation, interview and record review on 10/6/17 at 4:15 pm, LN 9 had just started to do the medication pass for Station 2 and part of Station 3. LN 9 stated I am kind of behind and I usually start around 3 pm but we are splitting medication carts today because we are short staffed. LN 9 stated it can take 2 to 3 hours to pass medications with all the interruptions due to no one being at the nursing station desk to take phone calls and physician orders. During a concurrent observation, interview and record review on 10/8/17 at 4:55 pm, LN 15 had not signed out her morning medications nor the evening medications, for Resident 8, 34, 43, and 44 . LN 15 stated she worked a double shift that day due to short staffing. LN 15 was unable to determine whether she had given the [MEDICATION NAME] (for low [MEDICAL CONDITION]) to Resident 44, then she proceeded to initial all the medications for both shifts that day. When LN 15 pulled out a drawer in the medication cart, there were two medication cups with resident names on them (Residents 8 and 37). LN 15 stated when she prepared the medications neither Resident 8 and 37 were in their rooms so she locked them in the cart between 3 and 4 pm. LN 15 stated this was probably not legal. LN 15 stated the medications should have been signed when given, not 12 hours after they had been administered. 20. During an interview on 10/8/17 at 4:30 pm, Resident 30 stated they are not getting to bed on time, usually late due to short nursing staffing. Resident 30 stated the other night a LN stated do not use call light for silly things we only have one person (CNA) for the night shift. 21. A review of Resident 10's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a nurse's note dated 7/4/17, indicated Resident 10 requested to be placed on a bed pan during the busy lunch time. Resident 10 needs appear to be above and beyond expectations at the expense of other residents care. Will need to educate staff and resident. A PRN note dated 7/25/17, indicated Resident 10 requested to be put on the bed pan nine times on the night shift, the last time she was put on the bed pan a bruise was on her right buttock and hip from all the times she had been on the bed pan. Charge nurse notified. No Event reported and no investigation found in the record. A PRN note dated 8/9/17 on night shift, indicated Resident 10 had bruising all over her buttocks, charge nurse notified. No event reported and no investigation were found in the record. A PRN note dated 8/13/17, night shift, indicated Resident 10 stated she had been on the bed pan for two hours. During an interview on 10/10/17 at 7:30 am, CNA 21 stated Resident 10's usual bowel movements were small, hard and round tiny pieces, and she had chronic constipation. During an interview on 10/25/17 at 3:50 pm, Social Services (SS) 1 stated she saw a change in Resident 10 when she stared not eating and drinking. SS 1 stated they were aware of the issue with the bed pan and thought that nursing would be taking care of whether the constant requests were an obsession, or a physical issue related to dehydration or constipation. SS 1 was unaware of the bruising the use of the bed pan had caused. 22. A review of a disciplinary action form dated 10/11 to 12/2017, indicated CNA 29 was in violation of a company policy when was asked to check and change residents in six rooms due to them being soaked and to strip some beds. Residents were not turned or checked during shift. CNA 29 was performing job duties in an unsafe careless manner. The facility self reported three incidences of sexual abuse in the past of unknown timeframe for CNA 29 with three different residents as follows: CNA 23 was told by her supervising Licensed Nurse (LN) 15 that CNA 29 was observed touching Resident 4's breasts and kissing her on the mouth. CNA 28 was told by her nurse supervisor (LN 15) that CNA 29 was observed giving Resident 13 a kiss on the mouth. CNA 29 told the facilty he had given Resident 27 a kiss on the mouth when she made kissing sounds. During an interview on 10/25/17 at 4:30 pm, the Director of Nursing (DON) stated CNAs 23, 28, 29, and LN 15 were all terminated after failing to report abuse allegations and following facility policy and procedures. The DON was unable to provide documentation of any training, education or oversight of CNA 29 during his 90 day probation for neglectful care. 23. Resident 18 was interviewed on 10/18/17 at 3:45 pm, regarding staff timeliness and respectful care. Resident 18 reported They are always shorthanded. Last week I waited two hours for someone to come. With the State in the building, it only takes seconds. Resident 18 described an incident with CNA 22, that occurred three weeks ago, in which he asked to have his urinal emptied and CNA 22 had asked him why. Resident 18 stated that CNA 22 told him that it still had room and she would be back later to empty it. Resident 18 stated that they went on to have an argument about CNA 22 not providing care that he requested. In that time, another CNA emptied the urinal for him. Resident 18 reported the incident to the Director of Staff Development (DSD) and CNA 22 was removed from caring for him. 24. During a confidential interview on 11/3/17 at 4:45 pm, a resident stated the facility continued to have short staffing and often waited up to 45 minutes for a bed pan. The resident stated there was less staffing on the skilled side than the Medicare unit. The resident stated it was really hard to wait for staff and the resident had had accidents. The resident stated she was worried she might lose her bladder control if it kept happening. 25. Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17 also had a recent fall resulting in a broken wrist and three broken fingers. Resident 17 was interviewed on 11/1/17. She stated that she was due for her pain medication and stated that LN 1 told her that she did not have an order for [REDACTED]. Resident 17 stated that LN 1 would not give her pain medication and Resident 17 stated she spoke to LN 7 on Station 2 who finally gave her her pain medication. On 11/29/17 at 1:40 pm, Medical Record Staff (MR 1) was interviewed. MR 1 stated while at the front desk at the facility, he was approached by Resident 17. Resident 17 told him that she was not getting her pain medication. MR 1 stated he walked down to Station 1 with Resident 17 to find out what was going on and this was when MR 1 witnessed a verbal altercation between Resident 17 and LN 1. LN 1 informed both Resident 1 and MR 1 that she only had routine pain medications. When MR 1 asked if Resident 17 had any as needed pain (prn)

Based on observation, interview and record review the facility failed to to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for two of 45 sampled residents (Resident 10 and 12) when: 1. Resident 10's [DIAGNOSES REDACTED]. This resulted in a significant weight loss for Resident 10, on 6/16/17 she lost 17 percent (%) in one month, on 7/20/17 she had lost 14.8 % in two months and on 8/4/17 she had lost 10.5 % in 2 months. 2. Resident 12 had an avoidable weight loss when the facility did not honor her requests to eat amongst her peer group. This resulted in a significant weight loss for Resident 12 when she lost 15 % of her weight in 3 months. Findings: 1. A review of Resident 10's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 10 was able to make health care decisions for herself. A review of a social services (SS) note dated 5/25/17, indicated Resident 10 was her own responsible party (RP) and was under the supervision of a center that provided services and support for persons with developmental disabilities to live productive lives. SS 1 documented that Resident 10 had mental intellect delay and at times suffered from intermittent confusion and forgetfulness. According to Resident 10's Weights and Vitals Summary, the following was included in the documented weights (not all inclusive): On 5/22/17-149 pounds (lbs) On 5/29/17-144.5 lbs On 6/5/17-141.6 lbs On 7/9/17-143.8 lbs On 7/17/17-141.8 lbs On 7/23/17-138.4 lbs On 8/1/17-133.4 lbs On 8/13/17-142.5 lbs On 9/2/17- 141.5 lbs On 9/24/17-128.6 lbs On 10/1/17-128 lbs Resident 10's record contained a physician order [REDACTED]. A review of a physician order [REDACTED]. In a review of an initial nutritional evaluation form dated 5/24/17, the registered dietician (RD) indicated Resident 10's desired body weight was 150 lbs plus or minus 10 %, with daily fluid intake requirements of 1700 to 2040 milliliters (ml) a day. The RD documented that Resident 10's usual body weight was 170 pounds (lbs) and she had lost weight while she was in the hospital down to 156 lbs. Resident 10 weighed 149 lbs upon admission to the facility on [DATE]. Resident 10 was eating a frozen nutritional treat (adds 500 kilocalories) twice a day. The RD indicated Resident 10 does not like thickened liquids and must be spoon fed liquids which may account for decreased fluid intake. Resident 10 liked her current weight and wanted to maintain. Resident 10's intake was 71 percent (%). In a review of a nutritional evaluation progress note dated 6/8/17, the RD indicated Resident 10's goal was to have gradual reduction in weight 150 lbs, plus or minus 10%. Resident 10's meal intake was 74 % and continue to monitor. In a review of nutritional evaluation progress note dated 6/16/17, the RD indicated Resident 10 had a weight loss of 10.4 lbs in three weeks. Resident had frozen nutritional treat twice a day, intake unclear. Resident now below desired weight goal. RD recommended to add nurtitional enhanced meal (NEM, adds 500 kilocalories) to diet, continue to monitor. Resident 10's intake 100 % in restorative nursing dining (assistance) In a nutritional evaluation progress note dated 6/22/17, the RD indicated Resident 10 gained weight at 142.6 lbs. Resident 10 felt the frozen nutritional made her gain weight and wants to lose another 10 pounds which would put her at 132 lbs. The RD wrote Resident 10 was her own responsible party (RP) and discontinued the frozen supplement. Resident 10 was eating 88 % of meals. In a nutritional evaluation progress note dated 7/5/17, the RD indicated Resident 10's diet was changed to NEM on 6/16/17 and no longer in need of NEM related to her desire to lose weight. Current meal intake 93 %. Discontinue NEM. In a nutritional evaluation progress note dated 7/20/17, the RD indicated Resident 10's wanted to lose weight and discontinue the NEM. Resident 10 fairly stable weights over past month. NEM had not been discontinued as recommended on previous review and will continue. Resident 10's meal intake 47 % of meals. Resident 10 stated wanted to continue to lose weight. In a nutritional evaluation progress note dated 7/28/17, the RD indicated Resident 10 was continuing on NEM. Resident 10 wanted to continue losing weight. Resident 10's meal intake was 76 %. In a nutritional evaluation progress note dated 8/4/17, the RD indicated Resident 10's weight was 133.4 lbs, down 10.4 lbs in one month. Recommended NEM to be added though Resident 10 was already on NEM. Intake down to 45.5 %, fluids 120-240 ml. Cal Dense (360 kilocalories) was added 60 ml three times a day. Will reconsider appetite stimulant due to poor intake. In a nutritional evaluation progress note dated 8/23/17, the RD indicated Resident 10 weighed 142.5 lbs on 8/13/17. Resident was started on Cal Dense, discontinue. The RD documented she had no idea why Resident 10's weights were going up and down. Continue to monitor with weekly weights. A review of Resident 10's record indicatred there were no weekly weights found in the record from 8/23 to 10/1/17. In a nutritional evaluation progress note dated 9/12/17, the RD indicated Resident 10 weight was 141.5 lbs. Resident discontinued NEM. Resident desired weight loss. Resident appropriate monthly weights. Meal intake stable at 51 %. Discontinue Cal Dense and reinstate NEM (current order). In a nutritional evaluation progress note dated 9/28/17, the RD indicated Resident 10 weighed 128.6 lbs a loss of 12.9 pounds. Resident had complained of nausea and vomit, plus refused to eat for 3 days, may be a reason for recent weight loss. Resident 10's meal intake at 50 %. Recommended NEM and a consent signed for Resident 10 to have regular liquids. Add fortified pudding to increase calorie intake. Resident within desired weight range. During a concurrent observation and interview on 10/8/17 at 5:15 pm, Resident 10 stated she used to get up for meals when she felt better. Resident 10 stated by the time staff get her up and dress she gets to the dining room, everyone is gone and her food was cold. A review of the meal monitoring flowsheets for (MONTH) to (MONTH) (YEAR), were incomplete for Resident 10. During a concurrent interview and record review on 10/25/17 at 2 pm, the Registered Dietician (RD) 2 stated after reviewing the RD notes who assessed Resident 10, indicated that it was not documented that they were aware of Resident 10's [DIAGNOSES REDACTED]. RD 2 stated it was concerning in the first few weeks of admission that Resident 10 was losing weight too quickly. RD 2 confirmed that the meal monitoring flowsheets (record the amount of food and oral intake) were incomplete for Resident 10 from (MONTH) to (MONTH) (YEAR). RD 2 stated the dieticians use this information (meal intake) to create resident's plans of care. RD 2 confirmed weekly weights from 8/23 to 10/1/17 were not consistently done. RD 2 confirmed there were no weight Interdisciplianary team (IDT) notes or physician notification found in Resident 10's record about the planned weight loss and frequent weight fluctations of Resident 10. During a concurrent interview and record review on 10/26/17 at 2:45 pm, the Medical Director (MD) stated he was unaware that Resident 10 was developmentally disabled. The MD stated he was unaware of the weight loss and due to her risk factors and [DIAGNOSES REDACTED]. The MD stated the IDT should have discussed the issues surrounding the weight fluctations and determine if a weight loss program was appropriate for Resident 10. During a concurrent interview and record review on 11/6/17 at 2:30 pm, the Director of Nursing (DON) confirmed that the weight IDT was not meeting regularly and was unable to provide any documentation in relation to the weight loss program being monitored by nursing. The DON stated the weight loss was requested by Resident 10 and that she was her our RP. 2. A review of Resident 12's record indicated she was admitted to the facility on [DATE] with [MEDICAL CONDITION] (affects the nervous system) disease and depression. Resident 12 was able to make health care decisions for self. According to Resident 12's Weights and Vitals Summary the following was included in the documented weights (not all inclusive): On 3/6/17- 122.6 pounds (lbs) On 6/6/17- 123.8 lbs On 7/17/17- 114.6 lbs No weights for (MONTH) (YEAR) On 9/2/17-107.6 lbs On 10/3/17-105.2 lbs A review of a nutrition hydration skin committee with no date or reason for review, indicated Resident 12 appeared to have significant weight loss and with possible scale error, suggest weekly weights until stable. A second undated entry on the same form indicated a signficant weight loss of 16.2 lbs over three months and 15 lbs over six months. Interdisciplinary team (IDT) recommends increasing Cal Dense (supplement) to 90 milliliters three times a day and house supplement to between meals. Resident 12 often refused to go to diningroom for meals. A review of a nutrition evaluation progress note dated 9/7/17, indicated Resident 12 intake stable with meal intake of 65 %. A review of a nutrition evaluation progress note dated 9/24/17, indicated Resident 12 had oral pain and provided many assistive devices to self feed. No evaluation of weights, meal intake or changes in plan of care. A review of a nutrition evaluation progress note dated 10/17/17, indicated Resident 12 record was reviewed after readmission from the hospital on [DATE]. Resident 12 last weight was on 10/3/17 indicated she lost 2.4 pounds. Resident 12 was a canidate for tube feeding, will discuss with family if weight loss continues. An IDT note dated 9/29/17, indicated a care conference was held and the daughter had concerns about Resident 12's weight loss. The note indicated the facility was in between registered dieticians and the Social Services Director (SSD), Director of Nursing (DON) and Executive Director (ADMIN) will cover until new hire was obtained. A social progress note dated 7/16/17, indicated Resident 12 was frustrated with her lack of body control with a clear sharp mind intact. Resident 12 stated she was frustrated with the inability to feed herself. A social progress note dated 9/29/17, indicated Resident 12 does not want to eat in the dayroom (assistive dining) and eats in her room. Resident 12 required assistance with eating due to her [MEDICAL CONDITION] which caused her hands to shake. During a interview of 11/1/17 at 1:27 pm, a family member (FM) 41 stated Resident 12 had lost nine pounds due to her needing more assistance with eating ([MEDICAL CONDITION] hands shaking, swallowing issues). FM 41 stated it was really tough trying to find staff assistance. FM 41 stated often Resident 12's bedside table not in reach so she could not get water to drink and had concerns about dehydration. FM 41 stated she talked to the facility about the dining room changes due to other residents complaining about the mess Resident 12 was making in the independent dining. FM 41 stated Resident 12 was losing weight due to not receiving the needed assistance and moving her from the alert resident dining. FM 41 stated Resident 12 likes the rehabilitation dining and has concerns that it will only be temporary. During a concurrent interview and record review on 11/3/17 at 4:30 pm, the Speech Therapist (SLP) stated there were complaints from other residents in the main dining room about Resident 12 making too much of a mess while eating. SLP stated Resident 12 was moved to day room with others who need assistance and who are not as alert. SLP stated Resident 12 was frustrated with that because she has good cognition. The SLP confirmed there were no weekly weights and there were gaps in the dietician assessments and delays in interventions for weight loss. The SLP stated the facility could have accommodated Resident 12's desire to eat with others with the same cognition and the change in dining setting did contribute to her weight loss. SLP stated Resident 12 was now in restorative nursing dining due to swallowing issues and getting the assistance she needed. During a concurrent observation and interview on 11/3/17 at 4:35 pm, Resident 12 was sitting in her wheelchair waiting for staff to assist her with her socks. Resident 12 stated she preferred the main dining room and that it was a frustrating and complicated situation when interviewed about her dining preferences. During an interview on 11/6/17 at 2:30 pm, the Director of Nursing (DON) confirmed during the months of July, (MONTH) and (MONTH) (YEAR), there were no regular weekly nutritional hydration Interdisciplinary team (IDT) team meetings.

