Every finding on record at Autumn Creek Post Acute

Based on interviews and record reviews, the facility did not ensure medical records were complete and accurate for two out of two sampled residents (Residents 1 and 2) when the Medication Administration Record did not indicate that medications had been administered.This had the potential for residents to receive too much medication and cause a decline in health status.Findings:A review of the facility's policy and procedure titled, General Provisions, dated 10/1/13, indicated resident medical records would be accurate and complete.A review of Resident 1's admission record indicated that Resident 1 was readmitted to the facility on [DATE] with the diagnoses of dementia (memory loss) and chronic (ongoing) pain. Resident 1 was not their own responsible party (RP, decision maker).A review of Resident 2's admission record indicated that Resident 2 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure) and chronic pain. Resident 2 was their own RP.During a concurrent interview and record review on 8/11/26 at 3:42 pm, with the Assistant Director of Nursing (ADON), Resident 1's Medication Admin Audit Report, (audit report) dated 7/29/26, was reviewed. The ADON confirmed that the audit report indicated the Licensed Nurse (LN) did not document the administration of seven medications on 7/28/26.During a concurrent interview and record review on 8/11/26 at 3:38 pm, with ADON, Resident 1's audit report, dated 7/30/26, was reviewed. The ADON confirmed, the audit report indicated the LN did not document the administration of five medications on 7/29/26.During a concurrent interview and record review on 8/11/26 at 3:50 pm, with ADON, Resident 2's audit report, dated 7/30/26 was reviewed. The ADON confirmed the audit report indicated the LN did not document the administration of four medications on 7/29/26. ADON indicated the facility ran the audit report on every business day and reviewed it to ensure the LNs were documenting the medications that were administered to the residents. The ADON indicated that when a lack of medication documentation was identified, the facility reached out to the LN to ensure the medication was provided and requested the LN to come to the facility to complete documentation. ADON confirmed, Resident 1 and 2's medical records were not complete.

Based on interview and record review, the facility failed to implement resident specific fall prevention interventions recommended by the Interdisciplinary Team (IDT) after a fall for two of three sampled residents (Resident 1 and 2).This failure has the potential to place all residents at risk of falls and injuries.Findings:A review of the facility's policy titled Fall Management Program, revised August 2025, indicated that fall risk evaluation and care planning require the IDT and/or a licensed nurse to develop a care plan based on identified risk factors. The licensed nurse must evaluate the resident's response to interventions weekly and update the care plan as needed. The policy further states that, for post fall assessment, evaluation, and documentation, the licensed nurse is responsible for confirming the resident's safety and stability before proceeding with post fall protocols, interviewing staff regarding the incident, completing a post fall evaluation, and updating the resident's care plan with recommended interventions. The Interdisciplinary Team (IDT) is responsible for investigating the fall, reviewing the resident's medical record and the Post Fall Evaluation, assessing the circumstances surrounding the fall, summarizing its conclusions in an IDT note, and revising the resident's care plan as necessary.A review of Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare following joint replacement surgery, difficulty in walking, and dementia. Upon admission, Resident 1 was identified as a high fall risk.A review of Resident 1's IDT note, dated 6/22/26 at 3:18 pm, indicated that Resident 1 lost her balance and stumbled on a mirror on 6/19/26, and discoloration on her face was observed on 6/20/26. The IDT recommended a medication regimen review (MRR, an interim pharmacy review of medication to verify interactions that increase risk for falls), and a therapy evaluation.A review of Resident 1's IDT note, dated 7/7/26 at 10:48 am, indicated that Resident 1 was observed by a CAN slowly lowering herself from a standing position to the floor on 7/6/26 at 5:05 pm. The IDT recommended keeping Resident 1 in high-visibility areas and continue frequent safety checks.A review of Resident 1's record titled Pharmacist Report to Nursing, dated 7/7/26 -completed two weeks after Resident 1's first fall on 6/19/26-indicated that no changes were recommended to the current medication regimen. This was the only medication regimen review (MRR) provided.A review of Resident 1's Therapy Post-Fall Screen (for the fall on 7/6/26), dated 7/6/26, indicated, Patient with increased behaviors requiring one on one supervision (close monitoring one patient to one staff member) at times. Patient with increased confusion and attempting to stand unassisted. The recommendations made by therapy on 7/6/26, including the need for one to one supervision at times as part of the IDT guidance, were not implemented. A review of Resident 2's admission record indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses which included cancer of the liver, hospice, muscle weakness, and difficulty in walking. Resident 1 was a high fall risk.A review of Resident 2's IDT note, dated 6/29/26 at 12:37 pm, indicated that Resident 2 had an unwitnessed fall on 6/26/26 at 2:25 pm. Resident 2 was found on the floor in her room, positioned facing the window. According to Resident 2, she was attempting an independent transfer from her wheelchair to the bed when she lost her balance and fell. The IDT reviewed the incident and recommended completion of a MRR, assessment for the use of a bed cane (a bedside assistive device-a short, single sided grab bar that slips between the mattress and box spring and secures to the bed frame with a safety strap. It is designed to provide support, stability, and balance for a resident when getting in or out of bed or repositioning at the bedside), and evaluation for orthostatic hypotension (a sudden drop in blood pressure when a person stands after sitting or lying down.)A review of Resident 2's Bed Rail Evaluation, dated 7/22/26, completed four and a half weeks after IDT's recommendation for a bed rail assessment, indicated that Resident 2 needs grab bars on both sides of the bed; however, the facility did not ensure timely completion or implementation of the recommended intervention. A review of Resident 2's record titled Pharmacist Report to Nursing, signed by the pharmacist on 7/23/26 -completed four and a half weeks after the IDT's recommendation for an MMR on 6/29/26-indicated that the facility did not ensure the timely completion of the required MRR.During an interview on 7/22/26 at 2:00 pm, with Licensed Vocational Nurse (LVN) who served as the fall prevention manager, he LVN stated that Resident 1 wanders and exhibits behaviors.During an observation on 7/23/26 at 10:15 am, in Resident 2's room, Resident 2 was observed asleep in bed with no bed cane or grab bar attached to the side of the bed.During a concurrent interview and record review on 7/23/26 at 11:25 am, with the Director of Nursing (DON), the DON acknowledged that the facility failed to timely implement the therapy recommendations for Resident 1 and stated that the pharmacy evaluation was completed two weeks after Resident 1's fall. The DON confirmed that Resident 1 was not tried on one to one supervision. The DON also stated that Resident 2 did not have the IDT recommendations implemented and that Resident 2's pharmacy evaluation was completed four and a half weeks post fall. The DON further confirmed that Resident 2's bed cane evaluation was conducted on 7/22/26, four weeks after the IDT meeting, and stated that the evaluation should have been completed at the time of the recommendation and implemented to prevent further falls.

Based on interview and record review, the facility failed to ensure that care plans were updated and individualized for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when interventions were not specific to the care needs of the resident. This had the potential for residents to not receive the interventions that were consistent with their care needs and have a negative impact on their physical and emotional well-being. Findings: A review of the facility's policy titled, Person Centered Care Planning, revised 4/24/2025 indicated, The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to precent decline or injury . The care plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practical . well being. All goals, objectives, interventions . from the . baseline care plan will be included in the resident's comprehensive care plan. A review of the facility's policy titled, Pressure Injury Prevention, revised 6/27/2024 indicated, Implement interventions identified in the plan of care which may include, but are not limited to, the following: a. Pressure redistributing devices for bed and chairb. Repositioning and turningc. Heel and elbow protectorsd. Increasing mobility (when appropriate) through a Restorative Nursing Program or therapyprograme. Off-loading pressure from heelsf. Use of (wedge) pillows for positioning and pressure reliefg. Moisturizers and barrier creams to protect the skinh. Bowel and bladder training, scheduled toileting, or incontinence management programs.i. Devices (bed trapeze bar, draw sheets, mechanical lifts, positioning aides, etc.) to reducefriction and shearing when repositioning.j. Contracture management programsk. Monitoring food and fluid intakeI. Confirming that the Resident has properly fitting shoes.m. Monitoring splints, casts, and site of medical tubes and catheters. The National Pressure Injury Advisory Panel (https://www.internationalguideline.com/the-international-guideline) provides the following guidance for pressure injury classification: Stage 1: Observable, pressure-related alteration of intact skin with non-blanchable [redness that does not go away when touched] redness of a localized area . it may appear. blue or purple.Stage 2: Partial thickness loss of (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (soft yellow or white substance that forms over a wound) or bruising. May also present as an intact or open/ruptured blister.Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling [severe tissue destruction of skin beneath the surface of a pressure injury where the skin separates and creates passages].Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (thick, hard, or rubbery patch of dead tissue that forms over wounds). Often includes undermining and tunnelingUnstageable Pressure Ulcer: Pressure ulcer/ injury known but unstageable due to slough and/or Eschar: Pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar.1.The record for Resident 1 was reviewed. Resident 1 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a malfunction of the brain caused by a chemical imbalance,) aphasia (difficulty speaking,) and need for assistance with personal care.A physician's order, dated 6/11/26 indicated, TX (treat) blanchable redness to sacral coccygeal (base of spine between buttock folds) area, cleanse with NS (normal saline) and pat dry. Apply foam dressing for pressure relief. A physician's order dated 6/11/26 indicated, wound consult (a physician who specializes in wounds) with follow up treatments as indicated. A physician's order dated 6/11/26 indicated, CCHO [controlled carbohydrate] standard portion diet. A physician's order dated 6/18/26 indicated, 4 oz [ounces] house supplement/milk shake two times daily with lunch and dinner. A physician's order dated 6/25/26 indicated, TX open discoloration to sacral coccygeal area. Cleanse with NS and pat dry. Apply Triad (an ointment used in wound treatments) to wound and cover with foam dressing every day shift every other day for 30 days. The physician's order dated 6/25/26, further indicated, LAL (low air loss) mattress related to impaired mobility and current wounds. A physician's order dated 6/27/26 indicated, Send [Resident 1] to. hospital for evaluation and treatment.A review of Resident 1's care plans was conducted. A care plan with the focus, Unstageable pressure to coccyx r/t (related to) immobility was reviewed. Under the section titled , Interventions the following were included, Follow facility policies/protocols for the prevention/treatment of skin break down, Administer medications as ordered, Monitor nutritional status. Serve diet as ordered. Monitor intake and record.Resident 1's care plan had not included any resident specific interventions such as her wound care treatments, nutritional supplements, the specialized mattress ordered by the physician, or specify the actions staff should take to prevent further skin breakdown based on her risk factors. The care plan did not specify any interventions or treatments that had been attempted and modified or discontinued. During an interview and current record review on 7/10/16 at 3:32 pm, with the Director of Nursing (DON) she reviewed the care plans for Resident 1. DON confirmed that the physician ordered interventions including wound treatments, nutritional supplementation, and a specialized mattress were not identified in Resident 1's care plan. DON stated that specific orders or treatments are never included in the care plan or kept updated because staff should review the physician's orders. DON confirmed the care plan directed staff to follow policies for skin breakdown, but stated staff should know their resident's specific needs, and again indicated staff could review the physician's orders or the policy. DON acknowledged that the LAL mattress ordered by the physician should have been included in the care plan and was not.2.The record for resident 2 was reviewed. Resident 2 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (left sided paralysis after a stroke,) pressure ulcer, malignant neoplasm (cancer) of the pancreas, and gastrostomy tube (a tube through which nutrition is delivered directly to the stomach.)A physician's order ,dated 6/7/26 indicated, Wound consultation with follow up treatment as needed.A physician's order, dated 6/17/26, indicated, LAL mattress for wound management r/t pressure injury. Use continuously until reassessment indicates no longer needed. Ensure mattress is functioning properly and setting matches current weight twice daily.A physician's order, dated 7/2/26, indicated, Tx coccyx stage 2 pressure, cleanse with NS and pay dry, apply Triad for preventive LOA (leave open to air- no dressing), every day shift for 14 days.A review of Resident 2's care plan with the focus, Resident has stage 2 pressure ulcer to coccyx r/t (related to) immobility was reviewed. Under the section titled, Interventions the following were included in the care plan, Follow facility policies/protocols for the prevention/treatment of skin break down, and Administer treatments as ordered. The care plan had not included or specified which interventions staff should take to prevent or treat Resident 2's stage 2 pressure ulcer, specify what medications or treatments were ordered by the physician, or that a low air loss mattress should be utilized. The care plan did not include any interventions that had been attempted and modified or discontinued.During an interview and current record review on 7/14/16 at 4:10 pm, with the Assistant Director of Nursing (ADON) she reviewed the care plan for Resident 2's pressure ulcer. ADON acknowledged that the care plan did not include individualized resident specific interventions including wound treatments and a specialized mattress ordered by the physician. 3.The record for Resident 3 was reviewed. Resident 3 was admitted on [DATE] with diagnoses that included, intrahepatic bile duct carcinoma (cancer of bile duct that involves the liver,) ileostomy (an opening from a part of the intestines to the outside of the abdomen so that waste bypasses the colon,) and pressure ulcer of sacral region stage 3. A physician's order, dated 6/3/26, indicated, Initiate LAL mattress for pressure redistribution and prevention of further skin breakdown. Utilize LAL mattress at all times while resident is in bed. Continue turning and repositioning every 2 hours as needed. Offload heels [keep heels elevated and off of the mattress] while in bed. A physician's order, dated 6/12/26, indicated, Prostat (a liquid protein supplement) two times a day to promote healing and healthy skin . document refusal. A physician's order, dated 6/12/26, indicated, Zinc [a mineral supplement] oral tablet 50 mg (milligrams) by mouth once daily to promote healing and healthy skin for 60 days. A physician's order, dated 6/17/26, indicated, LAL r/t impaired mobility and history of ulcers. Use continuously until reassessment indicates no longer needed. Ensure mattress is functioning properly and setting matches current weight every night shift. A physician's order, dated 7/3/26, indicated, TX coccyx Stage 3 pressure injury, cleanse with NS pat dry apply triad and LOA every day shift for 14 days.A review of Resident 3's care plan with the focus, Resident has stage 3 pressure ulcer to coccyx r/t (related to) immobility was reviewed. Under the section titled, Interventions the following were included in the care plan, Administer medications as ordered, administer treatments as ordered, and educate the resident/family . about the causes of skin breakdown.Resident 3's care plan did not specify what medications or treatments were ordered. It did not include the physician ordered interventions to reposition every 2 hours and offload (remove pressure from) the resident's heels while she is in bed. It did not include the use of a LAL mattress. The care plan did not indicate any interventions that had been attempted and modified or discontinued.During an interview and current record review on 7/14/16 at 4:10 pm, with the ADON, she reviewed the care plan for Resident 3's Stage 3 pressure ulcer. ADON confirmed Resident 3's care plan did not include individualized resident specific interventions including wound treatments, nutritional supplements, or the specialized mattress ordered by the physician.

Based on interview and record review, the facility failed to ensure that changes in residents health status were reported for one of five sampled residents when Resident 1's Responsible Party (person designated to make healthcare decisions when the resident is unable to) was not notified of changes in her wound. This resulted in the resident's representative being unaware of changes and unable to fully participate in advocating for and making choice's on Resident 1's behalf.Findings: A review of the facility's policy titled, Pressure Injury Prevention, revised 6/27/24 indicated, The physician and responsible party will be notified when there is a change in the condition of the pressure injury or skin integrity condition.The record for Resident 1 was reviewed. Resident 1 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a malfunction of the brain caused by a chemical imbalance,) aphasia (difficulty speaking,) and need for assistance with personal care.A physician's order reviewed, dated 6/11/26, indicated, TX [treat] blanchable redness to sacral coccygeal area [lower part of back], cleanse with NS [normal saline] and pat dry. Apply foam dressing for pressure relief.A physician's order reviewed, dated 6/25/26, indicated, TX open discoloration to sacral coccygeal area. Cleanse with NS and pat dry. Apply Triad (an ointment used in wound treatments) to wound and cover with foam dressing every day shift every other day for 30 days. The physician's order, dated 6/25/26, also indicated, LAL (low air loss) mattress related to impaired mobility and current wounds. A physician's order reviewed, dated 6/26/26 indicated, Resident is incapable of making health care decisions due to cognitive decline. and designated the resident's husband as her Responsible Party. A physician's order reviewed, dated 6/27/26, indicated, Send to. hospital for evaluation and treatment.During an interview and concurrent record review on 7/14/26 at 4 pm, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), both reviewed the record for Resident 1. DON confirmed that Resident 1 had been admitted with blanchable redness to her coccyx area and that there had been a change in Resident 1's skin condition when the wound worsened. DON confirmed that Resident 1's husband was her Responsible Party. When asked if the facility had notified Resident 1's husband of the change in her condition, DON stated the doctor had been notified. When asked again if the resident's husband had been notified ADON stated that the facility was unable to provide documentation that this notification had occurred. Both acknowledged that Resident 1's husband should have been notified by the facility when there was a change in her skin condition.

Based on interview and record review, the facility failed to report an alleged violation involving a resident fall resulting in a head injury and right hip fracture to the required state agency for one of four sampled residents (Resident 1). This failure had the potential to delay investigation and corrective actions, placing all residents at risk for ongoing safety hazards and preventable injury. Findings:During a review of the facility's policy titled Unusual Occurrence Reporting, effective 6/12/24, indicated that unusual occurrences must be reported to the appropriate agency within 24 hours by telephone and subsequently confirmed in writing.During a review of Resident 1's admission record, indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), muscle weakness, difficulty in walking, and need for assistance with personal care. Resident 1 was not her own health care decision maker.During a review of Resident 1's progress note, dated 3/21/26 at 4:07 pm, indicated that Resident 1 sustained an unwitnessed fall and reported lower back pain rated as 4 on a 0-10 pain scale (described as mild discomfort). The note documented that Resident 1 was confused and unable to recall the circumstances of the fall. Staff found Resident 1 lying on the floor in a prone position.During a review of Resident 1's progress note, dated 3/22/26 at 8:22 pm, indicated that Resident 1 had an unwitnessed fall on 3/21/26 at 2:45 pm. The note documented that Resident 1 had complained of hip pain since the fall and had shown mental decline. An in house x ray was obtained earlier on 3/22/26, and radiology later reported a right femoral neck fracture. Resident 1 was transported to the hospital at 4:30 pm.During a review of Resident 1's local hospital's emergency department records, dated 3/22/26 at 4:54 pm, indicated that Resident 1 was transferred from the facility following an unwitnessed fall with a probable right hip fracture and a closed head injury. The final impressions were, Closed fracture of the proximal end of the right femur (the thigh bone) and closed head injury.During interview on 5/21/26 at 12:26 pm, with the Administrator (Admin), the Admin acknowledged that Resident 1's fall was not reported to the state agency as required. When asked about the facility's expectation of reporting unusual occurrences, the Admin stated that a resident with dementia who experiences a fall resulting in a hip fracture must be reported.

Based on observation and interview the facility failed to ensure that all resident hallways were kept free of hazards during deep cleaning of resident rooms. This resulted in both sides of the hallway being obstruction, representing both a safety hazard for residents as well as a potential fire hazard due to the obstructed exit. This had the potential to negatively impact the safety and well being of all residents.During an observation on 5/5/26 at 11:05 am the hallway on Station # 2 was reviewed. The hallway contained rooms 12 - 20.Both sides of the hallway were lined with equipment and resident items against the walls. Outside of room [ROOM NUMBER] was a paper sign that indicated room [ROOM NUMBER] scheduled for deep clean may 15 at 9 am a staff member was observed inside the room cleaning. Items along the left hand side of the hallway included 3 bedside tables, 3 stacks of boxes, a wheelchair, an oxygen concentrator, and a med cart. On the right hand side of the hallway was 1 Hoyer lift, 1 walker, 4 wheelchairs, 4 bedside tables, and a large metal box venting air through a ceiling duct. Residents were inside rooms in the effected area, as well as attempting to ambulate in the hallway. During a concurrent interview and observation on 5/15/26 at 11:15 am with HSK (Housekeeper) she stated that she was deep cleaning room [ROOM NUMBER], which required all belongings to be moved out into the hall. HSK was uncertain how long the items had been in the hallways but stated she had been cleaning for over an hour. HSK confirmed that resident personal items and equipment were on both sides of the hallway. HSK was uncertain if the facility had a policy about maintaining resident safety when performing a deep clean, but stated putting items outside of the residents room is the normal process housekeeping follows. During a concurrent interview and observation on 5/15/26 at 11:20 am with ADON (Assistant Director of Nurses) she reviewed the hallway with rooms 12 - 20. ADON confirmed that resident personal items and care equipment were lined on both sides of the hallway, and that this presented a hazard to residents. ADON was uncertain if the facility had a policy related to keeping hallways unobstructed or that addressed where items should be stored during deep cleaning procedures. During an interview on 5/15/26 at 3:50 pm with ADON she confirmed that the facility did not have a policy to address items on both sides of the hallways but verbalized that the expectation is for any items stored in the hallways to be maintained on only one side; leaving the other side unobstructed for resident safety.