Based on observation, interview, and record review, the facility failed to consistently implement resident specific interventions to provide adequate supervision and safety to ensure that five of 45 sampled residents (Residents 3, 6, 16 and 17 ) were free from accidents and falls when: 1. Resident 6 was not adequately supervised to ensure his safety by determining his mental compentency to leave the facility to purchase a cigar. The facility failed to implement its Missing Resident/Elopement policy when it was known Resident 6 was reported missing an immediate search of the facility and an extended search outside the facilty was not initiated by the staff and the Licensed staff did not notify administration and the police timely of a missing resident. These failures resulted in an unusual occurrence when the facility was notified by the police department that the resident had been found deceased on [DATE] at 12:07 am, nine hours after leaving the facility to get a cigar. 2. The facility failed to implement a floor pad to prevent further injury from falls for Resident 16. 3. The facility failed to identify potential hazards and implement appropriate interventions to ensure that Resident 17 was free from avoidable accidents, per the Fall Management Policy. 4. The facility failed to evaluate staffing levels to ensure adequate supervision to protect Resident 4 from the aggressive behaviors of Resident 3. These failures resulted in avoidable accidents, injury, and death. Findings: 1. A facility policy titled Missing Resident/Elopement Procedures dated (MONTH) (YEAR), indicated the Center (facility) uses a systematic procedure to locate residents that are believed to have eloped or are missing from the Center. Missing residents are located as quickly as possible using available resources. Upon discovery of a missing resident immediately implement the search procedures. Step 1 the Licensed Nurse (LN) checks the resident sign out book and conducts a thorough search of the unit and notifies each unit nurse to search their units and report findings. The LN pages a message over the communication system to request the resident return to their room. Staff members search the entire building and common areas. If resident is not found the Director of Nursing Services calls responsible parties, the physician, the police and coordinates a vehicle foot search. Search any place that a resident had a history of [REDACTED]. A review of a Emergency Department report dated [DATE], indicated Resident 6 presented with chronic pancreatitis and abdominal pain with continuing opioid dependence for 8 to [AGE] years of oxycodone (strong narcotic pain medication) and Fentanyl (strong narcotic pain medication) patches. It was reported by a friend that Resident 6 had been overusing narcotic medications, consuming alcohol and had been confused and acting bizarrely. The [DIAGNOSES REDACTED]. A review of Resident 6's record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a physician order dated [DATE], indicated Trazodone (antidepressant) 100 milligrams at hour of sleep. Lexicomp (an online reference) indicated taking Trazodone with other drugs that make you sleepy can worsen this effect. Ask your doctor before taking trazodone with a sleeping pill, narcotic pain medicine, muscle relaxer, or medicine for anxiety, depression, or seizures. A nursing admission evaluation dated [DATE], indicated Resident 6's cognitive evaluation for dementia, delirium, disoriented, confused was marked yes. A review of a nurse's note dated [DATE] at 2 am, indicated Resident 6 was very confused tonight wanting to get his car. Resident 6 was a one person assist with activity of daily living (ADL)s and transfers. A review of the physician orders dated [DATE], indicated the Oxycodone (strong narcotic) extended release (ER) 30 milligrams (mg) one tab frequency increased to three times a day from twice a day. A review of the physician orders dated [DATE], indicated the Oxycodone immediate release 15 mg increased the frequency to every four hours as needed for pain, from every six hours. A review of a nurse's note dated [DATE] on the am and pm shift, indicated Resident 6 was alert with confusion. Resident 6 was independent with transfers and continued to have an unsteady walk. Resident 6 wandered into other resident rooms looking for his wife and car keys. A review of a weekly nurse's progress note date [DATE], indicated Resident 6 had an unsteady gait. A review of a physician order dated [DATE], indicated Resident 6 was to receive a Fentanyl (strong narcotic) patch 25 micrograms every 72 hours for pain. A review of a medication administration record (MAR) for (MONTH) (YEAR), indicated Resident 6 had a Fentanyl patch applied on [DATE]. An online drug reference from Lexicomp, indicated Oxycodone could cause life threatening respiratory depression. Oxycodone when used with other CNS (central nervous system) depressants can cause sedation. A conversion from Fentanyl patch to Oxycodone ER should be monitored closely and use a conservative conversion factor of Oxycodone ER 10 mg every 12 hours for every 25 mcg of Fentanyl. A review of the physician orders and MARs for (MONTH) (YEAR), indicated Resident 6 concurrently received Oxycodone ER 30 mg three times a day and a 25 mcg Fentanyl patch both long acting strong narcotics. A review of a smoking care plan dated [DATE], indicated Resident 6 smoked cigars and that the family was to provide and purchase smoking supplies, and the facility was not to assist with purchasing smoking supplies. The care plan did not indicate if Resident 6 was able to smoke independently or with supervision. A review of a physical therapy note dated [DATE], indicated Resident 6 was fatigued, able to walk 100 feet two times, and that the instructions were increased due to some confusion. Resident 6 had not met his long term physical therapy goals with a target date of [DATE]. A review of a physician note dated [DATE], a family nurse practitioner indicated Resident 6 was alert and forgetful. A review of the resident functional performance record for the month of (MONTH) (YEAR), indicated Resident 6 required supervision with limited assist for transfers and ambulation. A review of a note titled Unusual Occurrence dated [DATE], indicated the facility reported a Resident 6 wanted to go out and get more cigars and signed himself out at the reception desk at 3:12 pm on [DATE]. At change of shift on Sunday [DATE] at 6:30 pm, the day shift staff reported that Resident 6 had not yet returned to the facility. A historical weather website called Wunderground indicated on [DATE], the outside temperature where the facility was located, was 100.4 degrees Fahrenheit at 3 pm until 6:30 pm. A review of the medication administration record (MAR) dated (MONTH) (YEAR), indicated Resident 6 received a new Fentanyl 25 mcg patch at 8 am and Oxycodone 30 mg at 2 pm on [DATE], before leaving the facility. During an interview on [DATE] at 12:15 pm, a family member (FM) stated they came into the facility on [DATE] between 6 and 6:30 pm, to find out from Resident 6's roommate that he had been gone a long time. The FM stated they talked to the LN nurses who were doing a narcotic count during shift change, who stated they gave Resident 6 his afternoon medications and that he was his own RP. The LNs were unaware that Resident 6 was still gone. The FM stated the nursing staff did not look for Resident 6 nor call the police at that time. The FM stated they (the family member) went looking for Resident 6 then called the police. During an interview on [DATE] at 3:50 pm, Certified Nursing Assistant (CNA) 22 stated Resident 6 was confused and staff had to reorient him often to where his room was and to when to use the call light. CNA 22 stated Resident 6 would forget to use walker and refused to use it. During a interview on [DATE] at 10 am, the Director of Staff Development (DSD) 2 stated Resident 6 was his own responsible party at the time when he left the building on [DATE]. The DSD 2 stated the facility policy now was to have LN assess safety of all residents that are leaving the building. The DSD 2 stated the staff are to interview a resident when leaving the building about what their plans were and to estimate a time of return. The DSD 2 stated this information should be passed along during shift change reports that a resident has left the building. During an interview on [DATE] at 1:50 pm, the weekend receptionist (RECEP) stated Resident 6 was observed in the lobby on [DATE] in the afternoon. The RECEP stated Resident 6 mentioned he was going to get a cigar. The RECEP stated it was hot and that she told Resident 6 he should talk to a nurse before leaving. The RECEP stated Resident 6 was observed talking to someone and then came down to lobby without using a walker and signed himself out. The RECEP stated it was not the responsibility of the receptionist to ask residents about where they were going and when they would return. During an interview on [DATE] at 12:30 pm, the Medical Director (MD) stated nursing staff should ensure residents are competent before leaving the facility and they should know a time of expected return of a resident, within 2 to 4 hours. During an interview on [DATE] at 11:30 am, LN 7 stated staff were not always aware if residents left the building, where they were going and when they might return. During an interview on [DATE] at 2:40 pm, LN 10 stated Resident 6 had aggressive behavior on admission and was alert with periods of confusion. LN 10 stated Resident 6 became more confused when in pain and medicated. LN 10 stated Resident 6 was given pain medication at 2:45 to 3 pm on [DATE] before exiting the facility. LN 10 stated that on [DATE] at 6:30 pm, the narcotic count was being done with LN 11. LN 10 stated a family member of Resident 6 inquired where the resident was. LN 10 stated to the family member, Resident 6 was his own RP and they could not keep him in the facility. LN 10 did not initiate the missing resident protocol, call the police, or notify administration due to Resident 6 being his own RP During an interview on [DATE] at 3:30 pm, LN 11 stated Resident 6 asked where he could buy a cigar. LN 11 stated there was a discussion with LN 10 about Resident 6 being his own RP and that they were not allowed to stop him to talk about it to protect his resident rights. LN 11 stated Resident 6 was not questioned if a family member or friend could aquire a cigar for him, or where he was going, and when he would be back. LN 11 confirmed there was no assessment of his cognition or his ability to walk alone to a nearby store. LN 11 stated it was very hot that day and suggested Resident 6 take some water with him. LN 11 was unaware if Resident 6 had any money to buy cigars. During an interview on [DATE] at 2 pm, the Executive Director (ED) A stated the nursing staff had a hard time understanding the difference between honoring residents rights and ensuring their safety. ED A stated the staff thought they could not inquire or intervene with a resident that is their own RP. During an interview on [DATE] at 1:25 pm, an Occupational Therapist (OT) stated Resident 6 was oriented with episodes of confusion when during one therapy session he wanted to leave the building to help his wife with a flat tire. During a concurrent interview and record review on [DATE] at 1:45 pm, a Physical Therapist (PT) stated Resident 6 was confused at times. The PT stated Resident 6 had no endurance or strength though was progressing. Resident 6 did not require the use of his walker after a few sessions though still required rest periods and could not walk continuously. PT stated Resident 6 had only completed walking the facility about 500 feet during one therapy session. PT stated Resident 6 was not capable of walking to any store nearby, the nearest one being a half of a mile from the facility. During an interview on [DATE] at 2:25 pm, CNA 24 stated she worked the day Resident 6 left the faciity on [DATE]. CNA 24 stated Resident 6 wanted to smoke at 3 pm and there were no cigars available. CNA 24 stated Resident 6 explained his family had not returned his calls. CNA 24 was surprised Resident 6 had left the facility, and this was the first time he had requested to leave. CNA 24 stated when it was known Resident 6 had not returned, a Code White (notifies staff to search for missing resident) was not called in the facility to alert all staff that a resident was missing. CNA 24 stated the facility staff did not search for Resident 6 until after dinner was complete on [DATE] around 6:30 pm. CNA 24 stated they did not know about the Code White until the staff were recently inserviced about the facility elopement policy. During an interview on [DATE] at 2:30 pm, the MD stated Resident 6 should have only been taking one long acting narcotic not two at the same time (Oxycodone ER and Fentanyl). The MD stated he was unaware that Resident 6 was receiving two long acting narcotics Oxycodone ER and Fentanyl. The MD stated this put Resident 6 at risk for an overdose. A review of a note titled Unusual Occurrence dated [DATE], indicated the facility was notified by the police department that Resident 6 had been found deceased on [DATE] at 12:07 am. The autopsy report dated [DATE], indicated Resident 6 was wearing a blue long sleeve sweatshirt over a white T shirt. Resident 6's cause of death was probably a cardiac dysrhythmia, high blood pressure, chronic alcoholism, and dehydration. The toxicology report indicated Resident 6 had opioid and alcohol in his system. 2. A review of Resident 16's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. walking), and personal history of fall. Resident 16 had a Brief Interview for Mental Status (BIMS, a short test for checking mental capability) of 6, indicating she was not consistently alert and oriented and unable to make health care decisions for herself. The facility reported that on [DATE] at 7:50 pm, Resident 16 was found lying face down on her bedroom floor, after her roommate got up and alerted staff that she had fallen out of bed. Resident 16 was sent to the local hospital for bilateral (both sides) fractures of the nasal bones. A Fall Risk assessment dated [DATE] indicated that Resident 16 scored a 55 on the Morse Fall Scale (an assessment of a persons likelihood to fall), considered at high risk for falls. Resident 16's care plan dated [DATE], listed interventions of providing Resident 16 with non-slip mats at the bedside and to frequently remind Resident 16 to use the call light for assistance. A subsequent Fall Risk care plan dated [DATE], listed low bed as a post fall intervention. During a concurrent observation and interview with CNA 20 on [DATE] at 9:35 am, CNA 20 confirmed that there were no mats at the bedside of Resident 16 and the bed was not in a low position. CNA 20 was not aware if Resident 16 ever used her call light. During a concurrent observation and interview on [DATE] at 9:40 am, LN 8 confirmed that no mats were at the bedside and the bed was not in a low position as was indicated in the care plan. During an interview with CNA 23 on [DATE] at 11:30 am, she reported that all CNAs are supposed to refer to the care directives located inside the resident's closet doors, for information on resident care and items each resident should have. CNA 23 did not know if Resident 16 was at a high risk for falls, needed bedside mats or a low bed, as they were not listed on the care directive. During an interview with CNA 22 on [DATE] at 4 pm, she stated that Resident 16 has not ever used the call light in the 4 months that she has been employed because she just can't remember. When asked if Resident 16 should have her bed in a low position, CNA 22 responded, I don't think so. If it were low we would have mats at each side on the floor. CNA 22 typically works the night shift but frequently works extra shifts because we are always short. Right now, I'm waiting for another CNA to come in to get residents up for dinner. It's just me on this side and everyone has to wait. During a telephone interview with FM 39, he states that he has not seen mats along side the bed or the bed in a low position, for Resident 16, as they told me they would. FM 39 also reports that Resident 16 does not use the call light because she forgets. She needs to be checked. A review of the facility's Fall Evaluation and Management policy, updated (MONTH) (YEAR), noted that If the total Morse Scale score is 45 or greater, the resident is considered as having High Potential for falls. Implement appropriate care plan interventions for management. 3. A review of Resident 17's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. difficulty walking and weakness. The Minimum Data Set (MDS, a resident assessment) indicated Resident 17 had a BIMS of 12 (considered alert and oriented) but that she was not responsible for her own medical decisions. The facility reported that on [DATE], Resident 17 was found by another resident, lying on the ground on an outside patio area. On [DATE], Resident 17 received x-rays at the local hospital which showed she had fractures to her left wrist and three fingers of her left hand. During an observation and interview with Resident 17 in her room, on [DATE] at 12:50 pm, she described how she likes to walk around the facility, especially to be outside and move about as she pleases. I try to let the nurses know but mostly, I forget. When describing her fall on the patio, Resident 17 reported that the night she fell she did not alert anyone. I laid there for quite some time. I couldn't tell you how long. I think I tripped over my cane. During an interview with LN 1 on [DATE] at 7:30 am, describing Resident 17, she reported that Resident 17 is impulsive with frequent bipolar manic episodes. She loves to be outside to see the sun and moon. LN 1 stated that Resident 17 needed frequent reminders to let staff know where she was going. During an interview with LN 9 on [DATE] at 2:50 pm, she stated that Resident 17 is hard to miss. She comes and goes on her own. A review of the facility's care plans titled Alteration in Safety, dated [DATE] and [DATE], listed Resident 17's Morse Fall Scale score a 75 (very high risk for fall), related to her history of falls and her potential for future falls. The review of the facility policy Fall Evaluation and Management updated (MONTH) (YEAR), indicated that if a resident has a total Morse score of 45 or greater, the resident is considered as having High Potential for falls. Appropriate care plan interventions for fall management are to be implemented. During an interview with LN 9 on [DATE] at 2:50 pm, she stated that there was no specific method to monitor Resident 17 in the courtyard to maintain safety. 4. The facility reported that Resident 3 had a physical altercation with Resident 4 in the hallway near his room on [DATE] around 7:15 pm resulting in Resident 4 sustaining a blue/purplish lump to her left eyebrow. Resident 5 was in the vicinity of the incident and came between Resident 3 and 4 which stopped the altercation. During an interview with Resident 3 on [DATE] at 4 pm, the resident admitted that he hit Resident 4 stating, She was bothering me by making noises and getting too close to me. When Resident 3 was asked why he did not call for a nurse to help remove Resident 4 from his space he laughed and replied, You've got to be kidding! It takes anywhere from ,[DATE] minutes for any nurse to come and help. I will take care of it myself cause there is no staff to help! During an interview with CNA 12 on [DATE] at 2 pm she stated that there were a few residents on the PM shift that used a hoyer lift (a mechanical device used to lift residents in and out of bed safely) for their showers that required two (2) CNA staff to operate during the entire showering process. This does only leave one (1) CNA to oversee the care for the other 18 residents on Station 3 and 4 and if we are short-staffed then we have no one to be supervising residents while we are giving the two-person shower. CNA 12 confirmed that she was assigned to care for Resident 3 on [DATE] on the PM shift, but she was not aware of the altercation. I may have been giving a shower at that time. The review of Resident 4's record showed that she had memory loss and confusion and she self-propelled her wheelchair throughout the facility. The record review for Resident 3 showed that he has a history of aggressive behaviors towards other residents including striking out, verbal outbursts and negative interactions with other residents. The Interdisciplinary Team notes documented six (6) altercations with other residents over a 10 month period from (MONTH) (YEAR) to (MONTH) (YEAR) ([DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). It was noted in his physician orders that he was prescribed medication for explosive mood changes on [DATE].