Based on interview and record review, the facility failed to develop and implement safe discharge plan for one sampled resident (Resident 1) when the Interdisciplinary Team (IDT, a team composed of nursing, social work, and therapy who develop resident plan of care) did not ensure Caregiver (CG) had training and services were arrange before returning home. This resulted in Resident 1 falling in the facility parking lot on 3/6/26 at 2 pm, when the resident was dropped by the CG during a transfer from the wheelchair to the car.Findings:A review of a facility policy titled Discharge and Transfer of Residents , revised 3/21/25, indicated the facility may transfer or discharge a resident with an order from the resident's physician if the resident's health has improved significantly and services provided by the facility are no longer required.A review of an undated facility policy titled Discharge Against Medical Advice Operational Manual Policy , indicated the facility will make reasonable attempts to ensure the safety of residents wishing to leave the facility against medical advice.A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included heart disease, difficulty in walking and need for assistance with personal care. Resident 1 was able to make her own health care decisions.A review of Resident 1's Minimum Data Set (MDS) dated [DATE], in the section of Mobility, indicated the following mobility performance levels: Sit to lying required partial to moderate assistance; Lying to sitting on the side of the bed required substantial to maximum assistance; Sit to stand was dependent; and Chair to bed and toilet transfers required substantial to maximum assistance. Walking 10 feet, 50 feet, or 150 feet was not attempted due to medical condition or safety concerns.A review of Resident 1's physical therapy notes, dated 2/19/26, 2/20/26, 2/24/26, and 2/26/26, indicated that on 2/19/26 the Interdisciplinary Team coordinated to clarify Resident 1's weight bearing orders with the physician, with Resident 1 tolerating strengthening activities but unable to complete planned car transfer training due to the physician not being reached; on 2/20/26 Resident 1 demonstrated fear of falling during transfer training, reported episodes of excruciating right lower extremity knee pain, was intermittently unable to bear weight, required varying levels of assistance for transfers, and was unable to ambulate; on 2/24/26 Resident 1 reported concern about the right lower extremity collapsing during transfers, required assistance to safely complete turning to sit in the wheelchair, demonstrated anxiety and fear of falling, and had car transfer training canceled by the caregiver; and on 2/26/26 Resident 1 again demonstrated fear of falling during transfer training and required some assistance.A review of Resident 1's IDT meeting note, dated 2/27/26 at 2:02 pm, indicated that on 2/26/26 at approximately 10:00 am, Resident 1 reported fear that the CG was taking financial advantage of the resident, stating the CG had not provided bank statements and had pressured the resident to assign power of attorney (POA) after the resident received a substantial inheritance in mid 2025; Resident 1 reported signing the POA in September 2025 due to this pressure. The note also reflected that Resident 1 had made multiple prior reports of fear, distrust, and concerns regarding the CG, which the facility had reported to California Department of Public Health (CDPH) and the Ombudsman. During an Ombudsman meeting on 2/26/26, Resident 1 expressed a desire to revoke the financial POA and planned to consult with an attorney. It was further documented that the CG continued calling Resident 1 on the resident's personal phone, and Resident 1 continued answering the calls. Resident 1 was encouraged to report concerns to staff as they arise.A review of Resident 1's nursing notes, dated 2/27/26 at 7:30 am. indicated that at approximately 6:40 am, Resident 1's cell phone rang multiple times, prompting the Licensed Nurse (LN) to inform the resident that the CG was calling. Resident 1 requested that the LN answer the call and notify the CG that the resident wished to continue sleeping. The LN honored the resident's request and intercepted the call, during which the CG stated, It is a quarter to seven, why the hell are you still sleeping?! The LN advised the CG that Resident 1 had the right to rest, but the CG demanded that the LN wake the resident to speak with the CG. The LN reiterated that Resident 1's wishes would be followed, after which the CG stated, You are such an asshole! and abruptly ended the call.During an interview on 3/5/26 at 2:06 pm with the Director of Rehabilitation (DOR), the DOR stated that the CG had come into the facility and made demands. The DOR reported that on 2/28/26, the DOR asked Resident 1 whether the resident felt safe with the CG, and Resident 1 stated the CG had mental health issues and had thrown the resident's pain medications away. The DOR stated that these concerns were reported to the Administrator, who discussed the possibility of discharge. The DOR further stated concern regarding Resident 1's potential discharge and reported that the DOR would be completing an assessment that day and observing the caregiver's transfer of the resident prior to signing off for discharge.During an interview on 3/5/26 at 3:11 pm, with Social Services Assistant (SSA), the SSA stated that CG had demanded a meeting to assert that Resident 1 should not receive pain medication because the CG believed the resident was a drug addict, which the SSA stated was not clinically justified. The SSA reported that the meeting was ended because Resident 1 was present and became upset. The SSA further stated that there had been several prior meetings in which Resident 1 expressed fear due to the CG threatening to take the resident's dog and yelling at the resident, and that the CG frequently called Resident 1 in the middle of the night, waking the resident to talk. The SSA stated Resident 1 continued to express a desire to return home with the CG, although car transfer competency had not been signed off for discharge. The SSA reported concerns regarding the safety of discharging Resident 1 to the CG's care and stated that discharge against medical advice (AMA) had not been discussed with the resident.A review of Resident 1's IDT meeting note, dated 3/6/26 at 6:31 pm, indicated that Resident 1 was scheduled for discharge that day at the CG request; however, a licensed nurse reported that the CG did not wait for staff assistance during the car transfer, resulting in a witnessed fall in the facility parking lot. The IDT note documented that the CG had been offered education and hands on car transfer training multiple times by therapy but refused, including again on the day of discharge, stating the CG needed to leave. Multiple training attempts had been scheduled, but the CG repeatedly provided reasons for not attending. After Resident 1 returned to the facility following the fall, the resident expressed concern about safely transferring home and requested to remain in the facility. The IDT recommended scheduling a care conference with the Ombudsman and increasing staff presence during CG visits to ensure Resident 1's comfort and safety.A review of Resident 1's social services progress note, dated 3/9/2026 at 11:28 am, indicated that staff met with Resident 1 to assess the resident's psychosocial functioning following the attempted discharge with the caregiver, during which the resident was instructed to get into the SUV independently and subsequently dropped to the ground. The note documented that Resident 1 stated she was doing okay, but reported that the caregiver called earlier that day and told the resident, If you are not discharged by the 17th your world is going to be fire.A review of Resident 1's IDT note, dated 3/9/26 at 2:11 pm, Resident 1 reported that earlier that morning, the CG contacted the resident by personal phone and stated that if the resident did not discharge by 3/17/26, her life would go up in flames. Rehabilitation staff documented that Resident 1 appeared distressed and fearful following the call. During a subsequent interview with the Director of Nursing (DON), Resident 1 stated the CG told her that failure to discharge home by 3/17/26 would result in her life being permanently altered. The IDT note further indicated that Resident 1 has made multiple prior reports of fear, distrust, and concerns regarding the CG, and the facility has submitted multiple reports to CDPH and the Ombudsman.During an interview on 3/13/26 at 10:45 am, with the DOR, the DOR stated that on the day of discharge, CG appeared to be rushing to take Resident 1 outside. After Resident 1 fell, the resident stated that she wished to remain at the facility and reported that CG did not assist her and just let her fall. The DOR stated that Resident 1 also expressed, I can't believe she would let me fall. The DOR reported multiple attempts to arrange car transfer training but was unclear whether the training was intended for CG, Home Health agency, or the resident. The DOR stated that the discharge plan should have specified if the CG would be the mode of transport.During an interview on 3/13/26 at 11:26 am, with Resident 1, Resident 1 stated that during the 3/6/26 car transfer incident, CG dropped her while attempting to transfer her into the car and threatened that she would not pick up the resident's dog or provide her medications. Resident 1 reported she did not feel safe and was fearful of what the CG would or would not do for her. Resident 1 recalled that Home Health agency would not be available until Monday (3/9/26) and that the CG would be with her continuously over the weekend. Resident 1 stated the CG is forceful and yells at her when she does not comply with the CG's demands. Resident 1 confirmed that the DOR explained the need for all caregivers to be trained in transfer techniques and in the use of the new soft brace for her right knee.During an interview on 3/13/26 at 11:45 am, with DON, the DON confirmed she participated in the care plan meeting regarding Resident 1's potential discharge. The DON reported that the CG stated Resident 1 needed to leave the facility by March 7 to attend an appointment with the resident's primary care provider. The DON stated she informed the CG that Resident 1 must first meet discharge goals before leaving the facility. The DON reported she had multiple notes documenting the CG canceling scheduled training sessions. The DON stated the facility did not have evidence of a complete or coordinated discharge plan for Resident 1.During an interview on 3/13/26 at 1:18 pm, with Licensed Vocational Nurse (LVN A), the LVN A stated that on 3/6/26 the CG appeared to be in a rush. LVN A reported that he informed the CG he needed to prepare the paperwork and secure Resident 1's medications before providing discharge instructions and assisting with the transfer. LVN A stated that when he returned with the medications, Resident 1 and the CG were already outside, and Resident 1 was back in her wheelchair after the fall, visibly upset and telling the CG, You were rushing me. LVN A further reported that as Resident 1 returned inside the facility, the CG stated, You're on your own.During a review of a social services note, dated 3/19/26 at 12:25 pm, it indicated that Resident 1 left the facility AMA on that date.

Based on interview and record review, the facility failed to ensure all allegations of abuse were reported within 2 hours to the State Survey Agency in accordance with State Law for one sampled resident (Resident 1). This failure had the potential to put Resident 1 at risk for continued abuse. Findings:A review of the facility policy titled, Abuse Prevention and Management, effective date 06/12/24, indicated, Notification of Outside Agencies for All Allegations of Abuse - The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report and send a written report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.A review of a facility-reported incident, dated 2/25/26, indicated that CNA B reported an allegation of abuse. CNA B indicated that on 2/25/26 at approximately 3:45 pm, while giving care to Resident 1, she heard the Responsible Party (RP, decision maker), tell Resident 1 that she was an addict, and she was going to call Resident 1's doctor to get Resident 1 pain medication taken away. This report was received by The California Department of Public Health (CDPH, State Survey Agency) on 2/25/26 at 7:19 pm, more than three and a half hours after the incident.A review of the facility's record, written by the Director of Rehabilitation (DOR), indicated an allegation of abuse was reported to the DOR on 2/25/26 at 4:30 pm. During an interview on 3/5/26 at 2:06 pm, with the DOR, the DOR stated she had witnessed Resident 1's RP yelling at Resident 1 on the telephone. The DOR stated she asked Resident 1 if she felt safe with her RP, and her response was RP had mental health issues. Resident 1 informed the DOR she was concerned that when she was discharged with the RP, she was going to throw away her pain medications. The DOR stated she then informed the Administrator (ADMIN), of her concern about Resident 1 being discharged home with the RP. The DOR stated she was instructed to write a statement and give it to the ADMIN to submit with a similar allegation of abuse. The DOR confirmed she suspected abuse and acknowledged the allegation and that as a mandated reporter she should have reported it immediately to the appropriate agencies.During a concurrent interview and record review on 3/5/26 at 2:45 pm, with the ADMIN, the ADMIN stated the RP had concerns regarding Resident 1's pain medications and the ADMIN explained to the RP that medications are physician driven. When asked about numerous reports of abuse that were made regarding Resident 1, ADMIN stated she planned to combine two distinct allegations of abuse involving Resident 1 into a single report, rather than reporting each allegation independently which does not align with reporting requirements. When asked about the expectation of reporting abuse, the ADMIN acknowledged each report must be reported separately, that both she and the DOR had a responsibility to report the allegation and they did not follow their facility abuse policy.

Based on interview and record review, the facility failed to ensure sufficient competent staffing to meet the needs for three of four sampled residents (Residents 1, 2 and 3) when dependent residents required assistance with toileting waited a long time when call light initiated.This failure resulted in residents having unrelieved discomfort, emotional distress, and feelings of and neglect.Findings:A review of undated facility document titled,Certified Nursing Assistant (CNA) job description, indicated, a CNA's General Duties and Responsibilities including keep incontinent residents always clean and dry as possible and answer call lights promptly; A CNA's Clinical skill includes, Assist residents to/from bathroom promptly.A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included encounter for orthopedic aftercare following surgical amputation, difficulty in walking and need for assistance with personal care. Resident 1 was able to make his own health care decisions.A review of Resident 1's most recent Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/30/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 14 (cognitively intact). Resident 1 used a walker and or a wheelchair for her mobility. MDS indicated the need for partial/moderate assistance (helper does less than half the effort) for transfers.A review of Resident 1's fall care plan dated 2/2/26, indicated Resident 1 was at risk for falls due to gait/balance problems. Resident 1 needs prompt response to all requests for assistance.During interview on 2/13/26 at 1:02 pm, with Resident 1, Resident 1 stated, a few nights ago after dinner and medications I asked staff to take me to the restroom. Resident 1 stated a male staff member took him to the restroom. Resident 1 stated after he finished, he pushed the call light button and waited. Resident 1 stated after waiting a for a little while a female Certified Nursing Assistant (CNA) came by and turned off the call light, and did not help him out of the bathroom, just walked out of the room. Resident 1 stated he transferred himself to his wheelchair and sat in the doorway to the restroom, for a little bit then backed the wheelchair out and waited for approximately 45 minutes for staff to assist him back to bed. Resident 1 explained he then wheeled himself back to the bed and waited for staff, no one came so he self-transferred himself into the bed. Resident 1 stated he felt frustrated and kept his cool then went to bed.A review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis, difficulty in walking, not elsewhere classified and need for assistance with personal care. Resident 2 was able to make her own health care decisions.A review of Resident 2's most recent MDS dated [DATE], indicated Resident 2 had a BIMS score of 13 (cognitively intact). Resident 2 used a wheelchair for her mobility. MDS indicated the need for partial/moderate assistance (helper does more than half the effort) for toileting.A review of Resident 2's bowel and bladder care plan dated 12/9/25, indicated Resident 2 was at risk for urinary tract infection related to insufficient fluid intake and urine retention secondary to avoidance of voiding in brief. Offer privacy, dignity and prompt assistance when toiletingDuring Interview on 2/13/26 at 1:35 pm, with Resident 2, Resident 2 stated, care at the facility depends on the day and staff. Resident 2 stated there are not enough staff to care for her needs. Resident 2 stated facility was always short staffed mostly on day shift. Resident 2 stated she complained before to the nurse and was reported to social services. Resident 2 stated after the complaint things only seemed to change for a day or so. Resident 2 stated that when needing to use the restroom she has to wait 30 minutes to an hour. Resident 2 stated this caused incontinent accidents and did not want this to ruin her progress of controlling her bowel and bladder. Resident 2 stated an agency staff member once told to void in her brief. Resident 2 explained a couple months ago, and another CNA told her to have fun when trying to go to the bathroom on her own. Resident 2 stated that a female CNA was removed from her care. Resident 2 stated, it makes me feel like the facility doesn't give a shit like they are only in it for the money. Resident 2 stated almost every day she has an incontinent episode due to having to wait to be taken to the restroom. Resident 2 stated yesterday she fell asleep in the bathroom waiting 30 minutes for a staff member to assist her. A review of Resident 3's most recent MDS dated [DATE], indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis that included spinal surgery and arthritis. Resident 3 had a BIMS score of 15 (cognitively intact). Resident 3 used a wheelchair for her mobility. MDS indicated Resident 3 was dependent on staff for all transfers.During an interview on 2/13/26 at 2:13 pm, CNA A stated the day shift currently was short staffed. CNA A stated she was frequently asked to stay late if they can't get registry coverage due to staff call outs. CNA A stated she was able to give basic care and sometimes she had to skip giving resident showers due to short staffing. During an interview on 2/19/26 at 9:45 am, Resident 3 stated she needs assistance when transferring out of bed to wheelchair. Resident 3 stated it takes a while for staff to answer call lights. Resident 3 stated it seemed like facility was short staffed. Resident 3 stated she has had incontinence episodes due to staff delayed response to call light request. Resident 3 stated by the time they arrive she has already voided before they can get the bed pan which is embarrassing.A review of the facility staff schedule for February 11, 2026, indicated CNA B was asked to cover station 3 resulting from two employees calling out for their shift. Station 3 is the station where Residents 1, 2 and 3 reside.During an interview on 2/19/26 at 11:32 am, with CNA B who stated the Director of Staff Development spoke CNA B about the scheduler who asked CNA B to go to station three for 30 minutes. CNA B stated she was originally assigned to be on station one. CNA B stated she was unaware of the other CNAs on shift when she came to Station 3, she saw a bunch of call lights on, so she started checking call lights. CNA B stated she was asked about a Resident and if she turned off a call light. CNA B stated the resident she believed was in question needed help getting out of the bathroom but was already in the wheelchair so CNA B helped resident get into bed. CNA B stated there was a lot of miscommunications between staff. CNA B stated she was re-educated, but it was more like a short conversation than CNA B signed the paperwork. CNA B stated there is not enough staff on pm shift to meet the needs of Residents. CNA B stated a lot of call outs. CNA stated she has informed the nurse and also when attending staff meetings, she brings it up staffing, but she feels like falls on deaf ears.During an interview on 2/29/26 at 11:58 am, CNA C who stated Resident 1's niece informed CNA C that Resident 1 and herself were very frustrated due to Resident 1 having to get into a wheelchair and out of bathroom on his own. CNA C stated she was told Resident 1 waited a long time and had to get in bed by himself. CNA C stated CNA B hit the call light off but left Resident in the restroom who waited from nine to eleven pm in the restroom. CNA stated she knew who the other CNA was due to having to give her a report the day before when she took over the shift.During an interview on 02/24/26 at 2:15 pm, with the Director of staff Development (DSD), DSD determined it was CNA B in charge of the care of Resident 1, 2 and 3 who all reported waiting a long time for assistance. DSD stated CNA B was re-educated on answering call lights timely when residents request assistance with toileting.

Based on interview and record review, the facility failed to develop an initial person-centered care plan related to diabetes (blood sugar disease) for one of three residents (Resident 1). This failure had the potential to place Resident 1 at risk for not receiving the appropriate interventions and goals related to their diagnoses. Findings: During a review of the facility policy titled Person-Centered Care Planning, dated 4/24/25 indicated that the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns. The baseline care plan will be developed and implemented.within 48 hours of the resident's admission. During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes, kidney disease (loss of kidney function), and depression. During a review of Resident 1's initial Care Plan Report created on 2/6/26, indicated that there was no baseline care plan initiated for diabetes care. A care plan for diabetes was not created for Resident 1 until 2/20/26, 15 days after Resident 1 was admitted to the facility. During a review of Resident 1's electronic medication administration record (eMAR), dated 2/5/26, indicated that if Resident 1 had a blood sugar level of 400 or grater that the facility doctor needs to be notified for further instructions. On 2/11/26 at 5:30pm the eMAR indicated that Resident 1 had a blood sugar level of 435 and on 2/16/26 at 5:30pm Resident 1 had a blood sugar level of 400. During a review of Alert Note for Resident 1 dated 2/11/26 at 8:22pm, Licensed Nurse (LN) A documented that Resident 1 had a blood sugar of 435. LN A gave Resident 1 medication as ordered and the doctor was contacted for further orders. During an interview in Resident 1's room, on 2/17/26 at 10:55am, Resident 1 indicated that before they came into the facility their blood sugar was ranging from 55-200 but while they have been at the facility, it has been between 300-500. Resident 1 stated that no one has talked to them about the high blood sugars and what the facility is doing to manage their blood sugar. During a concurrent interview and record review, on 2/17/26 at 11:47 am with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON and ADON confirmed that being diabetic should have been on Resident 1's care plan. The ADON confirmed that Resident 1's care plan should have also been updated when Resident 1 had a high blood sugar that required the facility to call the doctor.