Based on observation, interview, and record review, the facility failed to provide comprehensive nursing and pain assessments and effective pain management, in accordance with the plan of care, for two of seven sampled residents (Residents 2 and 3) when: 1. Resident 3's increased and uncontrolled severe pain (on a scale of zero to 10, zero being no pain and 10 being the worst possible pain) from a pelvic fracture (broken pelvis) was not reported to the physician (MD, Medical Director), the Interdisciplinary team (IDT) did not assess or evaluate Resident 3's uncontrolled pain to ensure adequate pain management, and pain medication was not administered to treat Resident 3's pain, as ordered by the physician. These failures resulted in Resident 3 experiencing uncontrolled, severe pain that contributed to increased discomfort and decreased functional ability with ADL care (Activities of Daily Living- bed mobility, transfer, dressing, bathing, toileting, etc.) and therapy services. 2. Resident 2's severe pain was not treated effectively, the IDT did not adequately assess and evaluate Resident 2's uncontrolled pain to ensure adequate pain management, and pain medication was not administered for three days post fall nor timely when Resident 2 reported ineffective pain management. These failures resulted in Resident 2 experiencing increased and uncontrolled severe pain which contributed to refusals of ADL care and life sustaining [MEDICAL TREATMENT] treatment. Refer to F 312 and F 323. Findings: The facility's policy and procedure titled, Pain Management, revised 6/2016, directed facility staff to evaluate and attempt to manage/minimize pain in residents. The residents' pain level is evaluated every shift by the Licensed Nurse (LN), monitored and documented on the Medication Administration Record (MAR), using the Wong-Baker Pain Scale. When pain is not adequately controlled by current regimen, or if there is newly identified pain, the LN contacts the physician for consideration of new or modified treatment orders. 1. Resident 3's record was reviewed and indicated Resident 3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS, a resident assessment), dated 12/15/16, a Significant Change in Status Assessment, showed that Resident 3 required extensive assistance from staff and one person physical assistance in ADLs for the past 3 months. Resident 3 was re-admitted to the facility on [DATE], after a five day hospitalization for left zygomatic arch (disruption of bony arch at the outer border of the eye) fracture from a prior fall. Resident 3 did not have the capacity to make her own health care decisions. Resident 3's record contained physician's orders [REDACTED]. [MEDICATION NAME] (a strong narcotic pain medication) [MEDICATION NAME] (applied to the skin) patch 75 mcg/hr (micrograms per hour) every 3 days; [MEDICATION NAME] 50 mg (milligram) tablet, 2 tablets (100 mg) by mouth every 12 hours; [MEDICATION NAME] 650 mg by mouth every 4 hours as needed (PRN) for mild pain; [MEDICATION NAME] 50 mg by mouth every 6 hours PRN for moderate pain; and [MEDICATION NAME] 50 mg tablet 2 tablets (100 mg) by mouth every 6 hours as PRN for severe pain. The pain scale used to measure pain levels was 1-3= mild, 4-6=moderate, 7-9=severe, and 10 or above=worst possible. A review of the document titled, Physical Therapy Evaluation and Plan of Treatment, dated 2/15/17 (for the certification period from 2/15/17-3/13/17), indicated Resident 3 had 9/10 pain with movement that was intermittent and located at her low back area. Resident 3's pain exacerbated (worsened) during standing or walking. Resident 3's record indicated she had an unwitnessed fall on 2/26/17, and was sent to the emergency room (ER) for evaluation and returned to the facility. A review of the ER note, dated 2/26/17, indicated Resident 3 had reported to the Emergency Medical Services (EMS) personnel some complaints of pain behind and around her left ear, left shoulder and her left hip. Resident 3 complained of 6 out of 10 on a pain scale around her left ear. Resident 3's nurses notes were reviewed and indicated the following: On 2/26/17 (no time), Resident 3 fell in her room, hit her left ear/head, left upper arm, left hip. Sent to acute hospital for evaluation. On 2/26/17 at 12:45 pm, Resident 3 had returned from acute hospital and there was no injury related to the prior fall. On 2/26/17 at 6 pm, Resident 3 Complained of pain 10 out of 10 and received [MEDICATION NAME] 100 mg for pain. Responsible party (RP) was in and has a new DNR (Do Not Resuscitate) that she is filling out then will return it. She does have a UTI (urinary tract infection) but decided not to take any action and may seek comfort care . There was no documentation following the administration of the medication if the pain was relieved. On 2/27/17 (no time), Resident 3 continued to complain of left hip pain during the morning shift and that PRN medication was given to manage pain. Resident 3 had not gotten up for meals and refused to get up. There was no explanation in the record the reason for not getting up for meals. On 2/27/17 at 4 pm, Resident 3's physician was notified and received the order to transfer to acute hospital for x-ray of the left hip secondary to pain from the prior fall. There was no IDT note found in the record that discussed Resident 3's decline in ADL function and increased pain that resulted from the fall on 2/27/17. On 2/28/17 at 2 am, Resident 3 had returned from the acute hospital, x-ray showed a pelvic fracture and to follow-up with the ortho office in one week. A review of a pain assessment note, dated 3/1/17, indicated Resident 3 had hip pain. Resident 3 reported 6/10 (moderate pain) to 8/10 (severe pain). The onset of pain was noted as chronic and acute, and that the pain resulted in changes in activities, ADL function, and mobility. A review of the nursing note, dated 3/1/17 at 4 pm, indicated, Resident 3 .does appear to have increased pain rolling in bed . A review of the nursing note, dated 3/2/17 at 3 pm, indicated, Resident 3 was .unable to stand for increased time related to weakness . A review of the Medication Administration Record (MAR) for 3/2017 indicated Resident 3 reported 8/10 pain on 3/1/17 and 3/9/17, but did not receive PRN pain medication for the breakthrough pain of 8/10 (severe), as ordered. On 3/3/17 and 3/9/17, Resident 3 received [MEDICATION NAME] twice for her severe pain. A review of the Nurses' Progress Notes (weekly progress notes), dated 3/6/17, did not indicate how Resident 3's pelvic fracture condition was being monitored or treated. The section under disease diagnoses/health conditions was not completed (left blank). The weekly progress notes did not reflect Resident 3's current condition. The Resident Functional Performance Record (ADL Record) for 3/2017, was reviewed. The record consisted of percentage of meals taken, bed mobility, transfer, bathing, dressing, toileting, bowel and bladder function, etc., documented by the Certified Nursing Assistants (CNAs) on the back of the record sheet. The licensed nurse (LN) signed what was documented by the CNAs that shift which validated the report of care refusal. The record indicated: On 3/2, 3/7, 3/8 and 3/9/17, Resident 3 refused (R) dinner. On 3/2/17, Resident 3 refused dinner and liquids, but there was no LN signature acknowledging the refusal. Of the above refusals, there was no evidence nor documentation that an LN was notified of Resident 3's dinner refusals. On 3/3/17, Resident 3 refused care after 7:30 pm and refused to get dressed and help to get into bed. Notified the nurse. On 3/7/17, Resident 3 had been vomiting throughout the day. Notified the nurse and the daughter. Received some medicine for her upset stomach. On 3/9/17, Resident 3 refused to get up and dressed this morning. There were no changes to the plan of care found in the record. A review of the nursing notes, dated 3/2, 3/3, 3/7, 3/8 and 3/9/17, indicated there was no documentation that the MD was notified of Resident 3's condition and the reasons for Resident 3's meal and care refusals. There was no documentation that the MD was notified of the vomiting, and no order received to treat the vomiting at that time. The facility's policy and procedure titled, 24-Hour Report-Alert Charting, revised 9/2014, directed the facility staff to maintain a system for monitoring and communicating changes in resident condition. There was no plan of care developed and interventions identified by the facility to address Resident 3's refusals of ADL care. A review of the 3/2017 physical therapy treatment notes indicated: On 3/1/17, Resident 3 communicated pain using (faces) pain rating scale. Resident 3 had 5/10 pain with movement that was intermittent, located at the left hip pain, described as dull pain with weight bearing activities. Resident 3's response to treatment was poor tolerance; pelvic fracture; complained of left hip pain with movement; WBAT (weight bearing as tolerated). On 3/3/17, Resident 3's pain assessment was determined upon her behaviors exhibited when she pulled LLE (left lower extremity) away from the therapist. Resident 3's response to treatment was tolerated poor; LLE pain with movement; nursing notified; medicated. A review of the nursing note, dated 3/8/17 at 9 am, indicated, Resident 3 was unable to answer questions, has a change in level of consciousness (LOC), looks to be in distress, grimace on face, and moaning, which was not baseline for this resident. MD was notified and resident was supposed to have follow-up x-ray done today for pelvic fracture. Due to change of LOC, the MD clarified order to send to acute hospital for follow-up for pelvic x-ray and change in LOC . A review of the MAR, dated 3/8/17, indicated there was no breakthrough pain medication administered at the time when Resident 3 showed signs of pain when she was grimacing and moaning. During a concurrent observation and interview on 3/9/17 at 9:52 am, Resident 3 was awake, lying in her bed. Resident 3 stated she had not been feeling well lately, due to her recent fall on 2/26/17. Resident 3 stated she preferred to be in bed due to being uncomfortable and experienced increased pain every time she moved. On 3/9/17 at 2 pm, a concurrent interview and record review was conducted with CNA D. CNA D stated there had been a change in Resident 3's condition since the fall on 2/26/17. CNA D stated Resident 3 had expressed increased pain every time she was turned or changed when she grimace and moaned. CNA D stated Resident 3 had been refusing care, showers, and meals. CNA D stated Resident 3's condition had been communicated to the LNs. During an interview on 3/9/17 at 2:30 pm, CNA F stated since the last fall on 2/26/17, Resident 3 needed more assistance in transfers and feeding. CNA F stated Resident 3 complained of pain when being moved. An interview was conducted with CNA G on 3/9/17 at 2:50 pm. CNA G stated there was a change in Resident 3's condition when the fall on 2/26/17 occurred. Resident 3 needed extensive assistance from staff with ADLs. CNA G stated Resident 3 was observed expressing increased pain after the prior falls by grimacing and moaning. CNA G explained there has been a change in behavior with Resident 3 such as refusal of care; getting out of bed for meals and showers. CNA G stated LNs had been notified of any changes by documenting on the back of the ADL chart. A review of Resident 3's pain medication regimen on 3/9/17, indicated there was no change in pain medication since the pelvic fracture occurred after the fall on 2/26/17. During an interview and concurrent record review with the MD on 3/10/17 at 12 pm, he stated he was aware of the falls, but not aware of Resident 3's increasing pain resulting from the pelvic fracture sustained due to the fall. The MD stated if Resident 3 had increased pain, the LNs should be assessing and accurately monitoring her pain level so that the need for breakthrough PRN medication could be given. The MD confirmed that breakthrough pain medication was not administered, as ordered, as part of the plan of care. A review of a physician's orders [REDACTED]. During an interview with Resident 3's responsible party (RP) on 3/10/17 at 2:50 pm, she stated Resident 3 was not the same after her last fall on 2/26/17, which resulted in a pelvic fracture. RP stated that she received a phone call from a LN who told her that Resident 3 had a lot of pain in her left hip and needed to be sent to the hospital, where she was found to have a pelvic fracture. RP stated since then, she had visited the facility almost every day to see Resident 3. RP stated she observed Resident 3's pain through her facial expression and verbalization of where the pain was located. RP stated that Resident 3 would not move when in so much pain, and when she was being moved, that caused her to moan. RP stated Resident 3 had lived with her for a while and was taught how to ask what her pain scale was from 0-10. RP stated that during her visit on 3/9/17, she noticed increased pain in Resident 3 and informed the LN who was taking care of her during that evening shift, and explained to the LN how to determine if Resident 3 was in pain. RP stated she had a meeting with the Social Service Director (SSD) and the Director of Nursing (DON) asking to increase Resident 3's pain medication after the pelvic fracture. During an interview with LN B on 3/10/17 at 4 pm, stated Resident 3 was in more pain since her last fall on 2/26/17 when rolling in bed. On 3/13/17 at 10:15 am, a concurrent interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated he was responsible for auditing the ADL documentation at least weekly. The DSD stated the expectation for CNAs was to complete their audits as soon as possible. The DSD stated the CNAs should document on the back of the ADL charting any changes in residents' conditions, such as refusing care, showers, meals, etc., and the LNs were to sign it to acknowledge the problem. The DSD stated he was made aware of Resident 3's refusal of ADL care, but did not know the reasons for the refusals. The DSD confirmed Resident 3's refusals of care and episodes of vomiting were changes of condition and should have been reported to the charge nurse. The DSD confirmed there was no education provided to the CNA staff regarding Resident 3's refusals of care or what the facility would do to address it. On 3/13/17 at 11:05 am, an interview was conducted with the Certified Occupational Therapy Assistant (COTA). The COTA stated Resident 3 participated slowly with therapy and showed some signs of pain with movement. During an interview with LN C on 3/13/17 at 11:15 am, she stated the facility's process was to assess each resident for pain using the numeric pain scale (0-10), and the facial assessment if the residents were unable to verbalize their pain. LN C stated nurses were to document the pain scale and recheck at least an hour after the medication was given if it was effective. LN C stated nurses were to notify the physician if the pain was increasing or there was no relief from the medication. On 3/13/17 at 12 pm, a concurrent interview and record review was conducted with the DON and the Clinical Nurse Consultant (CNC). The DON stated the Interdisciplinary team (IDT, a group of different disciplines that meet to discuss resident care) was responsible to put all information together to assess Resident 3's pain and refusals of care and meals. The DON explained this was attained by interviewing staff, LNs every shift. The DON stated the MD should have been notified of Resident 3's changes in condition and that pain medication should have been given, as ordered, especially for breakthrough pain. The DON confirmed there were no new changes to the pain medication regimen. Both the DON and CNC confirmed that pain could be a factor in Resident 3 refusing care, showers, and getting out of bed. The DON and CNC both stated palliative care (comfort care) could have been provided to Resident 3. 