Based on interview and record review, the facility failed to ensure Nurse's Aides (NA, in training) were state certified prior to hiring and had competencies to provide direct resident care independently.This had the potential for all residents to not have their care needs met and at risk for injury when nine uncertified Nurse's Aides provided unsupervised direct resident care. Refer to F839.Findings:A review of Facility 1's records indicated they did not have an approved Nursing Assistant Training Program (NATP, six-week NA training program) that required approval from the California Department of Public Health (CDPH). A review of Facility 1's Current CNA/NA employee list indicated there are currently nine uncertified Nursing Assistants (NAs) identified as INS-Staff Training Aides on the list.A review of Facility 1's Nursing Assistant Job Description, undated, indicated, The Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the nursing care activities in which the nursing assistant has received clinical instruction and demonstrated competency. Under the Qualifications section, it stated, NA's must be currently enrolled in a NATP, that required approval from CDPH. NAs must have clinical competency while enrolled in the NATP.A review of Facility 1's NA's Can and Can't Do List undated, indicated NAs cannot provide direct resident observation, take vital signs, change briefs, feed residents, transfer residents, or any direct resident care at all.During an interview on 12/5/25 at 11:40 am, the Director of Staff Development (DSD), who worked at Facility 1, explained only Facility 2 had state approval for the NATP classes. DSD stated Facility 1, 2 and 3 meet before each NATP session and interview potential NA students and then hire five at each facility. DSD stated once NATP class were completed the five NAs are oriented to Facility 1 for 2 days then paired and shadowed another CNA for training and competencies. A review of Facility 1's nursing staff assignment sheets dated 11/3-11/7/2025 and 12/3-12/10/2025, indicated uncertified NAs were assigned to take vital signs and take resident assignments. NAs were taking vital signs and working independently and were not paired with a specific CNA for supervision.A review of CNA/NA list and the California Certified Nurse's Assistant Registry (certification verification website) on 1/13/2026 at 11:48 am, indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/6/2025. On 11/3/2025-11/5/2025, NA 1 was assigned to train with CNA 1 on the morning (AM) shift (6:30 am to 2:30 pm).NA 2 was hired on 9/5/2025, graduated on 10/17/2025, and remains uncertified to date (1/13/2026).On 11/5/2025 NA 2 was assigned a resident assignment with CNA 2 on PM (afternoon) shift (2:30 pm to 10:30 pm). On11/7/2025, NA 2 was assigned a resident assignment to train with CNA 3 on PM shift. On12/5/2025, NA 2 was assigned a resident assignment with CNA 10 on PM shift. From 12/6/2025-12/7/2025, NA 2 was assigned to vital signs and a resident assignment with CNA 2 on PM shift.NA 3 was hired on 10/22/2025 and became a certified Nurse's Aide on 12/19/2025. On 11/3/2025-11/4/2025, NA 3 was assigned to a resident assignment train with CNA 4 on night shift (NOC, 10:30 pm to 6:30 am). On 11/7/2025, NA 3 was assigned independently to a resident assignment on NOC shift. From 12/3/2025-12/4/2025, NA3 assigned a resident assignment with CNA 8 on NOC shift. From 12/6/2025-12/8/2025, NA 3 was assigned to vital signs on NOC shift, not paired with CNA.NA 4 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/6/2025. On11/3/2025, NA 4 was assigned a resident assignment with CNA 5 on the NOC shift. On 11/4/2025, NA 4 was assigned a resident assignment with CNA 6 on NOC shift. On 12/3/2025, NA 4 was assigned a resident assignment with CNA 9. On 12/4/2025, NA 4 was assigned a resident assignment with CNA 5. On12/6/2025, NA 4 was assigned to a resident assignment with CNA 6 on NOC shift.NA 5 was hired on 6/23/2025 and became a CNA on 1/12/2026. From 11/3/2025-11/7/2025, NA 5 were assigned to take vital signs independently on PM shift, not paired with a CNA. On12/4/2025,12/5/2025, and 12/8/2025, NA 5 was assigned to vital signs on PM shift, not paired with CNA.NA 6 was hired in June 2025, graduated 8/8/2025, and became a CNA on 1/7/2026. From 11/3/2025-11/7/2025, NA 6 was assigned to take vital signs independently on PM shift, not paired with a CNA. On 12/3/2025, 12/5/2025, and 12/8/2025, NA 6 was assigned to take vital signs on residents during the AM shift, not paired with CNA.NA 7 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/16/2025. On12/3/2025-12/5/2025, NA 7 was assigned a resident assignment with CNA 7 on NOC shift.NA 9 was hired on 6/13/2025 and became a CNA on 9/20/2025. On11/3/2025,11/4/2025,11/6/2025, and 11/7/2025, NA 9 was assigned to take vital signs independently on AM shift, not paired with CNA.During an interview with CNA 11 on 12/5/2026 at 12:15 pm, CNA 11 stated, they worked with a student NA last Friday on Station 2 that came from the NATP for Facility 1. They stated most NAs get hired after skills and written test were completed and were assigned to a unit working independently not paired with a CNA.During an interview with CNA 12 on 12/5/2025 at 12:21 pm, CNA 12 stated they had worked at Facility 1 since June 2025 and were assigned NAs to shadow (follow and observe) them. CNA 12 stated NAs were coming from Facility 1 and Facility 2's NATP and were usually hired after they were certified. CNA 12 stated there were a lot of new staff.During an interview with Administrator (Admin) for Facility 1 on 12/5/2025 at 12:45 pm, Admin stated uncertified NAs had been working at Facility 1 on the PM and NOC shifts. Admin stated they were not aware that uncertified NA and NA students were not allowed to be employed or have clinical training at Facility 1. Admin stated, the NATP and clinical routines were established under the previous leadership of Facility 1. Admin stated they plan to bring uncertified NAs back to AM shift for better supervision. Admin stated that currently uncertified NAs were supervised by the DSD.During an interview with NA 8 on 12/8/2025 at 9:02 am during their shift, NA 8 stated they were currently waiting to complete certification testing and they started working for Facility 1 on 6/1/2025. NA 8 stated they were not allowed to perform hands on care with residents but they had a couple of times because a resident was in need and no one was available.A review of CNA/NA staffing lists indicated NA 8 was hired on 4/14/2025.A review of the California CNA registry indicated, NA 8 remains uncertified to date (1/13/2026).During an interview on 12/10/2025 at 1:25 pm with NA 5, NA 5 stated they had worked at Facility 1 since August 2025 as an NA on the PM shift. They stated they were waiting for their state certification identification number. NA 5 stated they provided direct observation for fall risk residents, had independent assignments, and were occasionally paired with a CNA to shadow the CNA if the CNA wanted to show me how to perform a care task.During an interview with NA 2 on 12/10/2025 at 1:40 pm, NA 2 stated they were currently waiting for their state certification identification number. NA 2 stated they had been shadowing (direct resident care with the supervision of a CNA). NA 2 stated they worked with another NA who was also waiting for their state certification numbers.During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview and record review the Governing Body failed to provide oversight to a facility's Administration to ensure nine nurse's aides were state certified and had the competencies required prior to providing care to residents independently.This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.Findings:A review of Facility 1's Operations Manual Administrative Policies dated 6/4/2024, indicated the Governing Body (GB) engages Administrative Services to develop policies and procedures for the management and operations of the facility. The GB will review and confirm the adoption of all new and updated policies and procedures regarding the management and operations of the facility at least on an annual basis. The GB will direct the facility administrator to report any deviations from the template policies to the committee responsible for managing the policies and procedures. A review of Facility 1's current CNA/NA employee list undated, indicated there were nine uncertified Nursing Assistants.A review of Facility 1's Nursing Assistant Job Description, undated, indicated, The Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the nursing care activities in which the nursing assistant has received clinical instruction and demonstrated competency. Under the Qualifications section, it stated, NA's must be currently enrolled in a Nursing Assistant Training Program (NATP, six-week NA training program) that required approval from the California Department of Public Health (CDPH). NAs must have clinical competency while enrolled in the NATP.A review of Facility 1's NA's Can and Can't Do List undated, indicated NAs cannot provide direct resident observation, take vital signs, change briefs, feed residents, transfer residents, or any direct resident care at all. During an interview on 12/5/25 at 11:40 am, the Director of Staff Development (DSD), who worked at Facility 1, explained only Facility 2 had state approval for the NATP classes. DSD stated Facility 1, 2 and 3 meet before each NATP session and interview potential NA students and then hire five at each facility. DSD stated once NATP class were completed the five NAs are oriented to Facility 1 for 2 days then paired and shadowed another CNA for training and competencies. A review of Facility 1's nursing staff assignment sheets dated 11/3-11/7/2025 and 12/3-12/10/2025 on 12/30/2025 at 7:30 am, indicated uncertified NAs are assigned to take vital signs and take resident assignments. NAs were taking vital signs and working independently and were not paired with a specific CNA for supervision. A review of CNA/NA list and the California Certified Nurse's Assistant Registry (certification verification website) on 1/13/2026 at 11:48 am, indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/6/2025.On 11/3/2025-11/5/2025 NA 1 was assigned to train with CNA 1 on AM shift (6:30 am to 2:30 pm).NA 2 was hired on 9/5/2025, graduated on 10/17/2025, and remains uncertified to date (1/13/2026).On 11/5/2025 NA 2 was assigned a resident assignment with CNA 2 on PM shift (2:30 pm to 10:30 pm).On11/7/2025 NA 2 was assigned a resident assignment to train with CNA 3 on PM shift.On12/5/2025 NA 2 was assigned a resident assignment with CNA 10 on PM shift. From 12/6/2025-12/7/2025 NA 2 was assigned to vital signs and a resident assignment with CNA 2 on PM shift.NA 3 was hired on 10/22/2025 and became a certified Nurse's Aide on 12/19/2025. On 11/3/2025-11/4/2025 NA 3 was assigned to a resident assignment train with CNA 4 on night shift (NOC, 10:30 pm to 6:30 am).On 11/7/2025 NA 3 was assigned independently to a resident assignment on NOC shift. From 12/3/2025-12/4/2025 NA3 assigned a resident assignment with CNA 8 on NOC shift. From 12/6/2025-12/8/2025 NA 3 was assigned to vital signs on NOC shift, not paired with CNA.NA 4 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/6/2025. On11/3/2025 NA 4 was assigned a resident assignment with CNA 5 on the NOC shift. On 11/4/2025 NA 4 was assigned a resident assignment with CNA 6 on NOC shift. On 12/3/2025 NA 4 was assigned a resident assignment with CNA 9.On 12/4/2025 NA 4 was assigned a resident assignment with CNA 5.On12/6/2025 NA 4 was assigned to a resident assignment with CNA 6 CNA on NOC shift.NA 5 was hired on 6/23/2025 and became a CNA on 1/12/2026. From 11/3/2025-11/7/2025 NA 5 were assigned to take vital signs independently on PM shift, not paired with a CNA. On12/4/2025,12/5/2025, and 12/8/2025 NA 5 was assigned to vital signs on PM shift, not paired with CNA.NA 6 was hired in June 2025, graduated 8/8/2025, and became a CNA on 1/7/2026. From 11/3/2025-11/7/2025 NA 6 were assigned to take vital signs independently on PM shift, not paired with a CNA. On 12/3/2025, 12/5/2025, and 12/8/2025 NA 6 was assigned to take vital signs on residents during the AM shift, not paired with CNA.NA 7 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/16/2025. On12/3/2025-12/5/2025 NA 7 was assigned a resident assignment with CNA 7 on NOC shift.NA 9 hired on 6/13/2025 and became a CNA on 9/20/2025. On11/3/2025,11/4/2025,11/6/2025, and 11/7/2025 NA 9 was assigned to take vital signs independently on AM shift, not paired with CNA.A review of CNA/NA staffing lists indicated NA 8 was hired on 4/14/2025.A review of the California CNA registry indicated, NA 8 remains uncertified to date (1/13/2026).During an interview with Administrator (Admin) for Facility 1 on 12/5/2025 at 12:45 pm, Admin stated uncertified NAs are and have been working at Facility 1 on the PM and NOC shifts. Admin stated they were not aware that uncertified NA and NA students were not allowed to be employed or have clinical training at Facility 1. Admin stated, the NATP and clinical routines were established under the previous leadership of Facility 1. Admin stated they plan to bring uncertified NAs back to AM shift for better supervision. Admin stated that currently uncertified NAs are supervised by the DSD. During an interview on 12/10/2025 at 1:25 pm with NA 5, NA 5 stated they have worked at Facility 1 since August 2025 as an NA on the PM shift. They stated they are waiting for their state certification identification number. NA 5 stated they provide direct observation for fall risk residents, have independent assignments, and are occasionally paired with a CNA to shadow the CNA if the CNA wants to show me how to perform a care task. During an interview with NA 2 on 12/10/2025 at 1:40 pm, NA 2 stated they are currently waiting for their state certification identification number. NA 2 stated they have been shadowing (direct resident care with the supervision of a CNA). NA 2 stated they work with another NA who was also waiting for their state certification number.During an interview with the Governing Body, with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview and record review the facility did not ensure one out of three sampled residents (Resident 1) was provided with Physician ordered medications when Registered Nurse (RN) B did not transcribe (copy from a written order and entered into the electronic medical record, EMR) the Physician's orders. This failure had the potential to cause a decline in health status. Findings: A review of the facility's policy and procedure (P&P) titled, Medication-Administration, revised 6/26/25, indicated, the Licensed Nurse (LN) would administer all medications as prescribed by the Physician. A review of the undated Job Description, titled, RN Staff Nurse, indicated, nursing staff would provide care to residents as prescribed by the physician. The Job Description indicated nursing would Receive and transcribe (copy from paper form into electronic form) orders accurately from attending/alternate Physician. The Job Description indicated that the RN would order medication as prescribed by the Physician. A review of Resident 1's admission Record, dated 9/19/25, indicted admission to the facility on 9/19/25 with the diagnoses of displaced fracture of second cervical vertebra (broken neck bone), fracture of nasal bone (broken nose), fracture of upper end humerus (upper arm broken bone), and a recent fall. Resident 1 was their own decision maker and was discharged from the facility on 11/1/25. A review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated 9/22/25, indicated, Resident 1 had 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). Resident 1 scored a 14 out of 15, which indicated Resident 1 had a good memory. During an interview on 12/30/25 at 9:40 am, Resident 1 stated, I went to my doctors for a last-minute appointment [on 10/15/25], and she had orders for me to take medications, two creams. I didn't get them right away and I didn't get the medication until I ended up coming home and was discharged [on 11/1/25] from the facility. During a concurrent interview and record review on 12/30/25 at 2:30 pm, with Assistant Director of Nursing (ADON), Resident 1's handwritten Physician's Orders, dated 10/15/25 was reviewed. ADON confirmed, the Physician's Orders indicated the Urologist (a doctor that specialized in the urinary system for both males and females) ordered two new medications: Clotrimazole cream (an antifungal cream that treated skin infections) twice daily, place on upper thigh, groin (an area of the body that included the vagina) and vulva (the outside area of the vagina) as needed for redness and itching and Esterace (cream that contained female hormones that helped ease symptoms of menopause, such as redness, itching or dryness in the vagina) one gram inserted into the vagina once a week at bedtime for six months. ADON stated, when a resident left the facility for a doctor's appointment, we send them with a blank Physician's Orders note (the Physician writes their orders and recommendations onto the Physician's Orders note for the facility). ADON confirmed, the Physician's Orders were noted (signed and dated by the nurse, indicating it was reviewed, and Physician instructions were understood) by RN B, and stated, the ADON, DON, or Unit Manager Nurse were responsible to enter [transcribe] the new Physician's Orders into the electronic medical record (EMR). During a concurrent interview and record review on 12/30/25 at 2:35 pm, with ADON, Resident 1's Health Status Note (progress note), written by RN B, and dated 10/15/25 was reviewed. ADON confirmed, the progress note indicated that Resident 1 had an appointment with the Urologist and was placed on Clotrimazole cream and Esterace cream. ADON reviewed the Physician's Order section of the EMR. ADON confirmed, the Clotrimazole cream and Esterace cream were not entered as an order into Resident 1's EMR and stated, the cream orders should have been entered. During an interview on 12/31/25 at 8:36 am, Director of Nursing (DON) confirmed, an independent record review had been performed by DON and stated, the two medications were not ordered [for Resident 1].

Based on interview and record review, the facility failed to report an abuse allegation for Resident 1 within the required timeframe when a Certified Nursing Assistant (CNA 1) was witnessed shoving him back forcefully into his wheelchair.This failure had the potential to put all residents at continued risk for abuse by staff. Findings:A review of the facility policy titled AN01 Abuse Prevention and Management with the effective date of 06/12/2024 Indicated Purpose: To address the health, safety, welfare, dignity, and respect of residents. Reports of resident abuse, mistreatment, neglect exploitation, injuries of an unknown sources, and any suspicion of crimes are promptly reported and thoroughly investigated. P-AN01 with the effective date of 06/12/2024 indicated 7 Notification of Outside Agencies for all Allegations of Abuse. a. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written report to the Ombudsman, Law Enforcement, and California Department of Public Health (CDPH), and Certification within (2) hours.A review of Resident 1's record indicated he was admitted to the facility on [DATE], with diagnoses which included stroke with left side weakness and needed assistance with care. Resident 1 was able to make his own health care decisions. A review of facility incident report received by the California Department of Public Health (CDPH) dated 12/24/25 at 5:10 pm, indicated CNA 3 documented and reported to Licensed Nurse (LN 4) on 12/23/25 at 6:50 pm, an allegation of abuse. CNA 3 observed CNA 1 forcefully grab Resident 1's shirt and shoulders and shoved him back in his wheelchair to prevent a fall, then CNA 2 stated to Resident 1 see this is why we don't get you up. Administrator (Admin) of the facility reported this incident late on 12/24/25 at 5:10 pm, to CDPH.During a concurrent interview and record review on 12/29/2025 at 11:01 am, Admin stated the timeframe for reporting allegations of abuse was within 24 hours if there are no injuries. After reviewing the facility's abuse policy, Admin confirmed the reporting time was immediately or within 2 hours after an abuse allegation is made. Admin confirmed the facility had not reported the allegation of abuse to Resident 1 in accordance with their Abuse Policy.

Based on interview and record review, the facility failed to ensure Resident Representative (RP) had the right to retrieve the resident's personal belongings, when the RP of one of five sampled residents (Resident 5) was not given personal property back to them following the death of Resident 5. This failure by the facility had the potential to impact further property transfers, if not corrected. During a review of facility policy titled Personal Property, dated [DATE], indicated that the facility is required to ensure they take reasonable steps to protect resident's personal property, and the facility will return inventoried personal items to residents or their representative upon discharge in a timely manner, and take reasonable steps to safeguard the belongings in the interim. The facility policy also indicated that Upon the death of a resident, the resident representative will review the resident's inventory to ensure all personal items are taken at this time.During a review of Resident 5's clinical record, dated [DATE], indicated that Resident 5's RP was listed as RP 1, as the Emergency Contact #1, and as the Next of Kin. During a review of Resident 5's record titled, Personal Effects Inventory Form, dated [DATE], the record listed Resident 5's belongings as one nightgown with orange palm trees on it, and 1 pair of white socks. This form was signed by two staff members upon receipt of belongings at the facility, and followed facility procedure. This record did not have any documentation of removal or returning personal property to RP 1 following the death of Resident 5. During a review of Resident 5's records titled EInteract Change in Condition Evaluation, dated [DATE] at 10:30 pm, indicated that Resident 5 was transferred from facility to acute care via ambulance, due to a change in health condition. During a review of Resident 5's records titled Discharge Summary Notes - Death Summary, dated [DATE], indicated Resident 5 died at 2:10 pm, at local acute care hospital.During an interview with RP 1 on [DATE] at 11:52 am, RP 1 stated they never received Resident 5's personal property following their death outside the facility. RP 1 stated that after Resident 5 had died, they went to the facility to sign paperwork and retrieve personal property. Facility staff informed RP 1 that Resident 5's personal belongings had already been removed by Family member 3. Facility staff were unable to tell RP 1 or provide documentation regarding which belongings were taken by Family member 3. RP 1 stated that they were unable to retrieve any personal belongings from Family Member 3 and expressed sadness at the loss of those belongings. During a concurrent interview and record review with the administrator (ADMIN) on [DATE] at 2:37 pm, ADMIN confirmed that Resident 5's Personal Effects Inventory Form, dated [DATE], only listed the intake of belongings, and did not list any personal belongings were released to any family member after their death. ADMI stated No, [Resident 5's] inventory form is not signed. During an interview with Licensed Vocational Nurse (LVN )B on [DATE] at 2:46 pm, LVN B stated they had witnessed Family Member 3 inside the facility removing the personal belongings of Resident 5, a few days after Resident 5 died. LVN B stated she spoke to Family Member 3, expressed sympathy for Resident 5's passing, and observed Family Member 3 carrying a small bag of Resident 5's belongings out of the room. LVN B stated they did not think to check or update the inventory form at that time.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of two residents (Resident 1) sampled for falls. Resident 1 had four unwitnessed falls in seven days, three occurring after an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) was not replaced and contributed to Resident 1's falls by her attempting to toilet herself. Key failures included:Care Plan was not updated with new interventions to prevent further falls, despite the facility's fall policy requiring increased observation and structured routine for residents with two or more falls in a week.Nurses had not completed the required assessments, the Neurological (refers to brain, nerves and spinal cord function) Flow Sheet (a standardized document used by healthcare professionals to record and monitor a patient's neurological status over time. This tool is crucial for detecting subtle changes or a sudden deterioration in a patient's condition, especially in cases of head trauma that results in a brain bleed), for 72 hours after an unwitnessed fall, and the alert charting (nursing documentation once a shift concerning the status of a resident after a fall) for 72 hours, to determine if Resident 1 had a head injury and had not recognized when she showed signs of a brain bleed (signs of a brain bleed include: headache, confusion, difficulty in thinking, weakness of one side of the body and loss of balance and coordination.No bladder assessment or individualized toileting program (staff track the resident's bathroom habits over several days to identify patterns in urination) was done after the catheter came out.This resulted in repeated falls for Resident 1 and subsequently, a head injury that developed into a brain bleed that required hospitalization and resulted in the death of Resident 1.Findings:A review of the facility's policy and procedure (P&P) titled Fall Management Program revised [DATE], indicated it is the facility's purpose to provide a safe environment that minimizes complications associated with falls. The P&P indicated that the Licensed nurse and/or IDT (Interdisciplinary Team, a group of professionals to address complex problems) will develop a Plan of Care according to the identified risk factors and root cause. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment and update, initiate or revise a Plan of Care. The Licensed Nurse will complete the Neurological Flow Sheet for an un-witnessed fall. for seventy-two hours following the fall incident. Within 15-20 minutes after a fall the Licensed Nurse will initiate a post fall huddle utilizing the Post fall Huddle form. Once the post fall huddle is completed the Licensed Nurse will update the care plan with immediate recommendations. A resident who sustains multiple falls as defined as more than one fall in a day, week. will be considered a high risk to fall and as a result may sustain a major injury. These residents may: require more frequent observation of activities and whereabouts, may require a structured environment or routine, and may require special equipment to promote independence. These interventions will be documented on the resident's plan of care and in the resident's clinical record.A review of the facility's Fall Incident Checklist (undated), indicated that after a resident has a fall the staff is to place resident on alert charting for 72 hours, initiate frequent safety checks and implement a new intervention in the long-term care plan.A review of the facility's policy and procedure (P&P) titled Bowel and Bladder Indwelling Catheter -Insertion, Maintenance and Discontinuation of revised [DATE], indicated Discontinuation of an Indwelling Catheter. D. Bladder training (a therapy that aims to improve bladder control and uses scheduled urination timetable to help gain control of urination) will be provided as indicated per the Bowel and Bladder Training/Toileting Program. F. The residents' care plan will be updated as necessary.A review of the facility's P&P titled Bowel and Bladder Training/toileting Program revised [DATE], indicated, The licensed nurse will assess a Resident's bowel and bladder status.upon the removal of an indwelling catheter. Interventions identified by the licensed nurse and or the IDT will be care planned and communicated to the corresponding professional and to the facility staff for implementation. Following review and determination for the residents voiding (urinating)/bowel evacuation pattern, the licensed nurse will develop an individualized Bowel and Bladder Training Program to meet the Resident's needs. The established pattern and individualize bowel and bladder training intervention (s) will be documented in the care plan. A review of Resident 1's admission record dated [DATE], indicated Resident 1 was admitted to the facility from a local hospital on [DATE] with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of [DATE], Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's Hospital record titled Physical Therapist (PT) Therapy Daily/Treatment dated [DATE], PT documented discharge recommendation: 24-hour supervision/assist. A review of Resident 1's [DATE]'s Physician Orders indicated orders dated [DATE] which included medications that increased her risk for falls, frequent toilet needs and increased bleeding. Furosemide (a water pill that helps reduce fluid in the body through urination and caused Resident 1's increased risk for falls due to her frequent toilet needs) 20 mg (milligrams a measurement) daily. Rivaroxaban (a medication that prevents blood from clotting and increases the potential for bleeding and bruising) 15 mg daily. Resident is unable of making healthcare decisions.A review of Resident 1's Fall Care Plan dated [DATE], indicated, The Resident is at risk for falls related to deconditioning (the decline in physical and mental function), gait (the pattern how a person walks) balance problems, weakness interventions included: Call light is within reach and resident needs prompt response to all requests. Educate the resident about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear when ambulating or moving in wheelchair (w/c). Follow facility fall protocol. Physical Therapy to evaluate and treat as ordered or PRN (as needed). Fall 1:A review of Resident 1's Progress Notes titled Alert Note dated [DATE] at 9:55 pm, Licensed Vocational Nurse (LVN) B indicated Resident 1 was found to be yelling out for help. Resident 1 was found sitting on the floor in front of her closet.A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 10:30 pm, LVN B documented fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to brush her teeth. Resident 1's post fall risk score was 7 (at risk for falls).A review of Resident 1's Progress Notes titled IDT Progress Notes - Falls dated [DATE] at 7:23 am, the IDT clinical team documented the review of Resident 1's unwitnessed non-injury fall on [DATE] at 9:45 pm. During rounds resident was heard yelling out for help. Upon staff investigation, resident was seen sitting on the floor in front of her closet, wearing non-skid socks. Per (by means of) resident input, Resident stated, 'I was going to go brush my teeth and sat on the floor when I lost my balance.' Root cause of fall for Resident 1 was documented as adjusting to new facility and most likely adjusting to required supervision/SBA (stand by assist) for ADL's (activities of daily living, like brushing teeth, washing face, transferring to bed or wheelchair, walking and toileting) and probably not thinking she needed help. IDT rec (recommendation) is MRR (medication regimen review), continue with therapy evaluation for strengthening and safety transfers.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention (for the [DATE] fall) on [DATE] indicating to continue with therapy evaluation for strengthening and safety transfers. The care plan had not included assisting Resident 1 with brushing her teeth.A review of Resident 1's Progress Notes titled Alert Note dated [DATE] at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out and was not replaced. A review of Resident 1's [DATE] progress notes indicated there was no documentation in Resident 1's progress notes to indicate why the indwelling catheter was not replaced. A review of Resident 1's [DATE] Physician Orders indicated there was no order to discontinue the indwelling catheter. A review of Resident 1's [DATE] Care Plans indicated there was no Bowel and Bladder Care Plan developed and no individualized Bowel and Bladder Training Program to meet Resident 1's bladder needs, since she would then have to use the toilet instead of a urinary catheter to empty her bladder.Fall 2:A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 5:10 am, LVN C noted Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of the fall. Resident 1's post fall risk score was 14 (at high risk for falls).A review of Resident 1's Progress Notes titled IDT Progress Notes- Falls dated [DATE] at 7:23 am, IDT clinical team documented a review of Resident 1's unwitnessed. fall on [DATE] at 5:10 am. Per resident input, I fell and hit my head on the door'. 'I don't know what happened, I just fell' root cause of fall is adjusting to new facility, same root cause as Fall number one. IDT indicated Resident 1's indwelling catheter had been discontinued and there was no documented discussion about a toileting program for Resident 1.A review of Resident 1's Neurological Flow Sheet dated [DATE] starting at 5:10 am, indicated an incomplete flow sheet with no assessment of level of consciousness (ability to think clearly), movement (balance and coordination), hand grasps (determines if there is a weakness for one side of the body), pupil size (a sudden change in pupil size can be a sign of a brain bleed) and reaction for the first 24 hours.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] for orthostatic blood pressure (dropping of blood pressure that occurs when a person stands up from sitting or lying position) evaluation. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week. A review of Resident 1's Nursing Progress Notes/Alert Charting from [DATE] to [DATE] indicated that between [DATE] at 7:45 am, to [DATE] at 6:24 pm, for 82 hours, there was no shift (every eight hours) alert charting, for the required 72 hours after a fall, concerning Resident 1's condition after the [DATE] fall at 5:10 am.A review of Speech Therapy Evaluation and Plan of Treatment dated [DATE] at 6:13 pm, by Speech Language Pathologist (SLP), SLP documented However, due to the patient's high level of pain (10/10) and multiple attempts to complete the assessment, ST discontinued the session and discussed with patient that it will be completed during the next treatment session. ST continued to document PT (patient) requires 24/7 supervision and is a high fall risk. A review of Resident 1's [DATE]'s MAR indicated that on [DATE] at 6:35pm, Resident 1 complained of a headache rating a pain level of 6 (on a scale of 0-10, where 0 is no pain and 10 is the worst pain, one could experience). Resident 1 was given Tylenol 650 mg for moderate to severe pain. LVN B documented a follow up charting on [DATE] at 8:24 pm, indicating the Tylenol was ineffective and Resident 1's pain level was now a 5. No physician follow up documented.Fall 3:A review of Resident 1's Progress Note titled Alert Note by LVN B on [DATE] at 00:55 am, LVN B documented This resident was heard asking for help, upon arrival the resident was found to be sitting on the floor with her back against the bed. When asked what happened the resident stated that she was attempting to go back to bed from the bathroom but fell on the floor before sitting on the bed.A review of Resident 1's Progress Notes titled, IDT Progress Notes- Falls dated [DATE] at 8:26 am, IDT documented IDT clinical team review of unwitnessed non-injury fall [DATE] at 00:55 am. Root cause of fall was resident not requesting assistance with toileting need. IDT recommended is MRR, continue with therapy as ordered and therapy to post safety reminders to ask for help. Resident 1's need for toileting assistance or individualized toileting program, was not addressed.There was no Neurological Flow Sheet for Resident 1 for the date of [DATE] at 00:55 am for fall # 3 as per policy for an unwitnessed fall. This was confirmed by the Medical Records (MR) on [DATE] at 2:30 pm. A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] to continue with therapy as ordered. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week or individualized toileting program.A review of Resident 1's [DATE]'s MAR indicated that on [DATE] at 1:53 pm, Resident 1 complained of unidentified pain rating at a 5 and Tylenol 650 mg was given for pain. Follow up charting on [DATE] at 5:08 am, LVN B documented it was unknown if the Tylenol was helpful. A review of the Physical Therapy Treatment Encounter Note dated [DATE] at 2:53 pm, Physical Therapy Assistant (PTA), PTA documented Standing balance at sink for basic ADL's, w/ (with) low tolerance as pt (patient) presents with a headache. A review of the Occupational Therapy Treatment Encounter Notes dated [DATE] at 5:09 pm, by Occupational Therapy (OT), OT documented Response to session interventions: Pt (patient) presents extremely disoriented this date, pt (patient) repeatedly stated she did not feel well. Fall 4A review of Resident 1's Progress Note titled, Alert Note by LVN B on [DATE] at 9:10 pm, LVN B documented During med pass the resident was heard faintly asking for help. LN responded and noticed the resident was lying on her left side on the floor at the foot of her bed. A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 9:10 pm, LVN B documented Time of fall [DATE] at 9:00 pm, fall was not witnessed and occurred in resident room. Resident was attempting to self-toilet (go to the bathroom by herself) at time of fall. Fall risk score 19 (at high risk for falls).A review of Resident 1's IDT Progress Notes- Falls dated [DATE] at 7:21 am, IDT documented IDT clinical team review of 2nd unwitnessed non-injury fall on 8/19 at 9:00 pm. Root cause of fall is possibly that resident continues at this time adjusting to new environment and possibly adjustment to requiring assistance with care and remembering to request assistance. IDT recommends is MRR, continue with therapy for strengthening/safety transfers and continue with ST (Speech Therapy) for cognition (mental status).There was no Neurological Flow Sheet for Resident 1 for the date of [DATE] at 9:10 pm for fall #4. This was confirmed by MR on [DATE] at 2:30 pm.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] for therapy to post safety reminders to ask for help. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week or individualized toileting program. A review of a Progress Note titled e-INTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated [DATE] at 1:30 pm, Registered Nurse (RN) A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, blood pressure of174/122 (normal is at or less than 120/80) altered level of consciousness (a decrease in alertness, awareness and responsiveness) and increased confusion. Primary provider was notified and ordered to send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment.A review of the Ambulance report dated [DATE] at 2:30 pm, Paramedic (PM) documented, female sitting in her wheelchair complaining of a headache secondary to a fall 5 days ago. Staff report patient has fallen 4 times in the last 5 days. Pt experienced a head strike with the first fall 5 days ago. Staff report patient has become more altered today and began complaining of a splitting headache. Small contusion (bruise) to forehead.A review of the local hospital's report dated [DATE] by Medical Doctor (MD), MD documented, Over the last few days has had multiple falls with one known head strike. Is normally oriented x 4 (person, place, time, and situation) but today was found to be oriented x 1 (person) only and is confused. She is complaining of a headache. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS (central nervous system, brain and spinal cord, which act as the body's main control center) failure or compromise.A review of the local hospital's CT (computerized tomography, a type of X-ray) of the head was done and the final result dated [DATE] at 3:15 pm, was read by Radiologist (RD), RD indicated, Extensive subdural (a life-threatening large volume of bleeding in the outermost covering of the brain, most commonly caused by a severe head injury, but can also occur with minor trauma, especially in older adults and symptoms can develop days or weeks after an injury) and intraparenchymal hemorrhage(a bleed directly into the brain's functional tissue) in the left cerebral (brain) hemisphere with tiny focus of subarachnoid hemorrhage ( SAH, small bleed in the area between the brain and its middle protective membrane. Traumatic brain injury is a common cause of SAH), in the right frontal lobe and tiny focus subdural hemorrhage (small bleed on the right side of the brain) adjacent to the right frontal lobe. Localized mass effect (large amount of blood) in the left parietal (upper-back and rear areas of the brain) and occipital lobe (primary visual processing center of the brain) secondary to the large hematoma (bleed). A review of Resident 1's Death Certificate dated [DATE], indicated Resident 1 died on [DATE]. The cause of death was subdural hematoma caused by an unwitnessed fall at [Facility name].During a concurrent interview with the Director of Rehabilitation (DOR) and a record review on [DATE] at 11:45 am, Resident 1's Fall Care Plan was reviewed. DOR stated that Resident 1 required moderate assistance with staff for transferring, toileting and walking. The DOR stated that there were no adequate interventions after each fall, like increase supervision or use a fall mat by bed, to protect Resident 1 from falls and injuries and there should have been.During a concurrent interview with RN A and record review on [DATE] at 2:02 pm, Resident 1's progress note created on [DATE] as a late entry for the date of [DATE], by RN A was reviewed. RN A stated that on [DATE] at around 1:00 pm, the social service assistant approached her and stated that Resident 1 was not acting right. RN A stated that she assessed Resident 1 and she was holding her hands over her eyes, with eyes closed and a grimaced expression. Resident 1 stated she had a headache but could not give description of pain or pain source. RN A stated that Resident 1 had a bump with discoloration on her forehead and it measured 21mm (millimeters, a measurement of about an inch). The Physician was notified and recommended sending Resident 1 to the acute care hospital for further evaluation and treatment. RN A stated that with every unwitnessed fall the staff were supposed to perform neuro checks and every 8 hours and alert charting for 72 hours to evaluate a resident's condition after a fall, because they were assessing for a head injury. RN A was unable to provide documented alert charting or completed neuro checks for Resident 1 after fall number two on [DATE] and fall number three and four on [DATE]. RN A confirmed that they should have been done.During a concurrent interview with LVN E and record review on [DATE] at 3:02 pm, Resident 1's [DATE]'s Medication Administration Record (MAR) was reviewed. LVN E stated that Resident 1 was weak, had COVID and was in isolation (requiring a private room). Resident 1 would not use her call light. She would just get up and go (to the bathroom). She was supposed to have someone go with her. LVN E stated that hourly safety checks should have been done for Resident 1 due to her falls and condition, if hourly safety checks were done for a resident they would have been documented on the MAR. A review of Resident 1's MAR indicated that there were no hourly safety checks documented for Resident 1. During an interview with LVN B on [DATE] at 12:44 pm, LVN B stated that Resident 1 was confused, unstable, had a UTI and was getting up and down to the bathroom a lot. LVN said that after Resident 1's indwelling catheter came out she was going to the bathroom every 1-1/2 to 2 hours. LVN B stated that Resident 1 had fallen three times during her shifts out of the total of her four falls. LVN B recalled that when Resident 1 felt the urge to urinate, she would get up and go and would not use the call light to ask for assistance. LVN B stated that when there was enough staff scheduled, she had a staff member sit outside of Resident 1's room to increase Resident 1's supervision and assistance with toileting. LVN B said there was not always enough staff to do this. LVN B stated that she felt Resident 1 should have had a one on one intervention (meaning a staff member was assigned to Resident 1 all the time) in her Fall Care Plan to prevent her from falling. LVN B confirmed she did not put any new interventions into Resident 1's fall care plan concerning Resident 1's need to be a one on one. LVN B stated she did not know how to make care plans, and she needed training on this.During an interview with Certified Nursing Assistant (CNA) F on [DATE] at 1:27 pm, CNA F stated that Resident 1 would walk back and forth to the bathroom, not put her call light on, and would always shut her door to her room and needed to be checked on frequently.During an interview with CNA G on [DATE] at 2:13 pm, CNA G stated that Resident 1 was a high fall risk, and got up a lot without her walker, was in an isolation room and would not use her call light for help. CNA G stated that there were no special instructions about when to check on her.During a concurrent interview with the Director of Nursing (DON) and record reviews on [DATE] at 3:55 pm, Resident 1's [DATE] Progress Notes (which included the alert charting), Fall Care Plan, Physician Orders and Neurological Flow Sheets were reviewed. DON confirmed that Resident 1 was in the facility for seven days and had four unwitnessed falls, including one with a head strike, during that time. DON confirmed that Resident 1's indwelling catheter fell out and was not replaced even though there was not a Physician order to discontinue it. DON reviewed Resident 1's care plans and confirmed that there had been no bladder training to assist Resident 1 with bladder control and there should have been as per their policy. DON stated that Resident 1 had hit her head on the second fall ([DATE]) and after the DON reviewed Resident 1's Neurological Flow Sheet, Progress Notes and Care Plans, she confirmed that the [DATE] Neurological Flow Sheet had not been completed, no alert charting had been done for 72 hours, and no new interventions were put into place to prevent Resident 1 from falling again as per the Fall Management Policy. DON confirmed that on [DATE] Resident 1 had two falls and there were no Neurological Flow Sheets completed, no alert charting for 72 hours and no new fall interventions were developed to prevent future falls as per policy. DON stated that the interventions that should have been developed and implemented, to prevent falls, should have been to check resident before and after meals, and at bedtime for toileting needs and to monitor bowel and bladder needs every 2 hours after the indwelling catheter fell out and was not replaced. DON stated that a one-on-one intervention for supervision is only done as a last resort to prevent falls.