2. A review of Resident 2's record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was readmitted to the facility on [DATE], after an unwitnessed fall which resulted in a facial fracture requiring stitches under her right eye. Resident 2 was unable to make health care decisions for herself and Spanish was her primary language. A review of the pain assessment interview section of the comprehensive MDS, dated [DATE], indicated Resident 2 reported no pain. The MDS indicated Resident 2 received scheduled pain medication The quarterly MDS, dated [DATE], indicated that Resident 2 was unable to answer the questions and the staff assessment indicated she had non verbal sounds, facial expressions and protective body movements one to two times in the past five days. The MDS indicated Resident 2 received both scheduled and as needed pain medication. Review of an X-ray report, dated 2/27/17, indicated Resident 2 had a head injury from an unwitnessed ground fall with a large bruise to right eye with a cut. The report indicated Resident 2 had a right orbital (socket which holds eye) break with tissue damage and swelling. Review of the physician's orders [REDACTED].= no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, and 10 or above = worst possible pain). If Resident 2 was unable to verbalize a pain level, an additional scale using facial expressions was used for residents unable to communicate verbally. Expressions observed by care providers range from a happy face showing no hurting (zero pain) to a crying face (indicating the worst pain = 10). A less happy face = 1, 2 or 3 for mild pain, a middle range of grimacing = 4, 5 or 6 for moderate pain, and a sad face without tears = 7, 8, or 9 indicate severe pain on the pain scale. From 3/3/17 through 3/5/17, the MAR pain rating scale indicated that the nursing assessment of Resident 2's pain was 0 (no pain) for six out of eight nursing shifts. There were no verbal nor facial expressions documented on the MAR. On 3/4/17, at 4:00 pm, a nursing note indicated that Resident 2 refused all solid food, preferred to drink and not chew, Stating painful secondary to periorbital fracture. A new order was obtained from the MD to change Resident 2's diet to a drinkable puree (foods made into a smooth form) consistent carbohydrate renal (specific for end stage kidney disease) diet. A review of a Pain Evaluation note, dated 3/5/17, used as guidance by facility staff to assess Resident 2's pain, indicated she had aching and sharp pain at her head, back and face. The note indicated Resident 2 had severe to worst possible pain. A review of a MAR, indicated on 3/5/17 at 9:00 am, Resident 2 had moderate facial pain and received Tylenol 650 mg one tablet. A post administration assessment of the Tylenol on 3/5/17, indicated Resident 2 had no change in pain. A review of physician's orders [REDACTED]. No [MEDICATION NAME] was administered at this time. A review of nurse's notes, dated 3/5/17, on the evening shift, indicated Resident 2 had no complaints of pain due to routine pain medications given around the clock. A review of the nurse's notes, dated 3/6/17 at 5 am, indicated Resident 2 had complained of severe pain pointing at her head and back and was given two tablets of [MEDICATION NAME], 24 hours after she reported moderate, unrelieved pain. A Pain/Interdisciplinary Care Plan (IDT, a group that analyzes residents' plan of care), initiated 10/2/16 and updated 3/6/17, indicated Resident 2 was unable to verbalize discomfort and the non verbal pain scale was to be used such as facial grimacing, sounds of distress, and restlessness. The care planned interventions for Resident 2 indicated she was to be evaluated for a decline in physical functioning and the physician was to be notified of a change in condition for pain. A review of the shower sheets, dated 3/6/17 and 3/9/17, indicated Resident 2 refused a shower and/or bed bath, and that Resident 2 indicated she refused the shower on 3/6/17, due to pain and was hurting from going to [MEDICAL TREATMENT]. Review of the Resident Functional Performance Record (records activities for daily living) for the month of March 2017 included a note documented by a CNA, dated 3/6/17, that indicated Resident 2 was in pain, refused to shower, and the nurse was notified. A nurse's note, dated 3/8/17, on the morning shift, indicated Resident 2 refused to go to the [MEDICAL TREATMENT] center. A nurse's note, dated 3/9/17, on the evening shift, indicated Resident 2 refused to shower two times on the shift and appeared to have a decreased desire for treatment. A review of a Meal Monitoring Flowsheet for March 2017 was reviewed and indicated Resident 2 refused meals on 3/4/17, breakfast and lunch, on 3/5/17 refused lunch, on 3/8/17 refused lunch and on 3/10/17, refused breakfast, lunch and dinner. The percentages of meals consumed averaged 10-60 percent from 3/4-3/12/17, with one entry of 75 percent on 3/7/17. A review of the intake and output record, dated 3/7 to 3/10/17 for Resident 2, revealed the record was incomplete; did not include intake or output totals. On 3/10/17 at 10:05 am, Resident 2 was observed sleeping in bed. During a interview on 3/10/17 at 10:15 am, CNA F stated Resident 2 refused her shower yesterday, did not eat breakfast, and was very sleepy. CNA F stated, It's hard to tell what she is saying. CNA F described how Resident 2 required more assistance with transferring since the fall. When asked how she knows if Resident 2 has pain, CNA F says she looks at her face for grimacing. On 3/10/17 at 2:55 pm, during an interview, LN B stated that Resident 2 refused to go to [MEDICAL TREATMENT] today. When asked how she assessed Resident 2's pain, LN B stated that she relied on the CNAs working with the resident to report the information to her. A nurse's note, dated 3/10/17, on the night shift, indicated Resident 2 complained of severe pain and was given PRN [MEDICATION NAME]. The LN documented the [MEDICATION NAME] was effective, however, it only lasted two hours after administration. The MAR indicated Resident 2 was given two tablets of [MEDICATION NAME] for severe pain four times on 3/10/17. A nurse's note, dated 3/11/17, on the morning shift, indicated Resident 2 was crying out periodically throughout the shift and a PRN order was obtained for breakthrough pain. The physician was notified of the increased pain and refusal of [MEDICAL TREATMENT]. A physician's orders [REDACTED]. A review of the MAR indicated Resident 2 received two tablets of [MEDICATION NAME] on 3/11/17 at 4:30 pm, and the MS was administered on 3/11/17 at 10:10 pm, twelve hours after receiving the order. There were no IDT notes found in the record nor provided by the facility. During a concurrent interview on 3/13/17 at 10:42 am, CNA L stated Resident 2 was sleepier and asking to go to bed earlier and not getting up in the morning since the fall. CNA L stated Resident 2 whines and then motions to the area of her body that has pain. During a concurrent interview and record review on 3/13/17 at 12:30 pm, the DON and CNC confirmed Resident 2's pain could have been a factor in her sleeping more, eating less, and refusing showers and [MEDICAL TREATMENT]. When asked about the delay in pain medication for Resident 2, the DON replied, The IDT was supposed to put all the information together about Resident 2's change of condition and increased pain. The DON stated that the physician should have been notified and the medication should have been given timely when Resident 2's pain medication was ineffective.

Based on observation, interview, and record review, the facility failed to consistently implement adequate supervision, appropriate assistive devices, and revise a plan of care to ensure that Residents 2 and 3, were safe and free from avoidable falls when: 1. Resident 2 had six falls, two with major injury requiring hospitalization . The failure to implement resident specific care plans with fall interventions resulted in multiple fractures to her face, wrist and right arm (twice) which required hospital assessment and intervention. 2. Resident 3 had seven falls over a 2 month period from 12/14/15 to 2/15/16 that were unwitnessed and was placed in a Broda chair (specialized positioning chair) without evaluation for safety. This put Resident 3 at risk for harm due to her requiring assistance from staff to safely walk or transfer and was capable of independent mobility. Findings: A facility policy titled, Fall Evaluation and Management, updated January 2016, indicated the center implements a fall management plan based on resident evaluation. Certain factors may require implementation of specific care plan measures if a high potential for falls (fall score 13 or greater), residents who are confused or who have fallen in the past three months. A Licensed Nurse (LN) requests a medication review from the providing pharmacy, the Interdisciplinary team (IDT) reviews the response and notifies physician of results. The LN reviews transfer status, if therapy unavailable and determines safest method or transfer. Post fall documentation a IDT note that includes a brief summary of the fall, nursing evaluation, actions taken, who was notified and residents condition. Orthostatic vital signs, updates the care plan and care directives with new interventions. Alerts the following shifts to fall and care plan/directives changes per protocol. 1. A review of Resident 2's record indicated she was admitted to the facility 2/24/14, with [DIAGNOSES REDACTED]. Resident 2 was able to make health care decisions for herself. A fall risk evaluation dated 2/12/16, indicated Resident 2 did have falls risks though was not a high risk for falls. Fall #1 An Interdisciplinary (IDT) note dated 1/8/16, indicated Resident 2 fell in her room while closing her shades lost her balance and bumped her head. The IDT determined due to the amount of personal belongings in room, Resident 2 was unable to effectively use walker. A therapy referral was made to evaluated assistive devices to determine if Resident 2 could use a cane instead of a walker due to the identified issue of a cluttered room. Therapy was unable to allow the use of a cane due to Resident 2's balance problem. A quarterly Minimum Data Set (MDS, a resident assessment) dated 4/25/16, indicated Resident 2 was independent for mobility and transfers. A review of physician's orders [REDACTED]. On 2/24/15, Celexa (depression, anxiety) 20 milligrams (mgs) every day for depression. On 8/14/15, Fentanyl patch (strong opioid pain medication) 100 micrograms (mcg) put on skin every 72 hours for chronic pain. On 8/7/14, Meclizine HCL 25 mg as needed every eight hours for dizziness. On 10/8/15, Ativan (anxiety) 0.5 mg every eight hours as needed for verbal expression of distress. On 4/11/16, Coumadin (blood thinner) 2.5 milligrams (mgs) once a day for [DIAGNOSES REDACTED]rapid, irregular heart beat). Opioid, antidepressants, anti-anxiety and anti-dizziness medications have side affects which can put individuals at risk for falls. The blood thinner medication increased the time needed for the body to create clotting thus increasing the risk for bleed times. Fall #2 A nursing note dated 5/2/16 at 6 pm, indicated Resident 2 fell and had a purple raised lump to her forehead and complained of severe pain to her right arm. Resident 2 was sent to hospital for evaluation. A hospital consultation report dated 5/2/16, indicated Resident 2 fractured her right arm near where she had a shoulder replacement in the past. Resident 2 had right knee and ankle pain. The treatment was to place Resident 2's right shoulder in a splint and follow up in seven days. Resident 2 was discharged back to the facility on [DATE]. A review of an IDT note, dated 5/3/16, indicated Resident 2 was assisting her roommate make her bed when she tripped on a rug next to the bed and fell . The intervention to prevent further falls was to remove the rug. A fall risk evaluation, dated 5/2/16, 5/4/16, and 5/18/16 indicated Resident 2 continued to be at risk for falls although not a high risk. A new physician's orders [REDACTED]. A significant change in condition MDS, dated [DATE], indicated Resident 2 had a decline in function ability from being independent during transfers and now was a one person extensive assist with mobility and transfers. Fall #3 An IDT note, dated 6/6/16, indicated Resident 2 had a witnessed fall on 6/3/16 at 2 pm, while ambulating to the bathroom she tripped on the wheel on her chair. This fall resulted in a blood filled bruise to her forehead measuring 3.5 by 3.5 centimeter (cm), skin tear measuring 2.3 by 1.0 cm to her right cheek, and a skin tear measuring 1.5 by 0.2 cm to her right eyebrow. The IDT note indicated Resident 2 has some confusion and laboratory blood tests were ordered by the physician. A fall risk evaluation dated 6/3/16, indicated Resident 2 did have a high potential risk for falls. A nursing note dated 6/7/16 at 1:45 am, indicated Resident 2 had fallen unwitnessed in her room between two beds. Resident 2 stated she was in severe pain holding her right rib area which she had previously injured on 6/3/16 fall. Resident 2 had a skin tear measuring 3 by 2.5 cm to the left elbow and was sent to hospital for evaluation. Resident 2 returned from hospital with a left sprained elbow and left rib contusions. A nursing note, dated 6/7/16 at 2 pm, indicated Resident 2's roommate was found during the shift assisting her to transfer from bed to wheelchair. Resident 2 continued to try to self-transfer to the restroom without assistive devices and help from staff. Resident 2's family was aware of her unsafe actions and were in the process of designating an Responsible party (RP, decision maker) due to signs of a cognitive decline. The IDT note dated 6/10/16, indicated Resident 2 had increased confusion over the past few weeks and was having more falls lately. Resident 2 was her own RP. The IDT indicated it was difficult to place fall interventions for Resident 2 due to her agreeing to safety interventions of bed/chair alarms, therapy, assistive devices, and room modifications until time to implement, then she refused. A risk factor identified for Resident 2 was her roommate who often sought assistance from her. There was a lot of personal property in the room creating increased risks for falls. The IDT plan was to implement bed/chair alarms and a room change for safety of the resident. An IDT note, dated 6/15/16, indicated Resident 2's RP refused a room change for increased safety. An IDT note, dated 6/16/16, the Executive Director (ED) witnessed Resident 2 assisting her roommate to remove her sweater. ED and Social Services (SS) spoke with RP about high risk for falling behaviors and that staff felt the resident would be safer in a different room. No room change was