Based on interview and record review the facility failed to notify the Responsible Party (RP- the person who is responsible for making health care decisions for a resident) of falls and a change of condition for one of two residents (Resident 1) sampled for falls, when Resident 1 had four unwitnessed falls, her indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) fell out and was not replaced, a change in condition due to a head injury, was transferred to an emergency department (ED) and the RP was not notified.Refer to F689.This failure prevented the family from knowing about Resident 1's falls, condition changes, and transfer to the emergency department, hindering their ability to make informed decisions and participate in Resident 1's care.Findings.A review of the facility's policy titled Change in Condition dated 8/25/22 indicated A Licensed nurse will notify the resident's Physician/APP (advanced practice providers) and legal representative or an appropriate family member when there is an: a. Incident/accident involving the resident: b. An accident involving the resident which results in injury and has the potential for requiring physician intervention; c. A significant change in the resident's physical, mental or psychosocial status. g. A decision to transfer or discharge the resident from the facility. The Licensed Nurse will notify the family/surrogate (an RP) decision-maker of any changes in the resident's condition as soon as possible.A review of Resident 1's admission Record dated 8/13/25, indicated Resident 1 was admitted to the facility from a local hospital on 8/13/25 with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (a respiratory disease that easily spreads to other people), difficulty in walking, muscle weakness, cognitive communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. Resident 1's RP and Emergency contact #1 was Daughter A.A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of 8/20/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's August 2025's Physician Orders indicated an order dated 8/13/25 which included: Resident is unable to make healthcare decisions.A review of Resident 1's Durable Power of Attorney for Health Care (legal document that allows you to name a person to make medical treatment decisions for you if you cannot, an RP) dated and signed by Resident 1 on January 25, 2001, indicated that Resident 1's husband was designated and appointed to make health care decision for Resident 1. If Resident 1's husband was unable to act as her agent, then Resident 1's two daughters (Daughter A and Daughter B) are to serve as her decision maker for health care.A review of Resident 1's Progress Note titled N Adv - Post Fall Evaluation dated 8/13/25 at 10:30 pm, Licensed Vocational Nurse (LVN) B documented Time of Fall 8/13/25 9:45 pm. Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to brush her teeth. Resident 1's post fall risk score was 7 (at risk for falls). Resident's responsible party notified: Yes. Person contacted: Resident is her own RP. A review of Resident 1's Progress Note titled Alert Note dated 8/14/25 at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out. The indwelling catheter was not replaced. There was no documentation indicating the RP was notified.A review of Resident 1's Progress Note titled Social Service on 8/15/25 at 3:57 pm, Social Service (SS) documented Resident (1) request daughter, (name, Daughter A), to be her RP since her daughter is taking care of everything for herA review of Resident 1's Progress Note titled N Adv-post Fall Evaluation dated 8/19/25 at 01:05 am, concerning fall at 8/19/25 at 0:55 am, LVN B documented Unwitnessed fall responsible party notified: Yes, Person Contacted: Resident is her own RP.A review of Resident 1's Progress Note titled N Adv-post Fall Evaluation dated 8/19/25 at 9:10 pm, concerning fall at 8/19/25 at 9:00 pm, LVN B documented Unwitnessed fall responsible party notified: Yes, Person Contacted: Resident is her own RP.A review of a Progress Note titled eINTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated 8/20/25 at 1:30 pm, RN A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, BP=174/122 (normal is less than 120/80) altered level of consciousness and increased confusion potential signs of a head injury and/or brain bleed. Primary provider was notified and ordered to send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment. No documentation that the RP was notified of transfer to ED.A review of the ED provider notes from the local hospital dated 8/20/25 at 2:12 pm, indicated that Resident 1 arrived at the hospital on 8/20/25 at 2:12 pm.A review of Resident 1's progress notes titled Alert Note on 8/20/25 at 5:27 pm, RN A documented Called residents daughter (name of Daughter A), left voicemail message requesting return phone call to touch base about recent events and further plan of care. Three hours after Resident 1 arrived at the ED.During a phone interview with Daughter 1 on 10/2/25 at 3:59 pm, Daughter 1 stated that she had not been notified about Resident 1's indwelling catheter falling out and not being replaced, Residents 1's falls, and that she went to the ED on 8/20/25. Daughter 1 said that her father (Resident 1's husband) was in the hospital due to an illness and that the facility was informed on 8/15/25 to call her (Daughter 1) for any changes in condition but they failed to do so. Daughter 1 indicated she also had an illness that prevented her from going to the facility and was unable to visit Resident 1 so she relied on the facility to keep her informed of changes with Resident 1.During an interview on 10/21/25 at 2:02 pm, RN A stated that there was some confusion, as to who was Resident 1's RP.During an interview on 10/22/25 at 12:44 pm, LVN B stated that she did not call family when Resident 1 had her fall on 8/13/25 and her two falls 8/19/25 because her admission Record at those times indicated that Resident 1 was her own RP.During a concurrent interview with RN A and record review on 10/22/25 at 2:56 pm, Resident 1's Progress Notes titled Alert Note dated 8/14/25 at 11:28 am, was reviewed. RN A stated that when Resident 1's indwelling catheter fell out, the physician informed her not to replace the catheter. RN A confirmed that there was no documentation concerning the family or RP being notified concerning the discontinuation of the indwelling catheter and as per the facility policy.During a concurrent interview with the Director Of Nursing (DON), on 10/2/25 at 3:55 pm, Resident 1's Progress Note titled Social Service on 8/15/25 at 3:57 pm was reviewed. DON confirmed that Daughter A wanted to be notified of any changes in Resident 1's condition and was not sure why she wasn't.

Based on interview and record review the facility failed to ensure an injury of unknown origin and major accident for one of two residents (Resident 1) sampled for falls, was reported to the California Department of Health (CDPH) when Resident 1 had a bruise and bump on her head of unknown origin, unwitnessed falls, and a change in condition which sent Resident 1 to the hospital and eventually die due to a brain bleed.This failure to report had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse.FindingsA review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting dated [DATE], indicated The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies (California Department of Health, CDPH) c. Other Occurrences. ii. Major accidents. iv. Other occurrences that. affect the welfare, safety, or health of residents. Unusual occurrences are reported to the appropriate agency withing 24 hours by telephone and confirmed in writing.A review of Resident 1's admission record dated [DATE], indicated Resident 1 was admitted to the facility from a local hospital on [DATE] with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee.A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of [DATE], Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's Progress Notes titled IDT (Interdisciplinary Team, a group of professionals to address complex problems) Progress Notes- Falls dated [DATE] at 7:23 am, IDT clinical team documented a review of Resident 1's unwitnessed. fall on [DATE] at 5:10 am. Per resident input, I fell and hit my head on the door'. 'I don't know what happened, I just fell.'A review of Resident 1's Progress Notes titled Alert Note by Licensed Vocational Nurse (LVN) B on [DATE] at 00:55 am, the note indicated that Resident 1 had another unwitnessed fall.A review of Resident 1's Progress Note titled Alert Note by LVN B on [DATE] at 9:10 pm, the note indicated that Resident 1 had another unwitnessed fall.A review of a Progress Note titled eINTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated [DATE] at 1:30 pm, Registered Nurse (RN) A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, BP=174/122 (normal is less than 120/80) altered level of consciousness and increased confusion potential signs of a head injury and/or brain bleed. Primary provider was notified and ordered to send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment.A review of the Ambulance report dated [DATE] at 2:30 pm, Paramedic (PM) documented female sitting in her wheelchair complaining of a headache secondary to a fall 5 days ago. Staff report patient has fallen 4 times in the last 5 days. Pt experienced a head strike with the first fall 5 days ago. Staff report patient has become more altered today and began complaining of a splitting headache. Small contusion (bruise) to forehead .A review of the local hospitals report dated [DATE] by Medical Doctor (MD), MD documented Over the last few days has had multiple falls with one known head strike. Is normally oriented x 4 but today was found to be oriented x 1 only and is confused. She is complaining of a headache. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS (central nervous system, brain and spinal cord, which act as the body's main control center) failure or compromise.A review of the local hospital's CT (computerized tomography, a type of X-ray) of the head without contrast (no dye was used) was done and the final result dated [DATE] at 3:15 pm, was read by Radiologist (RD), RD indicated Extensive subdural (a life-threatening large volume of bleeding in the outermost covering of the brain, most commonly caused by a severe head injury, but can also occur with minor trauma, especially in older adults and symptoms can develop days or weeks after an injury) and intraparenchymal hemorrhage(a bleed directly into the brain's functional tissue) in the left cerebral (brain) hemisphere with tiny focus of subarachnoid hemorrhage ( SAH, small bleed in the area between the brain and its middle protective membrane. Traumatic brain injury is a common cause of SAH) in the right frontal lobe and tiny focus subdural hemorrhage (small bleed on the right side of the brain) adjacent to the right frontal lobe. Localized mass effect (large amount of blood) in the left parietal (upper-back and rear areas of the brain) and occipital lobe (primary visual processing center of the brain) secondary to the large hematoma (bleed). A review of Resident 1's Death Certificate dated [DATE], indicated Resident 1 died on [DATE] and the cause of death was subdural hematoma from a mechanical (falls caused by external or environmental factors, slipping or tripping) fall. Injury occurred at the Facility (name) and was due to an unwitnessed fall causing subdural hematoma.During a concurrent interview with RN A and record review on [DATE] at 2:02 pm, Resident 1's progress note created on [DATE] as a late entry for the date of [DATE], by RN A was reviewed. RN A stated that on [DATE] at around 1:00 pm, the social service assistant approached her and stated that Resident 1 was not acting right. RN A stated that she assessed Resident 1 and she was holding her hands over her eyes, with eyes closed and a grimaced expression. Resident 1 stated she had a headache but could not give description of pain or pain source. RN A stated that Resident 1 had a bump with discoloration (bruise) on her forehead and it measured 21mm (millimeters, a measurement of about an inch). The Physician was notified and recommended sending Resident 1 to the acute care setting for further evaluation and treatment.During an interview with the Director of Nursing (DON) on [DATE] at 3:26 pm, DON confirmed that the facility did not report this accident or bruise of unknown origin to the CDPH because Resident 1 went to the hospital and did not come back to their facility.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was admitted with an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag), had care and services to maintain normal bladder function when Resident 1('s): Did not have an assessment for the need of an indwelling catheter. Indwelling catheter was discontinued without a physician's order. Was not provided bladder training to restore normal bladder function after the indwelling catheter was removed. Did not have a care plan created with interventions concerning her bowel and bladder function.These failures caused Resident 1 to get up and down to the bathroom many times without assistance and have multiple falls.Findings:A review of the facility's policy titled Nursing Policy and Procedure (P&P)- Bowel and Bladder, Indwelling Catheter - insertion, maintenance and Discontinuation of. revision date of 7/22/25, indicated, A Licensed Nurse will assess the need for continued use of a catheter. The Licensed Nurse will notify the physician if the assessment indicates the need to discontinue catheter use and obtain orders. Bladder training (a therapy that aims to improve bladder control and uses scheduled urination timetable to help gain control of urination) will be provided as indicated per the Bowel and Bladder training/Toileting Program. The licensed nurse will monitor for any signs or symptoms of urinary burning, frequency, urgency, or suprapubic pain after the removal of the indwelling catheter and inform the physician for orders if noted or reported. The resident's care plan will be updated as necessary. A review of the facility's policy and procedure (P&P) titled Bowel and Bladder Training/Toileting Program revised August 21, 2020, the P&P indicated After the removal of a urinary catheter (indwelling catheter), services are provided to restore or improve bladder function to the furthest extent possible. The P&P continue to indicate: The licensed nurse will assess a Resident's bowel and bladder status. upon the removal of an indwelling catheter. Interventions identified by the licensed nurses and/or the Interdisciplinary Team (IDT, Interdisciplinary Team, a group of professionals to address complex problems) will be care planned and communicated to the corresponding professional and to the facility staff for implementation. The Certified Nursing Assistant (CNA). will observe and document the Resident's current voiding (urination)/bowel evacuation pattern for a minimum of three days. Following review and determination of the Resident's voiding/bowel evacuation pattern the licensed nurse will develop an individualized Bowel and Bladder Training Program to meet the Resident's needs. The established pattern and individualized bowel and bladder training interventions will be documented in the plan of care.A review of Resident 1's admission record dated 8/13/25, indicated Resident 1 was admitted to the facility from a local hospital on 8/13/25 with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the seven day observation period for a MDS assessment) of 8/20/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and was continent (able to control) with her bowel movements. A review of Resident 1's Progress Notes titled Alert Note dated 8/14/25 at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out. A review of Resident 1's Progress Notes titled IDT Progress Notes- Falls dated 8/15/25 at 7:23 am, IDT indicated Resident 1's indwelling catheter had been discontinued. A review of Resident 1's August 2025 Progress Notes indicated there was no documentation in Resident 1's progress notes to indicate why the indwelling catheter was not replaced. And there was no Alert Charting concerning Resident 1's status after the indwelling catheter was removed. A review of Resident 1's August 2025 Physician Orders indicated there was no order to discontinue the indwelling catheter. A review of Resident 1's August 2025 Assessments indicated there was no assessment of Resident 1's need for an indwelling catheter and there was no assessment for Resident 1's bladder status or bladder training after the indwelling catheter was removed. A review of Resident 1's August 2025 Care Plans indicated there was no Bowel and Bladder Base Line (a care plan that was done within three days of admission) Care Plan developed and no individualized Bowel and Bladder Training Program to meet Resident 1's bladder needs, since she would then have to use the toilet instead of a urinary catheter to empty her bladder. A concurrent interview with RN A and record review on 10/22/25 at 2:56 pm, Resident 1's 8/14/25 at 11:28 am, Progress Note titled Alert Note was reviewed. RN A said that Resident 1's indwelling catheter had fallen out and was never replaced because there was no indication (or diagnoses) to support the use of a catheter. RN A was unable to provide evidence that the physician was notified of the indwelling catheter falling out and that the Physician ordered it to have been discontinued. RN A stated that when an indwelling catheter was removed a resident was put on Alert Charting (a nursing assessment and charting every 8 hours, concerning a particular resident situation) to observe signs and symptoms of bleeding, or retention (where urine stays in the bladder and does not come out). A review of Resident 1's Alert Charting after 8/14/25 at 11:28 am, indicated there were no documented Alert Charting concerning Resident 1's bladder condition after the removal of the indwelling catheter. RN A stated that there was no bladder training done for Resident 1 because the Physician had not ordered it.During a concurrent interview with the Director of Nursing (DON) and record review on 10/22/25 at 2:56 pm, Resident 1's Progress Notes, Physician Orders, Assessments, and Care Plans were reviewed. DON reviewed Resident 1's Assessments and stated that she was not aware of an assessment to determine the need for an indwelling catheter. DON reviewed Resident 1's Physician Orders and confirmed that there was no order to discontinue Resident 1's indwelling catheter and there should have been. DON reviewed Resident 1's Assessments and confirmed that there was no bladder assessment or bladder training for Resident 1 after the indwelling catheter was left out and there should have been. DON reviewed Resident 1's care plans and confirmed that there was no Care Plan concerning Resident 1's interventions needed to restore bladder function.

This requirement was not met when a staff member reportedly spoke to a resident (Resident 1) using profane language and with a disrespectful tone. This had the potential to cause the resident to feel unsafe or that his environment was not home-like.Review of Resident 1's medical record indicated that he was admitted to the facility for Parkinson's Disease (a gradual worsening of coordination and movement caused by diseased brain cells), cognitive communication deficit (trouble speaking and thinking), depression and dementia (age related decline in brain function).A review of Resident 1's Basic Interview for Mental Status (BIMS) performed on 5/28/25 indicated his cognitive (thinking, memory) function was 12 on a scale of one to 15, or moderate cognitive impairment (lessened ability to think and remember).Review of the facility's policy titled, Residents' Rights -- Quality of Life, dated March 2015 indicated: XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility Staffpromote dignity and assist residents as needed .A review of the facility's Mission Statement and Code of Conduct (undated) indicated: Every employee must take personal responsibility for his or her own actions and behaviors. We want you to be part of developing and keeping a workplace culture of trust and respect both for your co-workers and the residents we serve, and, We also expect that you will communicate in a manner that is clear so that others will know that they can trust and depend upon what you say and do. If this is a problem for you, again, we want to know about it.Review of a report filed by the facility on 8/12/25 indicated that Certified Nursing Assistant, (CNA B) reported that she overheard CNA A state to a Resident 1, Shut the [expletive] up! Stop screaming, you are disturbing everyone around you!In an interview on 8/18/25 at 2:55 PM, Resident 1 stated that he overheard swearing by a staff member (the prior week), but was confused and could not remember which staff member he overheard or what exactly was said.In an interview on 8/18/25 at 2:58 PM, CNA A, (the CNA who allegedly spoke disrespectfully to Resident 1), stated she had no recollection of the event although she did know the resident.In a concurrent interview and record review on 8/18/25 at 3:10 PM, Administrator (ADM) confirmed that she received report of an Incident that allegedly happened 8/11/25 around 3:30 PM in which Certified Nursing Assistant (CNA A) was overheard by several staff swearing at Resident 1. ADM stated that CNA A was put on suspension for the rest of 8/11/25 until the facility investigated the incident. ADM stated that the facility's internal investigation concluded that there was insufficient evidence of abusive conduct, and that CNA A's comments might have been heard intermixed with swearing from Resident 1.In an interview on 8/19/25 at 10:20 AM, CNA B stated, I was working with the resident in C bed (in room [ROOM NUMBER]), [Resident 1] was in B bed next to me. [Resident 1] started screaming, and I overheard [CNA A say to [Resident 1]t, Shut the [expletive] up, you're disturbing everybody. CNA B indicated she could tell the difference between a male resident swearing and a CNA swearing at them.In a record review on 8/19/25 at 11:30 AM , ADM provided a printed phone text statement from CNA A that indicated: While on morning shift while I was helping another resident in C bed get up for breakfast, I overheard another CNA [CNA A] who was helping a resident in B bed to shut f up, stop screaming you are disturbing everyone around you.