made at this time. Fall #4 A nursing note dated 7/16/16 at 6 pm, indicated Resident 2 was found face down in bathroom. Resident 2 had a bloody nose and right arm pain. Resident 2 was sent to hospital for evaluation. An emergency room report, dated 7/16/16, indicated Resident 2's [DIAGNOSES REDACTED]. A post procedure progress note from the hospital dated 7/16/16, indicated Resident 2 had a right arm fracture and this was the second fracture in the same arm in two months. The right arm was procedurally reduced (moved back into alignment). A hospital radiology report, dated 7/16/16 at 8:45 pm, indicated Resident 2 had multiple nasal bone fractures and a right cheek bone arch fracture. A hospital verbal order form, dated 7/17/16, indicated Resident 2 was to have a sitter (one on one monitoring) as needed. Resident 2 was discharged back to facility on 7/22/16, with instructions to have right arm in splint, no physical therapy and to be reevaluated in two weeks. An IDT note, dated 7/21/16, included a family conference that discussed the return of Resident 2 to facility. The discussion was around the safety interventions and noncompliance with not using assistive devices when ambulating, turning the bed/chair alarms off, and not asking for help from staff. The family stated Resident 2 indicated, she was not going to ask for help every time she needed to use the bathroom. The RP had in the past declined a room change and agreed upon Resident 2's return to the facility, to a new room with one on one (1:1, continuous supervision) on the morning and evening shifts to assist in redirection from unsafe choices. The IDT discussed with the family the risks of osteoporosis (bone loss) and continued falls which may result in ongoing pathological (disease caused) fractures. A nurse's note, dated 7/25/16 at 10 am, indicated Resident 2 was evaluated by a Speech Therapist (ST). Resident 2 had multiple facial fractures to prevent a thorough oral exam and staff was educated not to put in upper dentures, and her diet was changed to pureed textures secondary to fractures. Resident 2 stated she did not want any male CNAs to help her with dressing and toileting. The 1:1 monitoring was in place for the morning and evening shift from 7/22-9/1/16. Resident 2 was on a 1:1 during the evening shift only starting 9/2/16. An IDT note dated 9/19/16, indicated the 1:1 monitoring for Resident 2 was discontinued for the evening shift on 9/19/16, due to Resident 2 doing very well due to following safety interventions and remembering to ask for help. IDT indicated they would continue to monitor and review progress. There was no IDT note that indicated any monitoring was in place for Resident 2 and no evaluation of the effectiveness of the 1:1 safety intervention. Fall #5 A nurse's note, dated 10/13/16 at 9 am, indicated Resident 2 had an unwitnessed fall which resulted in two black eyes, a right knee cut and her nose was bleeding (previously fractured). An IDT note, dated 10/14/16, indicated Resident 2 stated she went to the restroom and no one stayed with her. The investigation by the facility determined her call light was not initiated, her bed alarm was disconnected and she independently went to bathroom. The new safety intervention was to move the bed alarm to where Resident 2 cannot reach it to disarm, encourage her to use the call light for assistance, and she was not to be left alone in the bathroom. 1:1 monitoring remained discontinued. During a concurrent observation and interview on 10/21/16 at 3:30 pm, Resident 2 was observed with two black eyes sitting in her chair. Resident 2 stated she had recently fell because her call light was not being answered and she needed to go to the bathroom. She stated I tried to wait but could not. Resident 2 stated there are often long call wait times. Resident 2 stated she does not like to have male CNAs take care of her. Resident 2 stated she had peed her pants waiting for someone to help her to the bathroom. When questioned about the sitter she had in the past, Resident 2 stated she liked having the one to one attention. Fall #6 A nurse's note dated 10/24/16 at 7:45 pm, indicated Resident 2 was found sitting on the floor and stated she had fallen ambulating without assistance. Resident 2 had a 5 cm bruise in the center of her back and 3 cm by 2 cm wide skin tear to her right elbow. An IDT note dated 10/25/16, indicated Resident 2 was interviewed and stated a CNA assisted her to the bathroom and left her alone, she then walked back to her chair and fell backwards. IDT interview indicated the male CNA, stated Resident 2 asked her to leave for privacy (her stated preference no male CNAs). The IDT concluded without 1:1 staffing, Resident 2 would continue to fall despite current interventions in place. 1:1 monitoring resumed on the evening shift. The IDT and Care Plan interventions were not followed for the last fall on 10/25/16, when a male CNA was assisting Resident 2 with toileting and she was left alone in the bathroom. During a concurrent observation and interview on 11/3/16 at 3:30 pm, Resident 2 was sitting in her chair, her facial bruises were gone, and a sitter (1:1) was present. Resident 2 stated she had fallen again with no injuries and that is why someone was with her all the time. The sitter stated Resident 2 was being monitored 24 hours due to her falling again. During a concurrent observation and interview on 11/15/16 at 1:50 pm, CNA H was sitting with Resident 2. Resident 2 stated her shoulders are painful and medication helps with it. Resident 2 recalled the last two falls and stated they were bad. Resident 2 pointed out there was a box and an extra walker in front of her closet. CNA H confirmed the large television box and extra walker needed to be removed. The roommate stated their room was cluttered. During an interview on 11/17/16 at 12:35 pm, Licensed Nurse (LN) J stated Resident 2 was on 1:1 on evenings only and needs more supervision due to her impulsiveness. LN J stated they have to keep a close eye on her due to her not waiting for staff to ambulate to the bathroom. LN J stated Resident 2 was weaker since her last two falls. During a concurrent record review and interview on 12/1/16 at 9:55 am, the Medical Director (MD) stated a pharmacy and IDT review of Resident 2's medications should have been done when looking for contributing factors to her multiple falls. The MD stated 1:1 should be used as an intervention if it works. During a concurrent record review and interview on 12/1/16 at 4 pm, six falls and interventions implemented for Resident 2 were discussed with the Director of Nursing (DON). The DON stated Resident 2 was noncompliant with the safety interventions related to the use of assistive devices, asking for help from staff and bed/chair alarms. The DON confirmed Resident 2's roommate often requested assistance from Resident 2 and their room was cluttered, which put Resident 2 at risk for falls. The DON stated the family and Resident 2 refused to move until after the fourth fall and second fracture of her right arm. The DON was unable to state when safety of a resident versus family requests would outweigh the risk factors of falling. The DON confirmed there was no pharmacy review request submitted to the pharmacy consultant in relation to the repeated falls for Resident 2. The DON stated Resident 2 was started on a 1:1 for supervision related to noncompliance and multiple falls. The 1:1 monitoring was in place for the morning and evening shift from 7/22-9/1/16. Resident 2 was on a 1:1 during the evening shift only starting 9/2/16 and discontinued completely on the 9/19/16, due to Resident 2 doing very well. The DON was unable to state what clinical criteria was used to determine Resident 2 was doing better and no longer required 1:1 supervision on the evening shift. The DON stated the evening shift was chosen for the 1:1, due to their being more staff on the day shift and she was asleep on the night shift. The DON confirmed Resident 2 fell two more times after the 1:1 was discontinued and it was resumed on 10/25/16, due to her high fall risk factors. 2. A review of Resident 3's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident 3 was alert and oriented (cognitively intact) with fluctuating disorganized thinking. Resident 3 was dependent on assistance from staff for bed mobility, transfer, dressing, toilet use, bathing, and walking. Resident 3's assistive devices included a walker and a wheelchair. Resident 3 was occasionally incontinent of urine and was continent of bowel. A review of the admitting nurse's assessment, dated 12/14/15, indicated Resident 3 had a cast (used to stabilize a fractured bone for healing) to her left arm. No indication as to how the arm had been injured was found. The area of the assessment to identify whether a fall had occurred, prior to admission, was left blank. On 12/15/16 during an interview at 11:10 am, LN M stated that during a comprehensive review of Resident 3's record, no indication was found to explain how the left arm was fractured. A review of the nurse's notes, dated 12/15/15 at 3 am, indicated Resident 3 was not safety conscious with transfers. A review of the CNA charting, dated 12/2015 and 1/2016, indicated Resident 3 required limited to extensive assistance from staff for bed mobility, and transfers. A review of the fall risk care plan, initiated on 12/17/16, indicated Resident 3 had a history of [REDACTED]. The care plan indicated Resident 3 required assistance with elimination (toileting). Interventions did not include supervision. Falls: During an interview and concurrent record review, on 11/18/16 at 1:50 pm, the ADON confirmed the falls and interventions as described below. Fall #1 An IDT note, dated 12/21/15, indicated an unwitnessed, no injury, fall occurred on 12/21/15 at 12 am, when Resident 3 was found on the floor of the bathroom sitting with her back to her wheelchair. Resident 3 was attempting to transfer, without assistance, to the toilet. The fall assessment indicated the root cause of the fall was the amount of assistance in effect. Interventions in place at the time included a wheelchair alarm which was sounding. New interventions included encouraging call light use and clipping the call light to her clothes. Fall #2 An IDT note, 12/31/15, indicated an unwitnessed, no injury, fall occurred on 12/28/15 at 11:15 pm, when Resident 3 was found on the floor next to her bed. Interventions in place included a bed alarm which was sounding. New interventions included an every two hour toileting schedule and a bowel and bladder evaluation which was done. Fall #3 An IDT note, dated 1/4/16, indicated an unwitnessed fall, with injury, occurred on 12/31/15 at 8:15 pm, when Resident 3 was found on the floor next to her bed. The bed alarm was sounding. New interventions included her bed in low position with a padded mat next to the bed, and removing the bed controls since the resident had placed her bed in the highest position. No interventions were found regarding increasing the level of supervision for Resident 3, who had three falls in a period of two weeks while unsupervised. Fall #4 An IDT note, dated 2/11/16, indicated an unwitnessed, no injury, fall occurred on 1/30/16 at 6:30 pm, when Resident 3 was found on the floor after slipping out of her Broda chair, which had been put in place four days prior to the fall on 1/26/16. New interventions included a referral to therapy for Broda versus wheelchair assessment. During an interview, and concurrent record review, on 11/15/16 at 10:45 am, Occupational Therapist K (OT K) confirmed the Broda chair. During a concurrent review of OT and Physical Therapy (PT) services, no evidence was found regarding a therapy evaluation for appropriateness of using the Broda chair for Resident 3. OT K confirmed that therapy was not involved in the decision to place Resident 3 in the Broda chair. OT K explained the Broda chair was usually not used for residents who are independent with mobility because it is restrictive and becomes a safety hazard as a result. During an interview with on 11/15/16 at 11:10 am, OT L explained she had seen Resident 3 for OT services regularly during her stay in the facility. OT L stated Resident 3 was capable of ambulating (walking), but was not capable of ambulating safely without assistance. OT L stated Resident 3 lacked safety awareness and would try to ambulate anyway. OT L remembered intervening on several occasions when she observed Resident 3 getting up from her wheelchair and ambulating in the hall way and/or in her room. OT L stated Resident 3 was capable of self-propelling in her wheelchair with her feet and moved about the facility independently. OT L stated use of the Broda chair would restrict this movement. During an interview on 11/15/16 at 11:25 am, the Director of Rehab (DR) concurrently reviewed the computerized PT notation, dated 12/16/15 - 1/12/16, and 2/18 - 3/23/16. The notation indicated Resident 3 was capable of ambulating short distances with the assistance of a front wheel walker, and use of a gait belt (held by staff for stabilization). A review of the device evaluation form, dated 1/26/16, included a section titled; is device considered a restraint for this resident? after which the box titled No was checked. Documentation after the if no, why section included an explanation that the resident was more mobile with weight shift and it encouraged the resident to spend more time out of bed. No evidence was found regarding evaluation for the effect of the Broda chair on Resident 3's ability to independently self-propel in her wheelchair. No interventions were found regarding increasing the level of supervision for Resident 3, who had three falls in a period of six weeks while unsupervised. Fall #5 An IDT note, dated 2/8/16, indicated an unwitnessed, no injury, fall occurred on 2/7/16 at 10:50 pm, when Resident 3 was found sitting on the floor next to her bed and stated she wanted TP (toilet paper). The bed alarm was sounding. New interventions included a perimeter mat surrounding her bed. No interventions were found regarding increasing the level of supervision for Resident 3, who had experienced five falls, in a period of seven weeks, while unsupervised. Fall #6 An IDT note, dated 2/11/16, indicated an unwitnessed, no injury, fall occurred on 2/10/16 at 9:55 pm when Resident 3 was found sitting on the floor next to her bed with alarms sounding. The noted indicated Resident 3 had used the bathroom at 9 pm. After six evening falls had occurred (from 12/14/15 - 2/10/16), the IDT identified that most of Resident 3's falls occurred during the evening shift and recommended an anti-anxiety medication be given to the resident at 6 pm routinely. No interventions were found regarding increasing the level of supervision for Resident 3, who had experienced six falls in a period of seven and a half weeks while unsupervised. Fall #7 An IDT note, dated 2/16/16, indicated an unwitnessed, no injury, fall occurred on 2/15/16 at 3 pm, when Resident 3 had attempted to ambulate to the bathroom without assistance and slid down the wall onto the floor. The note indicated Resident 3 had been offered toileting at 1:30 pm (one and a half hours prior). No new interventions were found regarding increasing the level of supervision for Resident 3, who had experienced seven falls in a period of eight weeks while unsupervised.