Based on interview and record review, the facility failed to develop and implement a plan of care to prevent pressure injuries (damage to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure or pressure) for one of four sampled residents (Resident 4) when:1. Resident 4 developed a pressure injury on the sacrum (bony structure located at the base of the back), that progressed to osteomyelitis (an infection of the bone).2. Resident 4 developed pressure injuries on left calf, right and left heels from wearing therapeutic moon boots (maintains proper alignment of foot and ankle from turning inward and outward) brought in from his home.This system failure resulted in Resident 4 developing multiple pressure injuries, wound deterioration, subsequent serious life-threatening infection, and unnecessary pain. Findings:1. During a review of the facility policy titled Skin Integrity Management -Nursing Manual - Skin, dated 7/31/24, indicated the facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure injuries and any other skin integrity conditions. That a licensed nurse will complete a skin evaluation upon any change in skin integrity and conduct weekly skin evaluations. Wound treatments and consultation from a wound care specialist will be ordered by the physician, the physician will be notified of any changes in skin integrity, treatments and their effectiveness will be documented weekly in the medical record. Regardless of the risk skin risk score the licensed nurse will develop a care plan specific to the resident's risk factors in consultation with physician, the Interdisciplinary Team (IDT- a group of healthcare disciplines who work together to discuss resident care), registered dietician, and director of rehabilitation service. IDT will document and make recommendations, and the care plan will be updated as needed. Nursing staff will implement interventions identified in the care plan based on the individual risk factors which may include pressure reducing devices in bed and chair, reposition and turning, heel protectors, off-loading, moisturizers and barrier creams to protect the skin. The care plan will start up admission and update as necessary.During a record review of the undated face sheet of Resident 4, indicated Resident 4 was admitted on [DATE], with diagnoses that included Paralytic Syndrome (the loss of the ability to move a part or all the body), stroke, difficulty speaking, muscle weakness, and the need for assistance with personal care.During a review of record titled Adv - Skin Check, dated 3/20/25, at 5:41 pm, indicated Resident 4 was admitted with the following skin integrity concerns: A pressure injury to left hip, an abrasion on the right leg, redness to coccyx (tailbone area), scrapes on the right knee and surrounding area, and scrapes on both feet and toes.A review of a Braden Scale assessment (predicting pressure injury risk) dated 3/20/25, indicated Resident 4 risk a score of 13 (moderate for acquiring a pressure injury), a score of 12 indicated a high risk.A review of a Minimum Data Set (MDS, resident assessment) dated 3/27/25, indicated Resident 4 had limited range of motion on one side (left), required substantial maximal assistance when rolling side to side, and dependent on staff for moving from a lying position to sitting on the side of the bed. Resident 4 was identified as at risk for developing pressure ulcers. Resident 4 was bed and wheelchair bound.During a record review of record titled Order Summary Report, with a date range of 3/1/25 - 3/31/25, indicated a wound consultation with an order date of 3/20/25.A review of the care plans from 3/20/25 to 5/13/25 indicated no plan of care for pressure ulcer prevention for Resident 4. The first care plan was created on 4/13/25.During a record review of record titled Adv Skin, dated 4/3/25, at 11:23 pm, indicated that Resident 4 had blanching redness (redness that turns white when pressed, indicating blood flow) to coccyx.A review of physician treatment orders from 3/20/25 to 5/13/25 indicated no skin care treatments for the blanchable redness at the coccyx or sacrum. The first treatment order for the buttocks was dated 4/13/25. During a record review of record titled Progress Note New, dated 4/11/25, at 8 pm, indicated that Resident 4 returned to the facility after spinal surgery. Resident 4's skin was described as having a surgical incision on his back, blanchable redness to coccyx, and redness on both right and left hips with patches on top.During a record review of record titled Order Summary Report, with a date range of 4/1/25 - 4/30/25, indicated a second wound consultation with an order date of 4/11/25.During a record review of record titled Progress Note New, dated 4/20/25, at 11:15 am, indicated Resident 4 had a Braden skin assessment with the risk of developing pressure ulcers Score of 10, which indicated a high risk of developing pressure ulcers.During a record review of a record titled Progress Note New, dated 4/20/25, at 11:03 am, indicated Resident 4 has a facility acquired unstageable (base of the wound is not visible to determine the stage) deep tissue pressure injury on the sacrum (bony structure located at the base of the back), measuring 6 centimeters (cm) in length and 9 cm in width. Resident 4 was described as in bed most of the day and required maximum assistance moving and being repositioned in bed.During a record review of a record titled Order Summary Report, with a date range of 4/1/25 to 4/30/25, indicated an order for a Low Air Loss Mattress (LALM, a mattress with continual air flow to help prevent skin breakdown) with a start date (date intervention to begin) of 4/22/25.A review of the IDT Progress notes for Skin from the start of admission on [DATE] through 5/13/25, indicated the first meeting was on 4/24/25.During a record review of record titled Wound Care Progress Note, dated 4/28/25, indicated Resident 4 had multiple wounds. This is the first progress note from the wound care doctor, over a month from the date of the first wound consult order, over 2 weeks from the second. The wound on Resident 4's sacrum (bony structure located at the base of the back) was described as a new unstageable pressure injury, measuring 6.5 centimeters (cm) in length,10 cm in width, with no measurable depth.During a record review of record titled Wound Care Progress Note, dated 5/12/25, indicated Resident 4's sacral wound is described as follows: Unstageable due to necrosis (death of tissue) pressure injury on sacrum (bony structure located at the base of the back), measuring 6.5 cm in length,10 cm in width, and 1 cm in depth. Wound bed is described as having 60% necrotic tissue and progress is described as deteriorated. At this time a procedure where the necrotic muscle was cut away using a surgical blade was completed by the wound care doctor. During a record review of record titled SBAR Summary for Provider, dated 5/13/25, at 2:20 pm, indicated a change in condition regarding a skin wound or ulcer. The MD (Medical Director) was notified of Resident 4's surgical wound reopening, and a decline of the wound on the sacrum. Orders were given to send Resident 4 to the acute care hospital to be evaluated.During a record review of the acute care hospital note titled ED Provider Notes, date 5/13/25, indicated that Resident 4 was admitted to the acute care hospital with diagnoses of sacral (area of the lower back and buttocks) abscess (a localized collection of infection), decubitus ulcer Stage 3 (pressure injury to the muscle) at sacrum possible to the bone, cellulitis (bacterial infection of the skin), quadriplegia (paralysis or weakness in arms and legs), and osteomyelitis (an infection of the bone). The ED note indicated sepsis due to high white blood cell count (sign of infection).2. During a review of record titled Personal Effects Inventory Form, dated 3/20/25, indicated that Resident 4 arrived at the facility with a pair of black and grey therapeutic boots.A review of physician's orders from 3/20/25 to 5/13/25, indicated no orders for the therapeutic moon boots that Resident 4 brought from home.A review of the care plans from 3/20/25 to 5/13/25 indicated no plan of care for direct care staff to utilize therapeutic moon boots.During a record review of record titled Progress Notes New, dated 4/7/25, at 2:10 am, indicated Resident 4 left the facility for a scheduled surgery. Resident 4 left the facility in his own wheelchair, wearing therapeutic boots, with family accompanying him. Resident 4 was readmitted to the facility on [DATE].During a record review of record titled Wound Care Progress Note, dated 4/28/25, indicated Resident 4 had a new unstageable pressure injury on right heel, measuring 1.5 centimeters (cm) in length, 2 cm in width, with no measurable depth, and noted to be boot caused. New unstageable pressure injury on left calf, measuring 4 cm in length, 3 cm in width, noted to be caused by Moon boot.During a record review of record titled Wound Care Progress Note, dated 5/12/25, indicated Resident 4 continued to have wounds that were cause by moon boots with the addition of a new stage 2 pressure injury to left heel, measuring 0.7 cm in length, and 1 cm in width.During a telephone interview with Resident 4's family member (FM) on 6/12/25, at 12:45 pm, the family member expressed concerns with the care provided. They stated that it took a long time to get an air mattress, at least a couple of weeks, and they were concerned about how it would affect Resident 4's skin. FM expressed concern regarding the proper use of Resident 4's air mattress. During a visit on 5/2/25 they witnessed a staff member adjusting the air setting on the bed and were told the setting wasn't correct. They had requested a pad for Resident 4'd wheelchair multiple times but claim one was never provided. They eventually brought a pad from home. On 5/7/25 they saw the pressure wound on Resident 4's bottom and were shocked at how bad it was. They stated that he went back to the local hospital on 5/13/25 and passed away on 6/7/25. They stated that Resident 4 experienced unnecessary suffering due to his wounds before his passing.During an interview with Licensed Nurse A (LN A) on 7/9/25, at 1:35 pm, LN A stated that skin assessments are completed at the time of admission. Skin issues are reported to the facility doctor and all pressure injuries are seen by the wound care doctor. It is LN A's expectation that the wound care doctor will follow up on referrals within a week, and sooner for residents with urgent needs. Wound measurements are taken on the initial assessment. All wounds are followed by a wound care nurse, including areas of redness that have the potential to progress into a pressure injury. Low Air Loss mattress (LAL, a mattress with continual air flow to help prevent skin breakdown) mattresses are typically only provided to residents with Stage 3 or greater pressure injuries, unless they have other high-risk reasons. LN A stated the LAL mattress can be considered earlier than Stage 3 and that was done by the IDT Skin team. LN A recalled Resident 4 wearing therapeutic boots. Resident 4 was wearing the boots all the time until the wound care specialist requested that they only be worn when up. LN A does not recall any special training regarding the use of the boots.During an interview with the Director of Rehab (DOR), on 7/9/25, at 2:30 pm, DOR stated that they recall working with Resident 4. DOR remembers working with Resident 4 and that Resident 4 had been wearing a pair of therapeutic boots that were brought in from home. DOR stated that training is only provided for equipment that comes from therapy, therefore there was no training provided for the boots that Resident 4 was using. DOR confirmed that Resident 4 was always wearing the boots until the wound specialist advised otherwise. DOR did not evaluate the moon boots Resident 4 brought from home.During an interview with the Director of Nursing (DON), on 7/15/25, at 1:30 pm, DON confirmed that Resident 4 had a Braden scale score of 13 on 3/20/25, which indicated they were not at high risk for pressure injuries. While reviewing Resident 4's medical records DON confirmed that Resident 4 did have factors at the time of admission that indicated a high risk for pressure injuries and that her expectation is that a care plan would be developed and implemented to address those risks. While reviewing the care plans for Resident 4, DON confirmed that there was not a care plan in place for the risk of pressure injuries until 4/13/25. Resident 4 arrived at the facility with a pair of personal therapeutic boots. DON confirmed that there was not a care plan nor physician orders for therapeutic boots in place until 4/13/25. It is her expectation that both a care plan and orders should have been in place, and that staff should have been provided with training regarding the use of the boots. DON confirmed the boots were not evaluated for appropriateness for Resident 4. DON confirmed the first documentation assessing Resident 4 by the wound care doctor was on 4/28/25, over a month after the first consult was ordered. It is her expectation that a resident would be seen a week after the first consult is made. DON confirmed that the wound care doctor does visit the facility on a weekly basis. DON confirmed that a LA mattress was not ordered for Resident 4 until 4/22/25, and that it would have been a benefit to Resident 4 if the LAL mattress was provided sooner, due to having a planned spinal surgery and his risk factors. DON stated that after the initial skin assessment is completed on admission it is the treatment nurse's responsibility to complete a second skin check. DON was unable to locate documentation supporting changes in the resident's skin condition on coccyx or sacrum prior to the wound care doctor's documentation. DON agreed that there are inconsistencies in the skin documentation and orders regarding the coccyx, buttocks, and the sacrum making the documentation difficult to follow.During an interview with CNA A, on 7/15/25, at 3:15 pm, Certified Nursing Assistant (CNA A) stated that they had not had any specific training regarding the use of therapeutic boots. CNA stated Resident 4 wore the boots all the time to keep his feet from moving side to side.During an interview with LN B, on 7/15/25, at 3:30 pm, LN B stated that they do not recall any special training regarding therapeutic boots since they have worked at the facility. It is LN B's expectation that if a resident needed special equipment such as therapeutic boots, that the instructions for use would be found in the care plan or the doctor's order. If the resident was found using equipment that was not ordered LN B would notify the doctor to ensure that the equipment was appropriate for the resident.

Based on observation, interview and record review, the facility failed to promptly notify the Medical Director (MD), who was the attending physician, for one of three residents sampled for change of condition (Resident 1), when Resident 1 was experiencing signs and symptoms of stroke (a life-threatening medical emergency, when the blood supply to part of the brain is blocked or reduced) on [DATE], he was transferred to the Acute Hospital on [DATE]. This failure resulted in a three-day delay in transferring Resident 1 to the hospital for treatment, and increased Resident 1's pain and discomfort. Resident 1 suffered significant declines on his functional abilities: slurred speech, left-sided weakness, inability to swallow. Resident 1 died on [DATE], within a month of his initial admission ([DATE]). Findings: During a review of the facility's policy titled, Change of Condition, revised [DATE], indicated: A. The Facility will promptly inform the Resident, consult with the Resident's primary care physician, and notify the Resident's legal representative or an interested family member when the Resident experiences a significant change in their condition caused by a significant change in the Resident's physical mental or psychosocial status . B. The Facility will ensure Residents, family, legal representatives, and physicians are informed of changes in the Residents' condition in a timely manner. C. Any Facility staff member who observes a Change of Condition will report the change to the Med Tech or Licensed Nurse. The Med Tech or Licensed Nurse will assess the Change of Condition and determine what interventions are appropriate. 1. In the event of any of the following conditions, 911 will be notified immediately. a. Change in level of consciousness. b. Weakness. c. Signs and symptoms of stroke or heart attack. During a review of U.S. Center for Disease Control and Prevention (CDC) website page titled, Stroke, dated ,d+[DATE], indicated: 1. The key points During a stroke, every minute counts. Fast treatment can lessen the brain damage that stroke can cause. 2. Signs and Symptoms Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking, or difficulty understanding speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance, or lack of coordination. Sudden severe headache with no known cause. 3. Call [DATE] right away if you or someone else has any of these symptoms. 4. The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms. Stroke patients may not be eligible for these treatments if they don't arrive at the hospital in time. During a review of [NAME] Journals (a leading global publisher of current and influential medical, nursing, and allied health research) titled, Acute Ischemic Stroke: The Golden Hour, published in Nursing 2016 Critical Care, Volume 11, Number 3, indicated: 1. Stroke continues to be the leading cause of disability in the United States, contributing to poor quality of life and billions of dollars in health care cost. 2. A door-to-treatment time of 60 minutes or less is the goal. This 60-minute period is often referred to as the Golden Hour of acute ischemic stroke treatment . 3. Appropriate evaluation and treatment can make a critical difference between independence and disability for a patient with acute ischemic stroke. Rapid evaluation and treatment within the golden hour of acute ischemic stroke requires a coordinated, multidisciplinary approach and knowledge of the best practices, therapies, and available management techniques. During a review of Resident 1's admission record, the record indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of left lower limb, difficulty in walking, and high blood pressure. Resident 1 was his own health care decision maker. During a review of Resident 1's clinical record titled, Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the record indicated, Resident 1 chose to have Comfort-Focused Treatment - primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatment listed in Full and elective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. During a review of Resident 1's Admission progress note, dated [DATE] at 7:23 pm, by Licensed Nurse (LN) B, the note indicated, Resident 1 was alert and oriented to person, place, and time. Resident 1's speech was clear and able to understand and be understood when speaking. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool) at section C - Cognitive Pattern, section GG - Functional Abilities and Goals, and section J - Health Conditions, Pain Management, dated [DATE], the MDS indicated, 1. Resident 1 had a brief interview for mental status (BIMS) score of 12, suggesting that Resident 1's cognition was moderately impaired. 2. Resident 1 was independent at self-care (the need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness .). 3. Resident 1 was Independent at indoor Mobility (ambulation - need for assistance with walking from room to room, with or without a device such as cane, crutch, or walker) prior to the current illness . 4. Resident 1 had no impairment, no limitation in his range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point). 5. Resident 1 had no pain. During a review of Resident 1's progress note, dated [DATE] at 5:41 pm, by LN C, the note indicated, Resident 1 was noted to be pale, sleeping most of shift Noted little motivation this shift to participate (to take part in self-care) . During a review of Resident 1's progress note, dated [DATE] at 11:03 pm, by Registered Nurse (RN) D, the note indicated, Resident aware, mumbling but able to follow simple commands. Able to swallow medications well but in a slow manner . There's no note indicating that the MD was notified of Resident 1's change of condition. During a review of Resident 1's Social Services progress note, dated [DATE] at 2:02 pm, by the Social Services Director (SSD), the note indicated, unable to do care conference related to resident not feeling well . During a review of Resident 1's Social Services progress note, dated [DATE] at 5:21 pm, by RN E, the note indicated, Resident assessed and noted with decline in Level of Consciousness per Social Services Worker, Vital sign score and resident with tired appearance and increased difficulty with oral intake. The Physician was notified with orders received/noted to monitor at this time . Do-Not-Resuscitate (DNR- means that a person has decided not to have cardiopulmonary resuscitation attempted in the event their heart or breathing stops.) with comfort focused care During a review of Resident 1's progress note, dated [DATE] at 11:06 pm, by RN D, the note indicated, Resident 1 was alert to drowsy, awake and needs verbal cues to take medications and fluids in a slow manner . During a review of Resident 1's progress note, dated [DATE] at 11:37 am, by the Director of Nursing (DON), the note indicated, A staff reported to the DON that Resident 1 was unable to work with Occupational Therapy (OT) and could not move his left arm. The DON went to assess and found Resident 1's head leaning on his left, some drooling, Resident 1 was able to squeeze right hand, however, weakness on the left hand was noted, unable to move and wiggle left toes. The MD was notified and ordered to get Resident 1 sent out. The DON wrote, Resident 1 was his own responsible party (RP) and explained that nurse suspect stroke. He is DNR, comfort care, however, okay to get sent out for further evaluation and treatment. Emergency Medical Services (EMS) came and transported Resident 1. During a review of Resident 1's progress note, dated [DATE] at 11:43, by LN B, the note indicated, Resident 1 got sent out at approximately 11:40 am due to change in mental status and increased need for help with Activities of Daily Living (ADLs). Resident 1 presented with slurred speech and left sided weakness. Patient is own RP and told RN that he would like to be sent out to get checked out EMS arrived at 11:30 am, report given to EMS. Patient taken out of facility and sent to scute . During a review of Resident 1's Acute Hospital's Emergency Department (ED) Provider note, dated [DATE] at 11:59 am, the note indicated, the ED Provider received report from EMS, and was told that Patient was last seen well 4 days ago, patient had normal movement of all extremities and was conversant ., and Patient currently has no movement of the left side as well as slowed and garbled speech . Resident 1 was found to have cerebrovascular accident (CVA - stroke), Acute renal failure (sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, conserve electrolytes, and maintain fluid balance), and Chronic cellulitis. During a review of Resident 1's Acute Hospital Clinical Notes, titled, Case Management Discharge Planning Note, dated [DATE] at 4:16 pm, by the Acute Hospital Medical Social Worker (MSW) G, the note indicated, MSW G followed the request from the acute hospital medical doctor to locate Resident 1's Next of Kin. The MSW G completed Resident 1's Chart review and found names of Resident 1's friends and neighbors. MSW G contacted Friend H. Friend H told MSW G that she spoke to Resident 1 four days ago and Resident 1 said he was getting better and hope to discharge soon from Skill Nursing Facility. Per note, Friend H shared she is willing to talk with the medical doctor so Resident 1 does not go without treatment. During a review of Resident 1's Acute Hospital Speech Therapy Treatment note, dated [DATE] at 10:55 am, the note indicated, Resident 1 was seen by the Speech Therapy (ST) for swallow treatment, Resident 1 was noted to have eggs from breakfast drooling from left side of mouth when the ST entered ., and Resident 1 was high likelihood of aspiration (accidentally inhaling the food or liquid through the vocal cords into the airway) even with use of precautions . During a review of Resident 1's Clinical Admission record, dated [DATE], at 9:04 pm , the record indicated, Resident 1 was readmitted to the Skill Nursing Facility with diagnoses which included Right ischemic stroke (the blood supply to part of the right side of the brain is blocked or reduced) with left hemiparesis (weakness on the left side of the body), and urinary retention (the bladder doesn't empty completely). Resident 1 was still his own health care decision maker. During a review of Resident 1's MDS at section C - Cognitive Pattern, section GG - Functional Abilities and Goals, and section J - Health Conditions, Pain Management, dated [DATE], the MDS indicated, 1. Resident 1's BIMS score was 14, suggesting that Resident 1's cognition was intact. 2. Resident 1 had impairment on one side of his upper and lower extremities. 3. Resident 1 was completely dependent (the helper does all the effort), on toileting hygiene, shower/bath, and lower body dressing. 4. Resident 1 had generalized pain. During an interview on [DATE], at 2:05 pm, with LN L, LN L stated, I was really upset. They kept saying Resident 1 was on comfort care, comfort care is to make the patient as comfortable as possible, it's not to let them lay there and die. They should have sent him out earlier . During an interview on [DATE], at 4:14 pm, with SSD, SSD stated, I met Resident 1 on Friday, [DATE], in Resident 1's room. I scheduled his care conference. He answered his question completely. He completed his BIMs, he got 12. On Monday ([DATE]), I tried to interview him for care conference, he started talking gibberish. This is not him; he was alert and had a clear speech when I talked to him on Friday. I reported it to LN F. LN F was covering the Station 4 for the nurse, LN F usually worked at the Station 1 and was not familiar with the residents at the Station 4, so I also reported to the Assistant Director of Nursing (ADON)/RN E. Both LN F and ADON went into Resident 1's room and assessed the resident. They took his vital sign; LN F said his vitals were fine. I am not a nurse; I left the issue with them. However, I told them that he acted differently than how I saw him on Friday During an observation and interview on [DATE], at 3:16 pm, with Resident 1, in Resident 1's room, Resident 1 had his eyes closed, his head turned left, and appeared to be pale. During an interview with Resident 1, Resident 1 was struggling to raise his left hand, but it was unsuccessful. Resident 1 then tried to speak several times, but most of it was slurred and unable to be understood. When asked how was the facility treating you?, Resident 1 stated, not very good! Resident 1 confirmed his answer by nodding his head. When asked what you mean by not very good? Resident 1 stated, I can't tell you. During an interview on [DATE], at 3:24 pm, with RN J, RN J stated, Resident 1 needed 1:1 feeder (assisted feeding - the action of a person feeding another person who cannot otherwise feed themselves), he was not eating well. Food was coming out of his mouth. He had to use a straw to drink the food, he wasn't doing well, the food was drooling down from his mouth. During an interview on [DATE] at 3:41 pm with LN B, 1. LN B stated, she admitted and interviewed Resident 1 on [DATE], LN B said, Resident 1 was alert, he could eat, he could hold a normal conversation, he could move himself in the bed. 2. LN B stated, I was his nurse on [DATE]. When I went into his room in the morning, noticed he had a change of condition. I asked his name, he could not respond, his speech was slurred, he showed slow movement, I reported it to the DON right away. 3. LN B stated, Resident 1 now was a completely different person. He could not talk well; he could not eat and move like he used to when he first got here. During an interview on [DATE], at 4:01 pm, with DON, 1. The DON stated, Comfort care is to keep them comfortable, it doesn't mean not to treat. 2. The DON stated, Resident 1 had a change of condition on [DATE]. I told him, he had symptoms of stroke, that he could not lift his left arm and left leg, he had slurred speech. As a nurse, I wound be the patient advocate. I notified the doctor and Resident 1 agreed to be sent out to the Acute Hospital. 3. The DON stated that she did not know what happened on [DATE], however, she confirmed that the facility should have sent Resident 1 to the Acute Hospital earlier. 4. The DON stated that the licensed nursing staff should have known the signs and symptoms of stroke, we had an in-service for it. The DON said, they [licensed nursing staff] did not know what comfort care was. If you are on comfort care, it doesn't mean that I won't treat you. During a review of Resident 1's progress note, dated [DATE], at 6:10 pm, by LN K, the note indicated, Resident 1 struggled with sucking honey thick liquids through a straw throughout the shift . Resident 1 had elevated blood pressure and temperature . During a review of Resident 1's clinical record titled, Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work together to provide the care the patient needs) Progress Notes - Weight Variance & Nutritional condition, dated [DATE], at 3:50 pm, the note indicated, Resident 1 had significant weight loss of 12.8 pounds in a week. Resident 1 requested to be referred to the Gastrointestinal (GI) specialist to have a Gastrostomy tube (also called a G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) During a review of Resident 1's progress note, dated [DATE], at 3:54 pm, by LN M, the note indicated, Resident 1 was seen by the speech therapist. Resident 1 noted to be having difficulty swallowing. Resident 1 was aspirating. Resident 1 decided he does want a G-tube. MD notified. Referral for GI consult. During a review of Resident 1's IDT skin progress note, dated [DATE], at 1:40 pm, by Treatment Nurse (TN) Q, the note indicated, Resident 1 has been very lethargic and at risk for malnutrition. Resident 1 was noted to have shearing on left upper back related to being bedbound and immobile (Shearing wounds occur when forces are applied to body tissues or parts that cause these tissues to move in opposite directions. Shearing forces can put pressure on blood vessels, causing them to be closed off, resulting in reduced blood flow to an area). During a review of Resident 1's nursing progress note, dated [DATE], at 1:16 pm, by LN C, the note indicated, Resident 1 continued to be unable to take in meals, food rolls out of mouth, unable to swallow. Taking Honey thickened fluids by spoon, and most of the fluids also rolled out of his mouth . During a review of Resident 1's progress note, dated [DATE], at 6:05 pm, by LN S, the note indicated, Resident 1 was accepted to Hospice P services (a type of care that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). Resident 1 was prescribed with Roxanol (morphine sulfate, a highly concentrated solution of the narcotic analgesic morphine sulfate for oral administration used for the treatment of severe pain) 5 milligram (mg), 10 mg, and 15 mg via mouth every one hour, as needed (PRN), for mild to severe pain. During a review of Resident 1's Wound care progress note, dated [DATE], at 12:19 pm, by RN J, the note indicated, Resident 1 was in such pain and refused to have skin care, and the nurse was unable to console with touch or other non-pharmaceutical interventions. PRN pain medication administered. During a review of Resident 1's progress note, dated [DATE], at 11:06 am, by LN O, the note indicated, Hospice P notified LN O that Resident 1 had Deep Tissue Pressure Injury (DTPI) to right buttock and abrasion (scrape) to left side (DTPI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface). Resident 1 did not have any skin issue on both his buttocks noted while he was readmitted to the facility on [DATE]. During a review of Resident 1's IDT skin progress note, dated [DATE], at 2:59 pm, by TN Q, indicated Resident 1 had continued to refuse meal and medications. Resident 1 had a referral for G-tube placement, no updates for it at this time. TN Q was notified by the nurse and the nursing aids that Resident 1 was non-complaint with rotating a repositioning, and Resident 1 got aggressive and physically tried to prevent himself from being repositioned. Even after receiving pain medication still refused to turn . During a review of Resident 1's progress note, dated [DATE], at 12:51 pm, by Nursing Unit Manager (NUM) R, the note indicated, NUM R received new orders for Resident 1 from Hospice P. Resident 1 was prescribed with more routine pain medications - Norco, routine and as needed, and Morphine Sulfate, routine with one milliliter (ml) via mouth, three times a day, and continue with the previous PRN order for Morphine Sulfate for pain management. During a review of Resident 1's clinical record, the record indicated that Resident 1 had passed away on [DATE] at the facility. During an interview on [DATE], at 12:50 am, with administrator (ADMIN), ADMIN stated that she was very upset about what happened to Resident 1. ADMIN said LN B admitted Resident 1 on [DATE], and LN C took over the shift over the weekend. LN C did not know Resident 1's base line. When Resident 1 had a change of condition, LN C did not know, and LN B did not do the assessment on [DATE].