Based on interview and record review, the facility failed to ensure an effective pain management program for Resident 1 when, after the discovery of a significant injury of unknown origin (a broken thigh bone with bruising, swelling, and warm to touch), when a narcotic pain medication ([MEDICATION NAME]) was not administered for more than 26 hours after it was ordered, while the resident demonstrated physical symptoms of significant pain (crying out, facial grimace, moaning, yelling and resistance with movement due to pain). As a result, Resident 1's pain was not relieved and timely treatment was not provided, which resulted in significant physical symptoms of pain (crying out, facial grimace, moaning, yelling and resistance with movement that adversely affected the resident's ability to achieve her highest level of physical and psychosocial well-being. Resident 1 was transferred to a hospital for further evaluation and treatment. Resident 1's pain was treated with IV [MEDICATION NAME] (a potent narcotic), and she underwent surgical repair of her broken femur (thigh bone). Resident 1 was hospitalized for [REDACTED]. Findings: Resident 1's clinical record was reviewed. Admission documentation indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her MDS (Minimum Data Set, a standardized assessment), dated 5/9/14, she was totally dependent on staff for mobility and assistance with daily activities. The resident did not speak or understand others and her cognition was severely impaired. Resident 1 was noted to "always" be incontinent. A review of Resident 1's physician's orders [REDACTED]. On 7/16/14 at 2:45 pm, during an interview, CNA A stated that on 6/12/14, she and CNA B discovered a large bruise on Resident 1's right upper leg while turning the resident in bed and the resident was unable to say what happened due to her severe cognitive impairment, further stating that the resident required a Hoyer lift (a mechanical lifting device). CNA A stated that the bruise was reported to the charge nurse. On 7/16/14 at 2:40 pm, CNA B was interviewed. CNA B stated, while cleaning up the resident, he and CNA A saw a "huge" bruise on the back of the resident's right upper leg, "from the hip to the knee." On 6/12/14 at 3:00 pm, the physician (MD A) ordered nursing staff to monitor Resident 1's bruise. On 6/12/14 at 6 pm, MD A ordered [MEDICATION NAME] 5/325 milligrams by mouth every four hours, as needed for moderate pain (On a scale of 1-10, moderate pain is rated as 4-6/10). Review of the nurses's notes from 6/12 to 6/14/14 indicated the following: On 6/12/14 at 9:00 pm, Resident 1 had a bruise, pain and swelling to her right knee which was reported to Resident 1's physician and responsible party (legally appointed decision maker). On 6/12/14 at 10:00 pm, the Licensed Nurse (LN) staff was waiting for authorization for the [MEDICATION NAME] from the facility pharmacy. Resident 1 had pain when her leg was moved. On 6/13/14 at 4:30 am, Resident 1's right knee was "very swollen, warm to touch, skin tight around right knee, when leg moved resident cries out. Called pharmacy for authorization for [MEDICATION NAME] from e-kit (emergency drug kit-a limited supply of medications available in the facility for use when timeliness of medication administration is necessary to meet the residents treatment needs). Still awaiting authorization." On 6/13/14 "am," Resident 1 "complained of pain only during movement as evidenced by resistance and yelling. Called pharmacy to obtain e-kit authorization. Right leg bruised and warm to touch. Called physician's (MD A) office to obtain X-ray order to right leg due to pain, swelling, bruising, unavailable on Friday. Called MD A phone number, no answer. Will follow up later. Endorsed to evening shift for follow up." On 6/13/14 at 10:00 pm, Resident 1 exhibited "symptoms of pain to right knee, medicated with [MEDICATION NAME]." Resident 1 had bruising, warmth, and swelling. "Grimaces when moving head of bed. Contacted MD. Obtained order for X-ray of right knee. X-ray scheduled for 6/14/14." On 6/14/14 at 4:30 am, Resident 1 had "right knee pain when moved. Right knee remains swollen with skin tightness, increased warmth to area with some bruising." On 6/14/14 "am," "X-ray procedure done this morning. Awaiting results. Resident moans when leg is moved." On 6/14/14 at 3:00 pm, X-ray results were still pending. Resident 1 was having pain with transfers/movement. On 6/14/14 (no time indicated), "Telephone order from MD A - Resident sent to emergency room (ER) for fracture of right femur evidenced by X-ray report." A nurses note, dated 6/14/14 and timed at 7:30 pm, read, "Sent Resident to ER (emergency room ), per MD order due to fracture of femur as revealed by X-ray done in am (morning)." During an interview on 7/16/14 at 11:10 am, Licensed Nurse (LN) A confirmed that Resident 1's right knee on the evening of 6/12/14 was quite swollen, and the resident had pain with movement of her leg. She stated that she left Resident 1 in bed without moving her, as she did not have pharmacy authorization to give [MEDICATION NAME]. During an interview on 7/17/14 at 9:55 am, LN B stated that Resident 1 "was in a lot of pain" on the night of 6/12 to 6/13/14, and that she was unable to get authorization from the pharmacy to administer [MEDICATION NAME] from the emergency medications kit. Resident 1's Medication Administration Record [REDACTED]. [MEDICATION NAME] was not given until 6/13/14 at 8:30 pm, over 26 hours after it was ordered, when Resident 1's pain was rated 6/10. Review of the hospital's emergency report, dated 6/14/14, indicated Resident 1 had an x-ray of her right lower extremity that showed a "right supracondylar fracture, knee." A physician's history and physical examination [REDACTED]." Resident 1's pain was treated with intravenous (IV-through the vein) [MEDICATION NAME] (a potent narcotic), and she underwent surgical repair of her broken femur. Resident 1 was hospitalized for [REDACTED].

Based on interview and record review, the facility failed to provide one of one sampled residents (Resident 1) with the necessary services to attain his highest practicable physical well-being, in accordance with his plan of care which required that the resident had a staff member with him at all times. The resident was found on the floor in his room with a broken hip when the assigned staff member left the room to help another staff member. Resident 1 was transferred to the hospital for treatment and expired 19 days after the fall. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with Certified Nursing Assistant (CNA) Staff A on [DATE] at 6:10 am, she stated she worked the night shift, starting at 10:30 pm on [DATE], and ending at 6:30 am on [DATE]. She had been assigned to care for Resident 1 on that shift, as her only resident. She explained that Resident 1 was a 1:1, which meant that Resident 1 was the only resident she was assigned to provide services for and watch during her shift. She stated that Resident 1 had been identified as having multiple behavior issues and that she would re-direct him, as his behavior dictated. She stated that the resident had been up most of the night, making his bed and wandering around the room. "I got him changed and cleaned up and he laid down about 4:,[DATE]:45 am. I thought he was asleep. I left the room to help CNA Staff B get other residents out of bed. I was only gone about 20 minutes and when I went back in the room with Licensed Nurse (LN) Staff C, we found him on his back on the floor. This happened about 5:30 am. I never should have left him." CNA Staff A acknowledged that she had relief staff assigned so she could take her breaks and not leave Resident 1 alone. LN Staff C, the charge/medication nurse, was interviewed on [DATE] at 6:35 am. She stated that she thought CNA Staff A was in Resident 1's room with him, as his door was shut. She was giving medications across the hall from Resident 1's room. "I found out that CNA Staff A had left Resident 1's room to assist CNA Staff B. I went into Resident 1's room right after CNA Staff A did and found Resident 1 on the floor. CNA Staff A should never have left the resident alone as she was assigned to him as an 1:1." In an interview with CNA Staff B on [DATE] at 6:45 am, she stated that 1:1 means "not to leave the resident." Interviews were conducted on [DATE] from 12 pm through 1:40 pm with five CNAs (CNA Staff D, E, F, G, and H) who had been assigned on different shifts to care for Resident 1 from [DATE] through [DATE] as 1:1 care givers. All of these staff stated that an 1:1 meant that they were not to leave the resident alone at any time. They explained that another staff member was assigned to cover for them whenever they needed to take their meal or other breaks. In an interview with Administrative Staff 20 on [DATE] at 10 am, she stated that 1:1 means "staff stays in the room with the resident ,[DATE]." In an interview with Administrative Staff 21 on [DATE] at 8:25 am, she stated that the facility does not have a policy or procedure for their 1:1 staffing. Resident 1's record was reviewed with Administrative Staff 20 on [DATE] at 10 am and the following were noted: The MDS (Minimum Data Set-an assessment tool), dated [DATE], documented that Resident 1 was able to walk and transfer from his bed with oversight supervision and set-up help from staff only and the IDT (Interdisciplinary Team) Progress Note, dated [DATE] at 8 am, indicated, "1:1 to be re-implemented on noc (night) shift at this time." The Nursing Staffing Assignment and Sign-In Sheets for [DATE] were reviewed with Administrative Staff 22 on [DATE] at 12:15 pm. It showed that CNAs were assigned an 1:1 for Resident 1 and the relief assignments clearly indicated for each shift; day, evening, and night. The facility failed to consistently implement the plan of care as revised by the IDT on [DATE] due to CNA Staff A leaving Resident 1 unattended when he was on an 1:1. During the time that CNA Staff A was not in the room, Resident 1 fell and sustained a fractured right hip. The Resident expired 19 days after the fall, in the hospital.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) had a drug regimen that was free from unnecessary drugs when he was given the antipsychotic medication (use for stabilize mood and reduce anxiety, tension, and [MEDICAL CONDITION]), [MEDICATION NAME], without adequate monitoring, without adequate indications for its use, and in the presence of adverse consequences. In addition, the facility failed to adequately monitor the combination of two additional psychotherapeutic medications, [MEDICATION NAME] (used for irritability in psychiatric disorders) and [MEDICATION NAME] (used for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder (Mood disorder of an abnormally elevated arousal energy level and periods of depression) with the [MEDICATION NAME] for adverse consequences. These failures resulted in actual harm to Resident 1 when he fell and sustained a broken hip. Resident 1 was transferred to the hospital for treatment and expired 19 days after the fall. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review on [DATE] indicated that Resident 1 shared a room with his wife of [AGE] years, since he was admitted almost three years ago. Sometime before Christmas 2013, Resident 1 became agitated toward his wife, so the facility moved his wife to another room. The MDS (Minimum Data Set-an assessment tool) showed an acute change in the mental status from the resident's baseline from [DATE] to [DATE]. After Resident 1's wife was moved to another room in the facility, Resident 1 had increasing behaviors manifested by his wandering into other rooms and striking out at staff. In an interview with Resident 1's physician on [DATE] at 4 pm, he stated that the resident was having increased behaviors exhibited by his striking out at staff. The rationale he used for prescribing the antipsychotic medication, [MEDICATION NAME], on [DATE], was he had used this medication on other residents and "it works." He further stated that Resident 1 had [MEDICAL CONDITION]. When asked if he knew that the FDA (Federal Drug Administration) had a black box warning that read, "antipsychotics are not indicated for the treatment of [REDACTED]. the resident had." The physician was not aware nor did he check to see if any behavioral interventions had been attempted by the staff, prior to the administration of the [MEDICATION NAME]. He said that nursing staff had called him to report that Resident 1 was striking out at staff and asked him what he wanted to do. That was when he ordered the [MEDICATION NAME]. The physician stated that he chose not to follow the Pharmacy Consultant recommendations on [DATE] to "re-evaluate continued use of [MEDICATION NAME]. Consider a dose reduction to 2 mg (milligrams) BID (twice per day)." The rationale for this recommendation was "[MEDICATION NAME] side effects and extrapyramidal symptoms (EPS) commonly occur with the use of therapeutic doses of conventional 'typical' antipsychotic medications (common side effects include increased risk for falls and restlessness)." The recommendation also included the statement, "If this therapy is to continue, it is recommended that the prescribed document an assessment of risk verses benefit, indicating that it continues to be a valid therapeutic intervention for this individual." The physician stated during the interview, "I know that 6 milligrams is what the resident needed as he was striking out at staff." He also stated that he would have noted any risk verses benefit analysis in the medical record but could not remember exactly where. There was no risk verses benefit information from the physician in Resident 1's record. This was confirmed by Administrative Staff 20 on [DATE] at 10 am. During an interview with the Pharmacy Consultant on [DATE] at 12:50 pm, he restated his recommendation made to the facility in his report dated ,[DATE] through [DATE]. He said that he had asked for a review of the [MEDICATION NAME] because it may be time for the evaluation of the use of it and may be time for a gradual dose reduction or why such a recommendation would not be appropriate. "I saw a nursing note and thought it may be appropriate to give Resident 1 a sleeping aid because he seems to act out with more behaviors when he doesn't sleep the night before. He was not receiving a sleep aid." The Pharmacy Consultant stated during a second interview on [DATE] at 1:05 pm, that he "tuned into [MEDICATION NAME] because I don't see it (that antipsychotic medication) used anymore." In an interview with Administrative Staff 21 on [DATE] at 8:25 am, she stated that Resident 1 had been sharing a room with his wife in the facility for the past three years. She said that Resident 1's dementia had gotten worse and his behaviors had escalated which resulted in him striking out at his wife in ,[DATE], so the facility moved the residents to separate rooms. She stated, "we are keeping them separated." In an interview with Family Member A on [DATE] at 12:40 am, he stated that his parents had been married for [AGE] years and that his Dad, Resident 1, "always took care of Mom. He looked out for her. After the room move, Dad would wander, looking for her." During the record review on [DATE] at 10:30 am, the following were noted: a. The Care Plan conference notes, dated [DATE], read, "Resides with wife. Very attentive to the needs of his spouse. No [MEDICAL CONDITION]" (medications with mood-altering properties); b. The Interdisciplinary Notes, dated [DATE], read, "Pt (patient) wife/roommate has recently been moved to new room. Resident does exhibit some increased behaviors d/t (due to) looking for his wife"; c. The Care Plan conference notes, dated [DATE], showed that the resident had a "deteriorating condition, exhibiting increased signs of confusion and agitation. Resident is currently being separated from wife unless in public areas-i.e. hallways, lunch rooms-etc."; d. The Nurses Notes, dated [DATE] at 12:30 am, indicated that the resident was "aggressive and striking out at staff-pacing throughout the hallway-waking up other residents"; e. The Nurses Notes, dated [DATE] at 5:30 am, read, "resident was found with wife in room-CNA (Certified Nursing Assistant) attempted to remove wife and resident into the hallway-Resident became agitated and struck CNA. Yelled, [***] leave us alone-she's my wife!" f. The Nurses Notes, dated [DATE] at 1 pm, indicated that Resident 1 "wandered into another resident's room-became agitated"; g. The Nurses Notes, dated [DATE] at 10 pm, read, "toward end of shift about bedtime, he started entering other residents' rooms using bad language toward staff."; and h. The Nurses notes on [DATE], [DATE], [DATE], [DATE] and [DATE] showed that the resident was "very restless-up in room going through belongings,...restless-slept short periods,...entering other's rooms,...wandering in room-fidgeting with bedding-in closet,...very restless & (and) agitated-striking out at staff,...episodes of agitation and verbal aggressiveness with wandering in halls." During an interview with CNA Staff B on [DATE] at 6:45 am, she stated, "I would sit by his (Resident 1's) bed and he would pat my hand. He thought I was his wife." The medication orders were reviewed for Resident 1 on [DATE] and the following were noted: a. On [DATE], [MEDICATION NAME] 500 mg (milligrams) was ordered by mouth every 12 hours for dementia with behavioral disturbances evidenced by aggressive behavior; b. On [DATE], [MEDICATION NAME] 2 mg was ordered three times per day for a total of 6 mg per day for "[MEDICAL CONDITION]/dementia with behavioral disturbances as evidenced by aggressive behavior"; c. On [DATE], [MEDICATION NAME] 0.5 mg by mouth was ordered twice per day for dementia with behavioral disturbances as evidenced by aggressive behavior and striking out; and d. On [DATE], [MEDICATION NAME] 0.5 mg by mouth was ordered every 12 hours, as needed, (in addition to the scheduled [MEDICATION NAME]) for dementia with behavioral disturbances as evidenced by aggression and striking out. The behavior management sheets for [MEDICATION NAME], and [MEDICATION NAME] showed that there were no behaviors throughout all three shifts from [DATE]-11, 2014, but according to the nurses notes, there were multiple behaviors noted. The ADL (Activities of Daily Living) weekly progress notes showed a decline in Resident 1's ability to use the toilet, personal hygiene, bathing and dressing from [DATE] through [DATE], a five-week period of time. a. The resident was able to independently use the toilet until [DATE] through [DATE] when he required supervision to the toilet; b. The resident was able to take care of his personal hygiene needs with supervision and set up only from [DATE] through [DATE]. He declined the week of [DATE] through [DATE] (the week he was started on the [MEDICATION NAME]) through [DATE]. He now required limited assistance (support) to meet his personal hygiene needs; c. The resident required supervision and set up only for bathing from [DATE] through [DATE]. He declined the week of [DATE] through [DATE]. Resident 1 required staff assistance to meet his personal hygiene needs; and d. The resident was independent in dressing from [DATE] through [DATE]. He declined the week of [DATE] through [DATE], when he required staff assistance with dressing. The Federal Drug Administration (FDA) issued a FDA alert on [DATE] to healthcare professionals that stated, "[MEDICATION NAME]" was not indicated for the treatment of [REDACTED].) Lexi-Comp online shows a U.S. Boxed Warning for the use of [MEDICATION NAME]. "Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk of death compared to placebo." The FDA only approved [MEDICATION NAME] to treat epileptic [MEDICAL CONDITION], [MEDICAL CONDITIONS] for the prevention of migraines. [MEDICATION NAME] was never approved for the treatment of [REDACTED]. Additional reactions may include anxiety, excitation, agitation, hostility, aggression, rage, sleep disturbances/[MEDICAL CONDITION]. The potential adverse reactions for [MEDICATION NAME] as listed in Lexi-Comp online include: restlessness, [MEDICATION NAME] effects ([MEDICATION NAME] effects typically include constipation, dry mouth, blurred vision, dizziness, and slowing of urination), sedation and orthostatic [MEDICAL CONDITION] (a form of low blood pressure in which a person's blood pressure suddenly falls when standing up). Elderly patients taking [MEDICAL CONDITION] drugs may be at increased risk for falling and consequent [MEDICAL CONDITION]. Adverse behavioral effects include exacerbation of psychotic symptoms, paranoid reactions, lethargy, restlessness, [MEDICAL CONDITION], nocturnal confusion, bizarre dreams, and [MEDICAL CONDITION]. The potential adverse reactions to the medication [MEDICATION NAME] as listed in Lexi-Comp online include: weakness, dizziness and nervousness. The American Geriatrics Society 2012 Updated Beers Criteria for potentially inappropriate medication use in older adults identified Benzodiazepines to be strongly avoided due to increased risk of impaired cognition, [MEDICAL CONDITION], falls, and fractures. Due to increased sensitivity in this age group, avoid use for treatment of [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure that one of 24 sampled residents who entered the facility did not develop a pressure ulcer, received necessary treatment and services to promote healing, and that the pressure ulcer did not worsen (Resident 4) when he was not assessed as a high risk for pressure ulcers after his third week, did not provide a pressure relief mattress, did not care plan that he should be repositioned at least every 2 hours, did not develop a care plan when he had a condition change or developed a Stage II pressure ulcer (Partial thickness, loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled or sero-sanginous (blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (Bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.), inconsistent documentation of wound care, and provide services for showering. These failures contributed to Resident 4's Stage 3 pressure ulcer (Full thickness, skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling into the area. Bone/tendon is not visible or directly palpable.) in the gluteal fold area (tailbone) Findings: Resident 4, an [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/13 at 8:15 am, LN K stated that Resident 4 had remained at the facility since his admission. An initial admission Minimum Data Set (MDS, an assessment tool), dated 2/27/13, indicated that Resident 4 was rarely understood, required extensive assistance from staff for transfers and personal hygiene. Resident 4 was assessed not to have any pressure ulcers (skin breakdown caused by pressure and lack of circulation) on admission. He was assessed to be frequently incontinent of bladder and bowel (the inability to have control of bladder and bowel function). According the plan of care, dated 3/1/13, Resident 4 had multiple daily episodes of urinary incontinence and bowel incontinence all of the time. An Initial Skin Integrity Evaluation assessment, dated 2/20/13, assessed Resident 4 to be at moderate risk for the development of pressure ulcers. A plan of care titled, "Potential for Skin Integrity Impairment Care Plan was initiated on 2/20/13, with a list of approaches/interventions that included turning as needed/tolerated and pressure reducing mattress. The following week on the Initial Skin Integrity Evaluation, dated 3/1/13, Resident 4 was assessed to be at high risk for the development of pressure ulcers, however, there was no change in the plan of care to provide further interventions to address the increase in pressure ulcer development risk. The following week on the Initial Skin Integrity Evaluation, dated 3/8/13, Resident 4 was no longer assessed as a high risk, based on information that he walked occasionally, as slightly limited on mobility, and had adequate nutrition. According to the Activities of Daily Living (ADL) care plan, dated 2/16/13, Resident 4 did not walk in his room or hallway and was dependent on assistance for bed mobility. According to the Fall Risk care plan, on 3/8/13, Resident 4 attempted to get out of chair with Certified Nursing Assistant (CNA) assistance and lost his balance and both him and the CNA ended up on the floor. According to the ADL flow sheet, on 3/8/13, Resident 4 required extensive assistance/limited assistance with bed mobility, eating, toileting, and transfers. There was no supporting documentation that Resident 4 was walking. According to the Weight Record on 2/26/13, Resident 4 weighed 220 pounds and on 3/5/13, he weighed 207.8 pounds, a loss of 12 pounds in 1 week. A change of condition MDS, dated [DATE], disclosed that Resident 4 had a decline in mental status with communication, was always incontinent of bladder and bowel and had significant weight loss. There were no changes in approaches/interventions in his written plan of care for potential for skin breakdown. There was no documentation that a Skin Integrity Evaluation Form was conducted, per policy. According to the facility's "Skin Integrity Policy," dated 8/2009, the facility was to have "a systematic approach and monitoring process" for evaluating and documenting residents skin integrity to promote healing. In the event that a resident developed a pressure ulcer, care would be provided to treat, heal and prevent further pressure ulcers. In addition, under process "3. The nurse completes the Skin Integrity Evaluation Form quarterly or when there is a significant change in condition and establishes a care plan as indicated." There was no documented evidence that a skin integrity evaluation was conducted nor any changes made to the plan of care. The facility's Nurses notes from 2/16 to 8/29/13 were reviewed. On 5/11/13 at 12 am, documentation indicated open areas to Resident 4's right and left buttocks area. On 5/19/13 at 13:30 pm, nursing staff documented that the left buttocks area was healed and that the right buttocks open area was now at the gluteal fold area (tailbone). According to the Wound Evaluations, the date of onset of the pressure ulcer was 5/8/13. One Assessment, dated for 6/6/13, indicated that Resident 4's gluteal crease was a Stage II pressure ulcer (broken open superficial skin tissue from pressure) measuring 2 centimeters (cm) by 3 cm and a depth of 0.1 cm. On 6/5/13, during the am shift, nursing staff documented that the gluteal crease had worsened, contained eschar (blackened dead tissue) and that a new care plan had been implemented. There was no new care plan found in the record. On 6/24/13 at 2:45 pm, nursing documented that the right and left buttocks ulcers were healed, that the gluteal area contained 90% of yellow slough and that the wound edges were macerated (moistened). The entry read that a referral to Physical Therapy (PT) would be made for sharps debridement (cutting and clearing away of the slough and dead tissue so that the wound bed was healthy and healing can occur). The record showed no evidence that a referral to PT or a debridement was conducted. There was no documentation in the Interdisciplinary Progress Notes about Resident 4's gluteal pressure ulcer worsening (notes generated from a meeting where all the administrative department personal meet to discuss problems and develop a plan). The pressure ulcer care plan was initiated on 6/24/13, a month and a half after identifying a pressure ulcer on 5/8/13. The approach/interventions included repositioning every two hours, use of a pressure reduction mattress, and notify the physician if the pressure ulcer failed to demonstrate progress in healing within fourteen days. On 8/27/13 at 1:50 pm, during an interview with Licensed Nurse (LN) H, she stated that Resident 4 developed a Stage III pressure ulcer on 7/15/13. A MDS, dated [DATE], indicated that Resident 4 was still unable to complete a brief mental interview, and was dependant on staff for bed mobility, transfers, toileting, and personal hygiene. It identified that Resident 4 now had a Stage III pressure ulcer measuring 4 centimeters (cm) in length by 1 cm wide, and 0.1 cm deep (an open full thickness skin loss that may include undermining or tunneling). Under, "Skin and Ulcer Treatments," the MDS read that Resident 4 had a pressure reducing device for his bed. A second care plan for pressure ulcer was initiated on 7/26/13, which omitted the approach/intervention of using a protective device such as a pressure reduction mattress. Both care plans were in the record. From 8/26 to 8/29/13, Resident 4's bed was observed to not have a pressure reducing device on his bed nor were there any pillows observed in his room for turning and repositioning him off his pressure ulcer. On 8/29/13 at 8:35 am, Admin Nurse O confirmed that Resident 4 had just a mattress on his bed and that there was no special pressure reducing mattress or overlay in place. The following weekly Wound/Skin Evaluation and Documentation of Resident 4's Stage III pressure ulcer measurements were as follows: 7/15/13- length 4 cm, width 1 cm, and depth 0.1 cm. 7/22/13- length 3 cm, width 1 cm, and depth 0.2 cm. 7/29/13- length 2 cm, width 0.5 cm, and depth 0.1 cm. 8/5/13 - length 4 cm, width 1 cm, and depth 0.1 cm 8/12/13- length 4 cm, width 1.5 cm, and depth 0.1 cm, 8/19/13- length 4 cm, width 1.5 cm and depth 0.1 cm On 8/29/13 at 9:50 am, Resident 4's Family member was observed asking Admin Nurse O if Resident 4 was receiving his showers. Admin Nurse O stated that he had been receiving bed baths. Resident 4's Family Member was interviewed on 8/29/13 at 10:15 am. She stated that they had been asking for him to have showers, because he is incontinent of stool and urine. She stated that it had been an issue ever since he had been admitted to get the facility to give him a shower. She stated she felt it would also help clean his wound. A review of Resident 4's Shower/ Bath Sheet indicated: During the 31 days of May 2013, Resident 4 received 4 showers and the rest of the month he received partial bed baths. For 30 days during June 2013, Resident 4 received 6 showers and partial bed baths the rest of the month. For the 31 days in July of 2013, Resident 4 received 4 showers and for August 2013 he only received 2 documented showers. According to the care plan, "ADL Function Care Plan," dated 3/25/13, an approach/interventions included assistance with shower as scheduled, and as needed. The National Pressure Ulcer Advisory Panel (NPUAP) advises to consider all bed/ chair bound residents or those who can not reposition themselves at risk of the development of pressure ulcers. The NPUAP recommends that all residents are assessed at the time of admission, at regular intervals and when a change of condition occurs. Recommended interventions include frequent daily assessments, turning and repositioning schedules, pressure reducing mattresses, wedges, pillows and referrals to specialists when a treatment plan is not effective.

Based on observation, interview, and record review, the facility failed to ensure the necessary care and services were provided to four of 14 sampled residents (Residents 1, 2, 5 and 10)when: 1. The facility failed to provide an effective pain management program and administer pain medication to Resident 10, as ordered by her physician, to alleviate her pain. This failure resulted in the resident experiencing moderate pain (6, on a scale of 0-10; 0 being no pain and 10 being the worst pain) which impacted her physical mobility and had the potential to negatively impact her psychosocial well being, and has the potential for residents who have pain to not have their pain relieved and impact their function, mobility and quality of life. Refer to F 425. 2. The facility failed to ensure receipt of pertinent information after [MEDICAL TREATMENT] (a process of filtering the blood for people with kidney failure) treatments for 2 of 14 sampled residents (Residents 1 and 2) when: Five of five [MEDICAL TREATMENT] forms reviewed were incomplete for Resident 2. Ten out of 24 (of the most recent [MEDICAL TREATMENT] treatments) [MEDICAL TREATMENT] Transfer Forms were missing post (after treatment) [MEDICAL TREATMENT] weights for Resident 1. These failures to obtain this information increased the potential for after treatment [MEDICAL TREATMENT] complications to go unobserved, medications not given to be missed, and information necessary to the care of both residents to not be documented, increasing the risk for complications. 3. The facility failed to assess pain in a timely manner for 1 of 14 sampled residents (Resident 5). This failure had the potential to adversely affect the recognition and management of the resident's pain, which can impact the resident's function, mobility and quality of life. Findings: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Resident 10 on 11/19/13 at 10 am, she stated she was admitted to the facility at about 3 pm on the afternoon of 11/17/13. Resident 10 stated her pain level was a "6", indicating moderate pain (On a pain scale where zero means no pain and 10 being the worst pain). Resident 10 said she did not understand why pain medication which her doctor had ordered was not available to be given to her until midnight. During an interview with Resident 10 on 11/21/13 at 11:30 am, she stated she limited the amount of moving around in bed, and did not get out of bed on 11/17/13, in order to minimize her pain because there was no medication available to give her. The "Physician order [REDACTED]. A document titled, "Nursing Admission Evaluation," dated 11/17/13, was reviewed and indicated Resident 10 was admitted to the facility on [DATE] at 4:30 pm. Section 3 titled, "Alteration in Comfort" indicated, "actual pain-yes." A document titled, "Admission Assessment, Pain Evaluation Record," dated 11/18/13 and completed by the Director of Nursing (DON), indicated Resident 10 had sharp hip pain, rated "Painful (no relief with conservative strategies" which affects Resident 10's ability to sleep and perform activities of daily living (personal self care). It indicated the pain lessens with medications and is made worse by movement. Resident 10's "Pain-Interdisciplinary Care plan," developed on 11/19/13 by the DON, indicated that Resident 10 exhibited pain through verbal statements and facial grimacing. The care plan goals included relief of pain within one hour of pain medication administration and pain would be controlled to a pain scale of 0-4. The care plan included the intervention that the facility would provide "pain medication, as ordered by the physician." During an interview with LN B on 11/19/13 at 5:30 pm, she stated she had been the nurse caring for Resident 10 when she was admitted on [DATE]. She stated Resident 10's pain level was a "6", indicating moderate pain. LN B stated she had wanted to medicate Resident 10 with pain medication, but she could not access the narcotic medication from the emergency kit until the pharmacy granted permission. LN B stated she called the pharmacy four times in the seven hours following the residents admission, attempting to get authorization to remove pain medication from the emergency kit, in order to medicate Resident 10. LN B stated authorization from the pharmacy did not arrive until the next shift. During an interview with LN A on 11/20/13 at 2:50 pm, she stated getting access to narcotics in the emergency kit was "a constant ongoing problem which has been reported to management numerous times." During an interview with the General Manager (GM) of the facility's pharmacy on 11/21/13 at 2:30 pm, he stated the pharmacy received the first request to access the pain medication for Resident 10 in the emergency kit on 11/17/13, at 5:17 pm. The physician gave his authorization for the narcotic pain medication to the pharmacy at 8:30 pm. and the pharmacist did not grant the facility narcotic emergency kit access until 11:50 pm, approximately six hours after having received the initial request and three and one half hours after the physician granted his authorization. When asked to explain the delay in access of pain medication for Resident 10, the GM stated, "The pharmacist had to prioritize requests." During an interview with the Assistant Director of Nurses (ADON) on 11/21/13 at 10:30 am, she stated the facility expectation is for nursing to contact an administrative authority if they are unable to receive medications for residents from the pharmacy in a timely manner. She further stated the facility expectation was for new admission pain medications to be given within one to two hours of the residents admission into the facility. The ADON confirmed the facility did not provide pain medications to Resident 10 in an acceptable timeframe, and did not follow their process when administration was not notified at the time of the event of their inability to access narcotic medications. 2. a. Review of Resident 2's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 went out of the facility three times a week to another facility for [MEDICAL TREATMENT]. Review of Resident 2's [MEDICAL TREATMENT] Forms, dated from 10/5 through 10/17/13, indicated: One form was not dated by the facility or the [MEDICAL TREATMENT] staff; Another form was dated 10/5/13 by the facility but had a different date of 10/7/13 documented by the [MEDICAL TREATMENT] staff; Another form that had not been filled out by the [MEDICAL TREATMENT] facility on 10/8/13; and Two forms that had to be resent to the [MEDICAL TREATMENT] provider because they had not been returned to the facility with the resident on 10/15 and 10/17/13. During an interview on 11/20/13 at 8:50 am, the Director of Nurse's (DON) stated the facility uses a [MEDICAL TREATMENT] Transfer Form which they fill out with the status of the resident, prior to the resident leaving the facility. This allowed the [MEDICAL TREATMENT] facility to see if there were any important changes that had occurred since the resident's last visit and what the resident's current condition was. The DON stated the [MEDICAL TREATMENT] staff were to fill out the bottom of the form and return it with the resident at the end of their [MEDICAL TREATMENT] treatment, so the facility staff would know what the current weight of the resident was, what medications they had received while at [MEDICAL TREATMENT], and if there were any problems or special instructions to be aware of. The DON stated the [MEDICAL TREATMENT] facility did not always return the form when the resident returned to the facility and if it was returned, the form was not always completed. She stated this has been an ongoing problem. 2. b. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received [MEDICAL TREATMENT] treatments three times per week. According to the facility's policy and procedure for [MEDICAL TREATMENT], dated 6/2004, the facility communicates with the [MEDICAL TREATMENT] center using the [MEDICAL TREATMENT] Transfer Form. The policy and procedure also called for "...the [MEDICAL TREATMENT] center to provide the following information upon the resident's return from [MEDICAL TREATMENT]: Wet and dry weights (the residents' weights before and after [MEDICAL TREATMENT])." During a record review on 11/19/13 at 3:15 pm, it was noted that [MEDICAL TREATMENT] Transfer Forms with post [MEDICAL TREATMENT] weights were missing for ten out of the 24 most recent [MEDICAL TREATMENT] treatments that Resident 1 received. In a concurrent interview, the Assistant Director of Nursing (ADON) and Licensed Nurse (LN) F confirmed that there were missing [MEDICAL TREATMENT] Transfer Forms for October and November 2013. The November 2013 Physician order [REDACTED]." During the above interview, the ADON and LVN F confirmed that the facility was not weighing residents when the [MEDICAL TREATMENT] Transfer Sheets were not returned with the residents after [MEDICAL TREATMENT]. The facility's Weights Policy, dated 11/2012, stated, "For residents receiving [MEDICAL TREATMENT], the weight recorded is the most recent post [MEDICAL TREATMENT] weight. This weight is recorded on the Weight Record form in the resident's medical record..." During a concurrent interview and record review on 11/19/13 at 3:15 pm, the ADON and LN F confirmed that there were only two weights recorded on Resident 1's Weight Record for October and November 2013, and that all of Resident 1's post [MEDICAL TREATMENT] weights should have been recorded on the Weight Record. 3. Resident 5 was admitted to the facility on [DATE] for short term rehabilitation after surgical repair of a broken femur (thigh bone). According to the facility's policy and procedure for Pain Management, dated 9/2009, residents should be assessed for pain at admission using the Pain Evaluation Record. During a concurrent interview and record review on 11/21/13 at 7:45 am, the ADON confirmed that a Pain Evaluation Record was not completed for Resident 5 until 11/5/13, five days after the resident was admitted to the facility. She stated that it should have been done within 24 hours of the resident's admission.