Based on interview and record review, the facility failed to ensure the plan of care for a safe transfer was implemented for one of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) l and Nursing Assistant (NA) 2 did not use a Hoyer lift (a mechanical device for lifting and transferring immobile patients) and assisted Resident 1 to a standing position. Resident 1 was unable to stand and was lowered to the floor. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. Findings: A review of Resident 1's Admission Record indicated she was admitted to the facility on [DATE], with diagnoses that included displaced trimalleolar fracture of right lower leg (a fracture of the bones of the ankle), morbid (severe) obesity (severely overweight) and difficulty walking. A record review of Resident l's Minimum Data Set (MDS, a process for clinical assessment of all residents of nursing homes) dated 9/26/2023 Functional Status indicated Resident 1 required assistance and support to transfer to or from bed, chair, wheelchair or standing position. For balance during transitions and walking, Resident 1 was noted as not steady, only able to stabilize with staff assistance. Resident l's Fall Risk Assessment score was 13 (greater than 13 is high risk for falls). A record review of Resident 1's Lift/ Transfer Evaluation dated 8/18/2023 indicated the resident could not bear weight and her current weight was over 200 pounds. During record review of Physical Therapy Treatment Encounter Note dated 10/25/2023 indicated Resident 1 required substantial/maximal assistance for transfers. Resident 1 's Functional Skills Assessment Mobility Performance Score was 2 (ranges from 0-12 ,12 indicating a higher functional ability) It indicated Resident 1 was a fall risk with right lower leg pain. During a record review of Resident 1's fall care plan dated 10/26/2023, indicated she was at risk for falls with a past history of fall with ankle fracture prior to admission and required use of a Hoyer lift for transfers with assist of 2. During a record review of Interdisciplinary Team (IDT, a meeting between department heads to discuss/plan care) Progress note dated 10/26/2023, indicate at 2:50 PM CNA 1 went to the nurse's station during change of shift to report that Resident 1 was on the floor. CNA 1 reported that Resident 1 was supposed to have her shower and CNA 1 and NA 2 were trying to remove her brief prior to shower. CNA 1 claimed that Resident 1 offered to stand up so they can remove her brief easily and CNA 1 assisted her to stand up. Resident 1 was unable to support her weight and was very unsteady, so CNA 1 assisted Resident 1 to slide down to the floor. Resident l's right knee gave out and it hit the floor and she was then complaining of right knee pain. The Nurse Practitioner was notified and an order for x-ray was received. Resident 1 and family refused x-ray and requested to be sent out to acute care hospital. Resident 1 was transported by ambulance at 4:15 PM to acute care hospital and was found to have subtle, nondisplaced mildly impacted fractures of the proximal tibia, fibula neck and proximal fibular neck and proximal fibular shaft (fracturs of both bones of the right knee). A soft cast was applied, and resident returned to facility at approximately 8:10 PM. During record review of Resident 1's Pain Interview dated 9/26/2023 it indicated Resident 1 had pain in the previous 5 days, pain was occasional, had no effect on sleeping, did not limit Resident 1's day-to-day activities and pain scale rating was 4/10 (0 being no pain and 10 being the worst pain). During a review of Resident 1's Medication Administration Record dated 10/1/2023 through 11/30/2023 it indicated Resident 1 was taking Hysingla ER (a extended release opiate medication used to treat chronic pain) once daily. After the fall on 10/25/2023 Resident 1 was taking Norco 5-325 (a mixture of narcotic pain medication and Tylenol used to treat severe pain) for 13 days averaging 3 pills per day with an average pain scale of 8 (severe pain). Resident 1 also took Tramadol (a narcotic pain medication) on 4 days during that time with an average pain scale of 8. A review of Resident 1's Nurse's Note, dated 10/28/23 at 4:45 am, indicated that Resident 1 was asking why her pain medication was not brought to her on time. The nurse explained that the medication is ordered as needed for pain and not a routine schedule. The nurse further explained that if Resident 1 was asleep, the nurse would not wake Resident 1 to take her pain medication. Resident 1 refused incontinent care twice, because she needed four people to help turn her. A review of In-Service Mechanical Lift/Transfer Equipment lesson plan dated 10/25/23 taught by Director of Staff Development (DSD) and Director of Physical Therapy (DPT) indicated that the best safety controls are machines, equipment and devices that do the lifting and transferring for you including gait belts and electric lifts (Hoyer lifts are electric devices that lift and transfer a resident in a sling). A resident's physical needs and abilities must be constantly checked to ensure that the safest lifting techniques are being used. Before transferring a resident, check the Kardex, care plan, care card or assignment sheet. Factors that should be considered: the individual's required level of assistance, the resident's weight and height, the person's cognitive status and physical ability. You should always try to avoid physically lifting residents. Always follow your facility's policies for lifting. NA 1 attended this in-service. CNA l did not attend this in-service. A review of Module 5 of Nursing Assistant Certification lesson plan dated 2019, completed by CNA 1 and NA 1 indicated mechanical lift devices should be used for residents who are morbidly obese, have fragile skin or are unable to bear weight. A review of Medical Doctor orders dated 10/3l /2023 indicated an order for Hoyer transfer per therapy department every shift. During an interview on 11/9/2023 at 7:57 AM, with Resident 1 in her room she recounted the circumstances at the time of the fall on 10/25/2023. Resident 1 stated at approximately 2:50 PM, she had been transferred from her wheelchair to her shower chair via mechanical lift by CNA 1 and NA 2. Resident 1 stated once in the shower chair it was noticed that she still had on her brief. CNA 1 stated she would lift Resident 1 while NA 1 pulled down her incontinence brief. Resident 1 stated she said no, but CNA I lifted her up under her arms but couldn't support her weight, so Resident 1 slithered to the floor. Resident I landed most of her weight on her right knee with immediate pain. Resident l laid on the floor while they called for help. LVN 1 (Licensed Vocational Nurse) and Registered Nurse (RN) 1 arrived quickly and assisted her into the mechanical lift sling and was put back in bed. Resident 1 texted her son, who works at the local hospital, and told him what happened. Resident 1 and her son agreed she should be taken by ambulance to the hospital where he would be waiting for her. She returned to the facility that evening with a soft cast on her right leg with a diagnosis of right medial tibial fracture (a break of the lower leg bone). She was taking Norco (a narcotic pain medication) for the first 12 days after the fall, but the medication made her loopy. Resident l's pain medication was changed to Tramadol (a pain medication) and Tylenol (an over-the-counter pain medication). Resident 1 reports that before her fall she was able to stand for 15 seconds during her Physical Therapy (PT) session earlier in the day of her fall. Resident 1 is now having PT in her room in her bed and only on her upper body. On 11/8/2023 at 2:45 PM during interview with Director of Physical Therapy/Director of Rehab (DPT/DOR) stated that on 10/25/2023 Resident 1 was assessed as dependent assist which means she requires a Hoyer lift for transfers. When asked how CNAs know what level of assistance a resident requires, DPT/DOT stated that when a resident's status changes, physical therapy (PT) in services the CNAs. When asked if they in-service all CNAs on all shifts, DPT/DOR said no, the CNAs find out from the nurses. DPT/DOR stated that Resident 1's status hasn't changed in a long time. During record review of Emergency Department provider notes dated 10/25/2023 at 4:40 PM indicated the patient (Resident 1) had a fall while transferring at the care home. Patient is non-weight bearing (not allowed to put any weight) and staff allowed her to stand where she collapsed. She was getting physical therapy and had been bed bound for 18 months. Patient reported 10/10 on a pain scale (severe worst pain) to right knee. A review of Xray results indicated Resident I was diagnosed with a right subtle, nondisplaced mildly impacted fractures of the proximal tibia and subtle nondisplaced fractures of the proximal fibular neck and proximal fibula shaft and severe osteopenia (a fracture of the bones of the knee and a loss of bone strength). A soft cast was applied to right leg and Resident 1 was discharged via ambulance back to the facility at approximately 8:20 PM. On 11/9/2023 at 4:30 PM during telephone call with CNA 1 she recounted that on 10/25/23 at approximately 2:50 PM she was getting Resident 1 ready to shower. She and NA 2 had already used the Hoyer lift to transfer Resident 1 from her wheelchair to her shower chair. Resident 1 offered to stand up so her brief could be removed. CNA 1 assisted Resident 1 to stand but Resident 1's legs gave out and CNA 1 was unable to support her weight. CNA 1 assisted Resident 1 slowly to the floor where Resident 1 hit her knee, CNA 1 immediately went to the nurse's station to get help leaving NA 2 with Resident 1. When asked how CNAs find out a resident's transfer status, she stated CNAs must ask other CNAs or the nurses. She admitted she should have used the Hoyer lift but Resident 1 stated she could stand.

Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections when 1. staff did not monitor the urinary catheters (a drainage system placed in the bladder to drain urine) for 6 of 6 sampled residents (Residents 1, 3, 5, 7, 9, and 10) as ordered by the physician, and 2. Staff did not practice appropriate hand hygiene when providing pericare (cleaning an incontinent resident after elimination). These failures had the potential to contribute to 3 of 6 sampled residents (Residents 3, 9, and 10) having urinary tract infections, and to Resident 10's hospitalization for urinary tract infection with [CONDITION(S)] (blood poisoning). Findings: A review of a facility policy and procedure titled Indwelling Catheter revised 9/1/14, indicated that handwashing and glove use must be done when providing catheter care, and the care provided must be documented in the resident's clinical record. 1. A review of the clinical record indicated that Resident 1 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was his own responsible party. A review of physicians orders dated 11/17/20 indicated that Resident 1 must receive catheter care each shift, and must be monitored for changes in urine or symptoms of urinary tract infection. A review of the Treatment Administration Record (TAR) indicated that catheter care was not documented as provided to Resident 1 on the night shift 12/5/20 or 12/11/20, the day or night shifts on 12/12/20, the evening shift on 12/13/20, the night shift on 12/17/20 or 12/24/20, the day shift on 12/27/20, or the night shift on 12/29/20 or 1/18/21. A review of the TAR indicated that monitoring for changes in urine was not documented as provided to Resident 1 on the night shift 12/5/20 or 12/11/20, the day or night shifts on 12/12/20, the evening shift on 12/13/20, the night shift on 12/17/20 or 12/24/20, the day shift on 12/27/20, or the night shift on 12/29/20 or 1/18/21. A review of the TAR indicated that monitoring for symptoms of urinary tract infection was not documented as provided to Resident 1 on the night shift 12/5/20 or 12/11/20, the day or night shifts on 12/12/20, the evening shift on 12/13/20, the night shift on 12/17/20 or 12/24/20, the day shift on 12/27/20, or the night shift on 12/29/20 or 1/18/21. A review of the clinical record indicated that Resident 3 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 was her own responsible party. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not indicate that catheter care was provided to Resident 3 on the night shift 12/5/20, 12/7/20 or 12/11/20; the day or night shift 12/12/20; the evening shift 12/13/20; the night shift 12/17/20 or 12/24/20; the day shift 12/27/20; the night shift 12/29/20; the evening shift 1/1/21; or the night shift 1/18/21. A review of the TAR indicated that monitoring for changes in urine was not documented as provided to Resident 3 on the night shift 12/5/20, 12/7/20 or 12/11/20; the day or night shift 12/12/20; the evening shift 12/13/20; the night shift 12/17/20 or 12/24/20; the day shift 12/27/20; the night shift 12/29/20; the evening shift 1/1/21; or the night shift 1/18/21. Another review of the TAR found no documentaion to indicate monitoring for symptoms of urinary tract infection for Resident 3 on the night shift 12/5/20, 12/7/20 or 12/11/20; the day or night shift 12/12/20; the evening shift 12/13/20; the night shift 12/17/20 or 12/24/20; the day shift 12/27/20; the night shift 12/29/20; the evening shift 1/1/21; or the night shift 1/18/21. A review of a nursing note dated 1/3/21 at 1:23 PM indicated that Resident 3 experienced fever, pain, and cloudy urine. Resident 3 was sent to the hospital and returned to the facility the same day. A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated that Resident 5 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR found no documentation of catheter care provided to Resident 5 on the night shift 12/3/20 or 12/4/20; the evening shift or night shift 12/5/20; the day or evening shift 12/6/20; the evening or night shift 12/7/20; the night shift 12/8/20; the evening or night shift 12/11/20; the day or evening shift 12/12/20; the evening shift 12/13/20; the night shift 12/14/20, 12/15/20, or 12/17/20; the evening or night shift 12/18/20 or 12/19/20; the day shift on 12/20/20; the night shift 12/21/20; the evening or night shifts on 12/24/20 or 12/25/20; the day shift on 12/26/20 and 12/27/20; the night shift 1/1/21; the day or night shift 1/2/21; the day shift 1/3/21 or 1/4/21; the evening shift 1/7/21; the day shift 1/9/21 or 1/10/21; the night shift 1/13/21; the day shift 1/17/21; or the evening shift 1/22/21. A review of the TAR indicated that monitoring for changes in urine was not documented for Resident 5 on the night shift 12/3/20 or 12/4/20; the evening shift or night shift 12/5/20; the day or evening shift 12/6/20; the evening or night shift 12/7/20; the night shift 12/8/20; the evening or night shift 12/11/20; the day or evening shift 12/12/20; the evening shift 12/13/20; the night shift 12/14/20, 12/15/20, or 12/17/20; the evening or night shift 12/18/20 or 12/19/20; the day shift on 12/20/20; the night shift 12/21/20; the evening or night shifts on 12/24/20 or 12/25/20; the day shift on 12/26/20 and 12/27/20; the night shift 1/1/21; the day or night shift 1/2/21; the day shift 1/3/21 or 1/4/21; the evening shift 1/7/21; the day shift 1/9/21 or 1/10/21; the night shift 1/13/21; or the evening shift 1/22/21. Further review of the TAR found no indication of staff monitoring for symptoms of urinary tract infection for Resident 5 on the night shift 12/3/20 or 12/4/20; the evening shift or night shift 12/5/20; the day or evening shift 12/6/20; the evening or night shift 12/7/20; the night shift 12/8/20; the evening or night shift 12/11/20; the day or evening shift 12/12/20; the evening shift 12/13/20; the night shift 12/14/20, 12/15/20, or 12/17/20; the evening or night shift 12/18/20 or 12/19/20; the day shift on 12/20/20; the night shift 12/21/20; the evening or night shifts on 12/24/20 or 12/25/20; the day shift on 12/26/20 and 12/27/20; the night shift 1/1/21; the day or night shift 1/2/21; the day shift 1/3/21 or 1/4/21; the evening shift 1/7/21; the day shift 1/9/21 or 1/10/21; the night shift 1/13/21; or the evening shift 1/22/21. A review of the clinical record indicated that Resident 7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7 was his own responsible party. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR found no documentation to indicate catheter flushes for Resident 7 on 12/4/20, 12/8/20, 12/11/20, 12/17/20, 1/10/21, 1/16/21, or 1/22/21. A review of the TAR indicated that monitoring for changes in urine was not documented as provided to Resident 7 on the night shift 12/3/20; the evening or night shift 12/4/20; the day or night shift 12/5/20, the day shift 12/6/20; the day or night shift 12/7/20; none on 12/8/20 or 12/11/20; the day shift 12/12/20; the night shift 12/14/20 or 12/15/20; the evening or night shift 12/17/20; the day shift 12/24/20, 12/26/20, or 12/27/20; the day shift 1/2/21 or 1/3/21; the day or evening shift 1/10/21; the night shift 1/11/21, 1/13/21, or 1/14/21; the evening shift 1/16/21; the day shift 1/17/21; or the evening shift 1/22/21. A review of the TAR found no indication of staff monitoring for symptoms of urinary tract infection for Resident 7 on the night shift 12/3/20; the evening or night shift 12/4/20; the day or night shift 12/5/20, the day shift 12/6/20; the day or night shift 12/7/20; none on 12/8/20 or 12/11/20; the day shift 12/12/20; the night shift 12/14/20 or 12/15/20; the evening or night shift 12/17/20; the day shift 12/24/20, 12/26/20, or 12/27/20; the day shift 1/2/21 or 1/3/21; the day or evening shift 1/10/21; the night shift 1/11/21, 1/13/21, or 1/14/21; the evening shift 1/16/21; the day shift 1/17/21; or the evening shift 1/22/21. A review of the clinical record indicated that Resident 9 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was not his own responsible party. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not indicate staff providing catheter care for Resident 9 on the night shift 12/3/20 and 12/4/20; none on 12/5/20; day or evening shift 12/6/20; evening or night shift 12/7/20; night shift 12/8/20; none 12/11/20; day shift 12/12/20; evening 12/13/20; night shift 12/14/20, 12/15/20, or 12/17/20; evening shift 12/18/20; evening or night shift 12/19/20; day shift 12/20/20; night shift 12/21/20; evening or night shift 12/24/20 or 12/25/20; day shift 12/26/20 or 12/27/20; the night shift 1/1/21; day or night shift 12/2/21; day shift 1/3/21, 1/4/21, or 1/5/21; evening shift 1/7/21; day shift 1/9/21 or 1/10/21; night shift 1/13/21; day shift 1/17/21; or evening shift 1/22/21. A review of the TAR found no indication of staff monitoring for changes in urine for Resident 9 on the night shift 12/3/20 and 12/4/20; none on 12/5/20; day or evening shift 12/6/20; evening or night shift 12/7/20; night shift 12/8/20; none 12/11/20; day shift 12/12/20; evening 12/13/20; night shift 12/14/20, 12/15/20, or 12/17/20; evening shift 12/18/20; evening or night shift 12/19/20; day shift 12/20/20; night shift 12/21/20; evening or night shift 12/24/20 or 12/25/20; day shift 12/26/20 or 12/27/20; the night shift 1/1/21; day or night shift 12/2/21; day shift 1/3/21, 1/4/21, or 1/5/21; evening shift 1/7/21; day shift 1/9/21 or 1/10/21; night shift 1/13/21; day shift 1/17/21; or evening shift 1/22/21. Further review of the TAR found no documentation indicating the monitoring for symptoms of urinary tract infection for Resident 9 on the night shift 12/3/20 and 12/4/20; none on 12/5/20; day or evening shift 12/6/20; evening or night shift 12/7/20; night shift 12/8/20; none 12/11/20; day shift 12/12/20; evening 12/13/20; night shift 12/14/20, 12/15/20, or 12/17/20; evening shift 12/18/20; evening or night shift 12/19/20; day shift 12/20/20; night shift 12/21/20; evening or night shift 12/24/20 or 12/25/20; day shift 12/26/20 or 12/27/20; the night shift 1/1/21; day or night shift 12/2/21; day shift 1/3/21, 1/4/21, or 1/5/21; evening shift 1/7/21; day shift 1/9/21 or 1/10/21; night shift 1/13/21; day shift 1/17/21; or evening shift 1/22/21. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated that Resident 10 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR found no documentation regarding Resident 10 receiving catheter care on the night shift 6/27/20 or 6/28/20. A review of the TAR found no documentation regarding the monitoring of Resident 10 for urine changes on the night shift 6/27/20, 6/28/20, or 7/2/20. A review of the TAR found no documentation of Resident 10 being monitored for symptoms of urinary tract infection on the night shift 6/27/20 or 6/28/20. A review of a nursing note dated 7/11/20 at 8:28 AM indicated that Resident 10 experienced high blood pressure and heart rate, and nausea and vomiting, and was sent to the hospital. A hospital history and physical note dated 7/11/20 indicated that Resident 10 had been admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/26/21 at 3:30 PM, LN 7 stated that she is unable to perform all patient care tasks if the facility is short-staffed. LN 7 will pass medications first, then prioritize the remaining tasks and do them if there is time. During an interview and record review on 1/26/21 at 10 AM, the Infection Preventionist (IP) confirmed that staff did not consistently perform physician ordered catheter care and monitoring for residents. 2. During an observation and interview on 2/1/21 at 9:40 AM, Certified Nursing Assistant (CNA) 4 was seen to pick up a piece of paper from the floor, discard it, then don clean gloves and perform pericare for a resident without sanitizing or washing hands between discarding the paper and donning the clean gloves. CNA 4 confirmed she neglected the hand hygiene opportunity. During an observation and interview on 2/1/21 at 9:50 AM, CNA 5 was observed to provide pericare for a resident, changing gloves between tasks, but without sanitizing or washing hands between glove changes. CNA 5 confirmed she neglected the hand hygiene opportunities.