Based on observation, interview, and record review, the facility failed to ensure an effective pain management for one of 24 sampled residents (Resident 16) severe pain of 8 out of 10. This failure resulted in Resident 16 unnecessarily suffering severe pain and anxiety several times daily. Findings:A record review revealed that Resident 16, an elderly female in her nineties, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/26/13 at 8:40 am, during an initial tour of the facility, Resident 16's roommate stated that Resident 16 was in pain "all the time." Resident 16 stated that she was feeling anxious because she was short of breath and was experiencing pain in her chest. Resident 16 was verbalizing her distress by soft moaning. Review of the Medication Administration Record [REDACTED]. There was no documentation that these medications were effective to relieve her symptoms. No pain medication was given. Initial nursing assessment, dated 8/20/13, showed that Resident 16 was alert and oriented to person and place. Resident 16's pain level was assessed to be severe, 8 out of 10 (where zero was "no pain" and 10 was "worst possible pain"). According to the pain scale, mild pain level was 1 - 3, moderate pain was 4 - 6, severe pain was 7 - 10.Resident 16's physician orders, dated 8/20/2013, showed orders for the following medications for pain/anxiety management: -[MEDICATION NAME] 0.5 mg (milligrams), to be given every four hours as needed for anxiety;-Tylenol 650 mg, to be given every four hours, as needed for mild pain (1-3);-[MEDICATION NAME] 5/325 mg, to be given every four hours, as needed for moderate pain (4-6); and-[MEDICATION NAME] 100 mg, to be given every six hours, as needed (documented as a physician's telephone order, dated 8/23/13) for moderate pain (4-6).-No medication for severe pain (7-10) was orderedResident 16's MAR, dated 8/2013, showed the following administration of the medications for a pain level of "8" except for one time on 8/26/13:-[MEDICATION NAME] was administered four times on 8/21/13;-[MEDICATION NAME] and [MEDICATION NAME] were administered together two times. [MEDICATION NAME] was administered a third and fourth time alone;-On 8/23/13, [MEDICATION NAME] and [MEDICATION NAME] were administered together two times for anxiety and pain, and a third time when she was moaning in pain; -On 8/24/13, [MEDICATION NAME] and [MEDICATION NAME] were administered together two times for anxiety and pain. The nurse did not determine the effectiveness after one dose of pain medication;-On 8/25/13, [MEDICATION NAME] and [MEDICATION NAME] were administered together two times for anxiety and pain. [MEDICATION NAME] was administered a third time for a pain; -On 8/26/13, [MEDICATION NAME] was not administered. [MEDICATION NAME] was administered one time together with [MEDICATION NAME] (a medication to relieve shortness of breath). [MEDICATION NAME] was administered one time for a pain level of 5 out of 10, but the nurse did not document the effectiveness of this dose;-On 8/27/13, [MEDICATION NAME] was administered with [MEDICATION NAME] for anxiety and pain. [MEDICATION NAME] was administered a third and fourth time alone. The nurse did not document the effectiveness of all 4 doses; and-On 8/28/13, [MEDICATION NAME] and [MEDICATION NAME] were administered together four times for anxiety and pain. [MEDICATION NAME] was administered a fifth time alone. On 8/29/13 at 9:45 am, during an interview, Resident 16 stated that she had frequent pain and that her current pain level was eight out of 10. Review of the 8/2013 MAR indicated [REDACTED]. On 8/28/13 at 8:10 am, during an interview, LN Y explained the facilities process to address resident pain. LN Y explained that addressing resident pain timely was one of highest priorities for the medication administration nurse. LN Y stated that the resident' pain should be assessed as immediately as possible, and hoped that pain medication could be administered within five minutes of the assessment. If the pain medication was not due to be given yet and the resident was having breakthrough pain, she would try non-medication interventions. LN Y stated that if the resident was still in pain, she would notify the resident's physician regarding pain management needs. If anxiety was present, she would try non-medication interventions, administer medications, as necessary, and notify physician of the residents condition, as needed.On 8/29/13 at 10:45 am, during an interview, Licensed Nurse (LN) Z confirmed that Resident 16 was admitted after experiencing traumatic injuries that resulted in pain. LN Z confirmed that when the physician did not order routine pain medication for Resident 16 upon admission, the nursing staff should have notified the physician that Resident 16 was requiring multiple medications daily for severe pain and anxiety, although the medications given were ordered to treat moderate pain and anxiety. LN Z confirmed that the pain management interventions currently in place, were not effectively treating Resident 16's severe pain. On 8/29/13 a review of facility's undated Pain Management policy directed: -Residents are assessed at admission ... as needed when their condition related to pain changes or as deemed appropriate by a nurse using the ... prn medication review .... -When pain is identified or there is a change in condition, the nurse contacts the physician for appropriate treatment orders. -When an as needed (PRN) dose is administered, the nurse should document on the reverse side of the MAR, the medication given, the reason and the pain evaluation score. After the PRN medication has had time to take effect, the nurse documents results/effectiveness and resulting pain evaluation score to determine the effectiveness of the PRN pain medication.

Based on interview and record review, the facility failed to monitor and supervise one of three residents when his low blood pressure increased his risk for falling. This resulted in a fall and a hip fracture requiring surgery. (Resident 1) Findings: Resident 1 was first admitted to the facility on [DATE], following a stay at an acute care hospital where he had been treated for [REDACTED]. tract infection (bacteria in the bladder and/or kidneys), and multiple cardiovascular (heart and blood vessel) disease processes. He had received three hemodialysis treatments (HD; the process of cleansing the blood of waste by sending the blood through a filtering machine, and where blood volume is reduced). According to the National Institute of Health website (www.nhlbi.nih.gov; www.ninds.nih.gov), a normal range for blood pressure (BP) is from 120/90 to 90/60, and "orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position... It may be caused by hypovolemia (a decreased amount of blood in the body), from the excessive use of diuretics (medications to reduce excess fluids), vasodilators (medications used to lower the BP)...or medical conditions such as diabetes. Symptoms, which generally occur after sudden standing, include dizziness, lightheadedness, blurred vision, and syncope (temporary loss of consciousness)." In a "Discharge Summary" from the acute care hospital, dated 5/10/11, the physician dictated that Resident 1 had diagnoses of "Orthostatic hypotension and presyncope (dizziness preceding fainting) due to blood pressure medications." It also specified that particular medications and dosages were changed to improve the blood pressure problem. A discharge medications list that came from the acute care hospital, dated 5/10/11, read, "Dosage change" for Lasix (a diuretic) and for metoprolol (to prevent hypertension, high blood pressure), seven new medications were started; and eight other medications were stopped. The facility's standard admission orders Rehabilitation potential: Good", and listed Resident 1's medications including Aldactone (aids in the elimination of excessive body fluids), and Lasix, Flomax (to improve the flow of urine by relaxing the enlarged prostate), and metoprolol. Orders also included that Resident 1 was to have his blood sugar level checked three times a day before meals and at bedtime, to receive insulin (to reduce blood sugar) as needed, and was to continue HD three times a week. According to the Nursing Drug Handbook (2010), and per Lexi-comp-Online (a nationally recognized drug information resource), Aldactone, Lasix, Flomax and metoprolol each carry warnings of two or more adverse side effects of dizziness, fatigue, orthostatic hypotension, weakness, vertigo (disabling sensation of surroundings spinning or tilting), confusion, lethargy (mental and physical sluggishness), ataxia (shaky movements and unsteady walking), asthenia (loss of strength), syncope (fainting), and somnolence (trance-like sleepiness). All four medications have an alert to carefully monitor for a drop in BP, which can lead to these adverse effects. A physical therapy evaluation, dated 5/11/11, for Resident 1, read, "impairments...contractures (stiffing of joints and loss of strength and mobility) in both hands, stiffness in both knees, forward-flexed posture, shaky movement control, functional decline, and poor energy." On 5/11/11, the physical therapist documented in his notes, "With treatment (HD) today, patient became dizzy upon arising. Patient has had orthostatic hypotension in hospital. Monitor." A fall risk evaluation form for Resident 1, dated 5/12/11, had an incomplete assessment of 11 of the 12 items listed under evaluation of "Gait/Balance." The only item assessed was that Resident 1 required the use of an assistive device for mobility. In the section, "Medications", no additional point was added for, "a change in medication and/or change in dosage...." Under evaluation of "Predisposing Diseases" the nurse documented "0". The incomplete assessment, resulted in Resident 1 being scored at "low risk" for having a fall. A "Fall Risk" care plan (CP), dated 5/12/11, did not include Aldactone among the listed medications, listed no diagnoses, instructed staff to, "monitor for dizziness/vertigo" and "monitor blood pressure each week." The "Vital Sign" record showed BP checks for Resident 1, with no time specified, 115/79 on 5/10/11, 116/69 and 125/75 on 5/11/75, and 93/61 on 5/12/11. A night shift nursing note, dated 5/13/11 at 2 am, documented Resident 1's blood pressure as 98/54. On 5/13/11, after Resident 1 had received an HD treatment, a physical therapist assistant (PTA) A documented in the nurses notes, "During skilled physical therapy treatment patient twice displayed orthostatic hypotension with BP: sitting 93/60 and standing 67/48, returned resident to bed, report to nursing, later in day BP: supine 112/66 and sitting 80/49. " During an interview with PTA A on 6/8/12 at 9:30 am, PTA A stated that he had attempted physical therapy with Resident 1 at approximately 3:30 pm on 5/13/11. He stated that when Resident 1 could not safely proceed, he took him back to his bed and reported directly to the registered nurse in charge. The fall risk care plan was not updated following the night shift nurse's notes or PTA A's reporting of Resident 1's low blood pressures on 5/13/11. During an interview on 5/24/12 at 12:50 pm, PT F stated that safety awareness, impaired vision, very poor hearing, poor balance with legs that bowed out, and drops in blood pressure, particularly following HD, were all problems for Resident 1 from "when he first got here." During an interview on 6/7/12 at 2:35 am, PT Manager H stated that Resident 1 was non-compliant with instructions as he did not want to "bother" anybody by requesting assistance. She agreed that having an enlarged prostate could bring on an urgent need to stand to urinate, and that the side effects of many of his medications possibly contributed to his confusion. On 5/13/11 at 10:00 pm, Registered Nurse (RN) B noted, "at (9:15 pm) heard CNA (Certified Nursing Assistant) yelling for help - ran to Rm 312 and saw resident on floor on his left side...skin tear to left forearm...resident complained of severe left hip pain and was unable to move lower extremity...medics called and resident sent to emergency room . Resident stated he got dizzy. PT reported earlier in shift that resident was having orthostatic hypotension. Resident was reminded to sit up slowly and use call light before getting up." On 5/13/11 there were no nursing notes from RN B prior to Resident 1's fall, and there were no updates on Resident 1's Fall Risk care plan regarding hypotension. During an interview on 6/15/12 at 1:50 pm, RN B acknowledged that she did not check Resident 1's BP and did not report the information from the PTA A to the physician during the five+ hours preceding his fall on 5/13/11. According to the emergency room physician's admitting "History and Physical," dated 5/14/11, Resident 1 was diagnosed with [REDACTED]. During interviews on 5/25/12 at 3:20 pm and 7/13/12 at 5 pm, the contributing factors that placed Resident 1 at high risk for falls were discussed with DON C and Administrator D. Resident 1 was not monitored by the nurse and that the physician was not notified of his low BP in the five+ hours prior to his fall on 5/13/11.