Based on observations, interviews, and record review, the facility failed to properly prevent and contain COVID-19 when 1. Staff were not properly using personal protective equipment (PPE), and 2. Staff were not monitoring residents consistently for symptoms of COVID-19. These failures had the potential to contribute to the outbreak of COVID-19 at the facility. Findings: 1. A review of a facility policy and procedure titled Infection Control - Policies and Procedures revised [DATE], indicated that the facility is to prevent the transmission of disease and maintain a safe and sanitary environment in the facility. A review of the facility COVID-19 Mitigation Plan dated [DATE], indicated that residents in a yellow unit (residents who have been exposed to COVID-19, or their status is unknown) are placed on transmission-based precautions. A review of the guidance on the Center for Disease Control (CDC) website titled Responding to Coronavirus (COVID-19) in Nursing Homes, updated [DATE], indicated that all recommended PPE should be worn, including gowns, when caring for residents with an unknown COVID-19 status, or when caring for all residents if cases are widespread. A review of the guidance on the CDC website titled Preparing for COVID-19 in Nursing Homes, updated [DATE], indicated Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. During an observation and interview on [DATE] at 3 PM, the hallway for rooms 6 - 11, a yellow unit, no PPE carts were seen. Licensed Nurse (LN) 1 stated gowns were not worn on this unit because the residents were asymptomatic. During an observation and interview on [DATE] at 3:50 PM, Certified Nursing Assistant (CNA) 1 was seen at the bedside in room [ROOM NUMBER], a room in a yellow unit, wearing only a respirator for protection. CNA 1 stated full isolation was not used on that unit because residents were asymptomatic. During an interview on [DATE] at 3 PM, LN 2 stated rooms 6 - 11 did not need gowns because residents were asymptomatic. During an observation and interview on [DATE] at 3:15 PM, gowns were seen hanging on the doors of rooms [ROOM NUMBERS], in a yellow unit. CNA 2 stated that gowns were reused, and the gowns hanging on the door had already been used. During an observation and interview on [DATE] at 3:30 PM, no PPE carts were seen in the hallway of unit 1. LN 3 stated that unit 1 was a yellow unit, but did not require full isolation and staff did not wear gowns. LN 3 was unable to state why full precautions were not required. During an observation and interview on [DATE] at 2:20 PM, gowns were seen hanging on the open doors of resident rooms on Unit 4. CNA 3 was seen to take a gown from the door of room [ROOM NUMBER] and don it. CNA 3 stated they get 1 gown per shift per resident, and reuse their gowns. During an observation and interview on [DATE] at 2:25 PM, no PPE carts were seen in the hallway of rooms 50 - 57. LN 4 confirmed that rooms 50 - 57 were yellow, but that staff did not use gowns for those rooms. During an interview on [DATE] at 2:35 PM, LN 5 stated that all of unit 4 was yellow. The residents in rooms 50 - 57 were new admits, so staff did not wear gowns for them, while the remaining residents did require gowns because they left the facility regularly to go to [CONDITION(S)]. LN 5 also stated that staff get 1 gown per shift per resident, and hang the used gown on the room doors for reuse. During an observation and interview on [DATE] at 3:10 PM, gowns were seen hanging on the door of room [ROOM NUMBER]. CNA 1 stated they were using 1 gown per shift per resident because they were short of gowns. During an observation and interview on [DATE] at 3:15 PM, LN 6 was seen without a mask speaking to a resident in the hallway. LN 6 confirmed that his mask had been lowered. During an interview on [DATE] at 3:35 PM, the Infection Preventionist (IP) confirmed that gowns had not been used in all yellow areas of the facility. 2. 2. A review of the facility COVID-19 Mitigation Plan dated [DATE] indicated that staff must monitor residents in the COVID-19 unit every 4 hours for COVID-19 symptoms, including oxygen saturation (O2 Sat, blood oxygen levels); and monitoring must be documented in the resident clinical record. A review of the clinical record indicated that Resident 3 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 was her own responsible party. A review of a laboratory nursing note dated [DATE] at 7:50 PM indicated that Resident 3 had tested positive for COVID-19, and had been moved to the COVID-19 unit. A review of a vital signs summary for Resident 3 indicated that O2 Sats were monitored only once or twice a day on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], no O2 Sat was documented in the summary at all. A review of a handwritten record titled COVID-19 Q Shift Monitoring indicated that Resident 3 had been monitored, including O2 Sat only once or twice a day on [DATE]; [DATE]; [DATE]; [DATE], [DATE], [DATE]; [DATE], [DATE]; and [DATE]. A review of the vital signs summary and the COVID-19 Q Shift Monitoring document found no evidence of Resident 3 being monitored consistently every four hours per facility protocol. A review of the clinical record indicated that Resident 7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7 was his own responsible party. A review of a nursing infection note dated [DATE] at 6:35 PM indicated that Resident 7 had tested positive for COVID-19 and had been moved to the COVID-19 unit. A review of a vital signs summary for Resident 7 indicated that, from [DATE] to [DATE], O2 Sats were not monitored consistently every four hours, and on [DATE], there was no record of any O2 Sat monitoring at all. A review of a handwritten record titled COVID-19 Q Shift Monitoring indicated that the facility did not monitor Resident 7 four times a day as ordered on ,d+[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of the vital signs summary data confirmed there was no monitoring consistently documented every 4 hours for Resident 7 while in the COVID-19 unit. A review of the clinical record indicated that Resident 8 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. A nursing note dated [DATE] at 6:27 PM indicated that Resident 8 had pneumonia and was to begin antibiotics. On [DATE], the physician ordered Resident 8 to undergo a COVID-19 test. Another review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a laboratory report dated [DATE] indicated that on [DATE] Resident 8 tested negative for COVID-19. A review of a laboratory report dated [DATE] indicated that on [DATE] Resident 8 tested positive for COVID-19. A review of a nursing note dated [DATE] at 7:51 PM indicated that Resident 8 had been moved to the COVID-19 unit. A review of a vital signs summary for Resident 8 indicated that O2 Sats were monitored on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE] at 10:43 PM; ,d+[DATE]; and [DATE] only one to three times per day. No O2 Sats at all were documented in the summary on [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. A review of a handwritten record titled COVID-19 Q Shift Monitoring indicated that Resident 8 had been monitored, including O2 Sat only once or twice a day on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No monitoring had been documented for Resident 8 on [DATE], [DATE], [DATE], or [DATE]. Review of COVID-19 Q Shift Monitoring along with the vital signs summary data found no consistent documentation to indicate Resident 8 being monitored every 4 hours in the COVID-19 unit, and no monitoring at all on [DATE], [DATE], or [DATE]. A review of a nursing note dated [DATE] indicated that Resident 8 had been moved from the COVID-19 unit to a yellow unit, and was symptom free but extremely weak. There was no documentation of a COVID-19 test at that time. A review of a nursing note dated [DATE] indicated that Resident 8 had collapsed, experiencing a low O2 Sat and a rapid heart rate. A review of a nursing note date [DATE] indicated that Resident 8 was experiencing shortness of breath and low O2 Sats. The physician ordered Resident 8 to be sent to the hospital. A review of a hospital History and Physical dated [DATE] indicated that Resident 8 had been admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a hospital Discharge Summary dated [DATE] indicated that Resident 8 had died on [DATE] of COVID-19. During an interview on [DATE] at 11:40 AM, LN 8 stated that there is only 1 licensed nurse staffed on the COVID-19 unit, and if there are too many residents, not all monitoring gets done. During an interview and record review on [DATE] at 10 AM, IP confirmed that monitoring for symptoms of COVID-19 was incomplete for Residents 3, 7, and 8.

Based on interview and record review, the facility failed to ensure care and treatment, consistent with the physician's orders, were implemented for one resident (Resident 1) when; 1. An ordered wound culture (a test to discover the cause of infection) was not done, 2. Documentation of wound monitoring and assessment was incomplete, 3. The wound physician note and orders from 6/27/18 were not available in the chart, 4. Physician ordered intravenous (IV) antibiotic therapy (placing medication directly into the bloodstream) was not administered as ordered 5. Labs were not followed up on for [MEDICATION NAME] (a blood thinner) monitoring for Resident 1, and 6. The physician was not notified of the missing wound culture or lab results. These multiple failures in quality of care resulted in Resident 1 receiving the incorrect antibiotic to fight his infection and for wound changes to be missed, and resulted in missed doses of IV antibiotic and unmonitored lab results, contributing to hospitalization , a delay in surgery, and loss of the right foot. Findings: A review of the clinical record indicated that Resident 1 was admitted to the facility on [DATE] with [MEDICAL CONDITION] (a soft tissue infection), dislocated bones with a wound in the right foot, a history of blood clots, and diabetes. Resident 1 was able to make his own healthcare decisions. 1. A review of a physician order dated 6/25/18 indicated a culture of the wound on the right foot, to be completed by 6/26/18. A review of the care plan for Resident 1 did not include the physician-ordered wound culture. A review of the Medication Administration Record [REDACTED]. During an interview on 3/27/19 at 2:20 PM, the Director of Nurses (DON) confirmed with the contracted laboratory that there were no results of a wound culture for Resident 1, and the physician-ordered wound culture had not been done. During a concurrent interview and record review on 4/5/19 at 10:30 AM, Licensed Nurse (LN) 3 stated the expectation for licensed nurses is to complete a wound culture as ordered by the physician. LN 3 confirmed that the wound culture for Resident 1 had not been done as ordered. 2. A review of a facility policy titled Pressure Injury and Skin Integrity Treatment revised 8/12/16 indicated that The Licensed Nurse will document the status of all skin conditions at least weekly. A review of the care plan for Resident 1 indicated the care plan did not include personalized wound care or the physician-ordered wound culture. The nursing admission assessment dated [DATE] indicated the presence of [MEDICAL CONDITION] and a protruding bone in the right foot, and did not otherwise describe the appearance of the wound. The wound weekly monitoring assessment dated [DATE] indicated a skin tear on the right foot measuring 1 x 3.5 centimeters with irregular, distinct edges, with no further description of the bone protruding. During a concurrent interview and record review on 4/5/19 at 10:45 AM, ADON confirmed that the wound care notes dated 6/26/18 and 6/28/18 were insufficient, and the expectation is that nurses would provide more descriptive detail of a wound. 3. During an interview on 4/5/19 at 12:30 PM, Medical Records (MR) 1 confirmed that there was no copy of the initial wound physician note from 6/27/18, directing all wound treatment, in the chart. A review of a fax from the facility dated 8/28/19 indicated that the wound care physician had no note of the visit to Resident 1 on 6/27/18. 4. A review of a facility policy titled Medication - Administration dated 1/1/12 indicated that medications must be administered as prescribed, that tests upon which medication administration is conditioned must be performed prior to administration of the medication as required, and the results recorded. The Licensed Nurse (LN) must document each medication given, and any reason for not giving it. a. A review of the physician's orders for Resident 1 indicated an order dated 6/26/18 to place a PICC (intravenous medication infusion) line, and to administer [MEDICATION NAME] (an antibiotic) IV 1 gram daily for ten days, to be completed by 7/6/18. A review of the Medication Administration Record [REDACTED]. b. A review of the physician's orders for [MEDICATION NAME] (an antibiotic) IV were as follows: on 6/26/18, 1500 milligrams daily for seven days, on 6/29/18 1 gram twice daily, and on 7/1/18 1.25 grams twice daily until 7/2/18. A review of the MAR indicated [REDACTED]. During an interview with on 3/27/19 at 1:00 PM, LN 1 confirmed that one dose of [MEDICATION NAME] was not documented as given on 6/27/18, 7/4/18, or 7/5/18; and one dose of [MEDICATION NAME] was not documented as given on 7/2/18. During an interview on 3/27/19 at 4 PM, the DON confirmed that there was no order to discontinue [MEDICATION NAME], nursing had not completed the course of therapy as ordered, or contacted the physician for clarification of the order. 5. A review of a facility policy titled Medication - Administration dated 1/1/12 indicated that medications must be administered as prescribed, that tests upon which medication administration is conditioned must be performed prior to administration of the medication as required, and the results recorded. The LN must document each medication given, and the reason for not giving it. A review of a facility policy and procedure titled Appendix 5: Medication Issues of Particular Relevance in Older Adults revised 8/14 indicated that the use of [MEDICATION NAME] (a blood thinner) must be monitored by [MEDICATION NAME] Time/International Normalization Ratio (PT/INR) because without monitoring, the use of [MEDICATION NAME] can increase the risk of life-threatening bleeding, or be ineffective against dangerous blood clots. A review of the medical record for Resident 1 indicated an order dated 6/25/18 for [MEDICATION NAME], and an order for [REDACTED]. During a concurrent interview and record review on 3/29/19 at 12:45 PM, MR 1 was unable to locate documentation of lab results or physician notification and original order dated 7/12/18 for labs for Resident 1. MR 1 requested and received a copy of labs dated 7/12/18 on 3/29/19 from the laboratory at 4:21 PM. During a concurrent interview and record review on 4/5/19 at 10:45 AM, ADON stated the expectation for licensed staff is to follow up on lab results and medication orders, and verify any changes or questions with the physician. 6. A review of a policy titled Change of Condition Notification revised 4/1/15 indicated that the LN must notify the physician of laboratory and test results as soon as possible, and document such notification in the clinical record. A review of a physician order dated 6/25/18 indicated a culture of the wound on the right foot, to be completed by 6/26/18. A review of the medical record indicated that the wound culture was not documented in the Medication Administration Record [REDACTED]. During an interview on 3/27/19 at 2:20 PM, the DON confirmed with the contracted laboratory there were no results of a wound culture for Resident 1. During the interview, the DON also confirmed the physician-ordered wound culture had not been done nor the physician notified. During a concurrent interview and record review on 4/5/19 at 10:30 AM, LN 3 stated the expectation for licensed nurses is to complete a wound culture as ordered by the physician. LN 3 confirmed that the wound culture for Resident 1 had not been done as ordered nor the physician notified. A review of the medical record for Resident 1 indicated an order dated 6/25/18 for [MEDICATION NAME], and an order for [REDACTED]. During a concurrent interview and record review on 4/5/19 at 10:45 AM, the ADON stated the expectation for licensed staff is to follow up on lab results and medication orders, and verify any changes or questions with the physician. The ADON confirmed that the physician had not been notified of these lab results. During a telephone interview with the Medical Director (MD), the MD stated he had no recollection of staff calling him regarding the wound or antibiotic treatment. The medical record for Resident 1 indicated he was transferred to the hospital on [DATE] because his foot infection had worsened. A review of the hospital admission record dated 7/17/19 for Resident 1 indicated that he had osteo[DIAGNOSES REDACTED] (bone infection), and that a surgery was planned. The surgery, scheduled for 7/19/18, was canceled due to an elevated INR (prolonged bleeding time). Resident 1 had his right foot amputated on 7/25/18.

Based on interviews and record review, the facility failed to ensure that one resident was free of significant medication errors when Resident 1 did not receive five doses of physician ordered intravenous (IV) antibiotic therapy. These failures directly resulted in the ineffective treatment of [REDACTED]. Findings: A review of the clinical record indicated that Resident 1 was admitted to the facility on [DATE] with [MEDICAL CONDITION] (a soft tissue infection), dislocated bones with a wound in the right foot, a history of blood clots, and diabetes. Resident 1 was able to make his own healthcare decisions. A review of a facility policy titled Medication - Administration dated 1/1/12 indicated that medications must be administered as prescribed, that tests upon which medication administration is conditioned must be performed prior to administration of the medication as required, and the results recorded. The Licensed Nurse (LN 1) must document each medication given, and any reason for not giving it. A review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the physician's orders [REDACTED]. A review of the MAR indicated [REDACTED]. During an interview on 3/27/19 at 1:00 PM, LN 1 confirmed that one dose of [MEDICATION NAME] was not documented as given on 6/27/18, 7/4/18, or 7/5/18; and one dose of [MEDICATION NAME] was not documented as given on 7/2/18. During an interview on 3/27/19 at 4 PM, the DON (Director of Nurses) confirmed that there was no order to discontinue [MEDICATION NAME], nursing had not completed the course of therapy as ordered, or contacted the physician for clarification of the order. A review of the medical record for Resident 1 indicated he was transferred to the hospital on [DATE] because his foot infection had worsened. A review of the hospital admission record dated 7/17/19 for Resident 1 indicated that he had osteo[DIAGNOSES REDACTED] (bone infection), and that surgery was planned. The surgery, scheduled for 7/19/18, was cancelled due to an elevated INR. Resident 1 had his right foot amputated on 7/25/18.

Based on observation, interview, and record review, the facility failed to prevent avoidable resident to resident altercations by failing to implement it's Abuse policy to take actions prevent abuse including identifying, correcting, and intervening in situations in which abuse was likely. The facility failed to identify the potential risks of Resident 79's aggressive behaviors and provide adequate monitoring and interventions to prevent occurrences of conflict for three of 28 sampled residents (Resident 63, 49 and 50) when: 1. While unsupervised, on 6/25/18, Resident 79 poured juice on Resident 49's (roommate) face and hair, and hit his forehead with the cup. This resulted in forehead injury with bleeding, causing pain and emotional distress for Resident 49. 2. On 7/7/18, Resident 79 entered unobserved into Resident 50's room (across the hall) and when asked to leave, became upset and hit her on the forehead repeatedly with a book. This resulted in Resident 50 feeling afraid and scared for both herself and her roommate, as there room was across the hall from Resident 79. 3. On 8/18/18, Resident 79 entered Resident 63's room, and punched her in the chest/stomach area. This resulted in Resident 63 stating she had pain for days after he hit her. Resident 63 was uncomfortable and avoided contact with Resident 79. The facility's failure to have an effective system to supervise Resident 79 which left the Residents 63, 49 and 50 unprotected, and the other residents at risk for potential abuse that could result in serious harm. An Immediate Jeopardy was identified, the Administrator was verbally notified on 8/28/18 at 5:46 pm, in the presence Director of Nursing Services (DON) and the Regulatory Quality Management Consultant . An immediate corrective action plan to address supervision of Resident 79 was provided by the facility's administrator. The IJ was abated on 8/29/18 at 5:30 pm, with evidence of staff education provided. Findings: The facility's policy and procedure titled, Abuse/Criminal Activity - Prevention Program, dated 2/2018, indicated the purpose of the policy was to, . ensure the health, safety, and comfort of residents by preventing abuse, mistreatment, and crimes. The policy indicated, The facility does not condone any form of resident abuse, neglect . mistreatment . and develops facility policies procedures, training programs, and systems to promote an environment free from abuse and mistreatment The procedure included staff training for dementia management such as responding to aggressive behavior or catastrophic reactions. The procedure directive indicated the facility, . Maintains adequate staffing on all shifts to ensure that the needs of each resident are met A review of Resident 79's admission records indicated he was transferred from a Skilled Nursing Facility (SNF 1) and was admitted to SNF 2 on 3/15/18. Resident 79 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS, a resident assessment and care planning tool), dated 3/22/18, indicated Resident 79's memory was severely impaired. A review of Resident 79's physician (MD) order from SNF 1, dated 3/2018, instructed staff to Monitor for signs and symptoms (S&S) of aggression, striking out, verbal threats, raised fist, every shift related to unspecified dementia with behavioral symptoms The MD orders were sent with Resident 79 when he was transferred to SNF 2 on 3/15/18 to ensure a continuum of care. A review of Resident 79's MD order, dated 3/16/18, (the day after SNF 2's admission), indicated to monitor for signs and symptoms (S/S) of aggression: striking out, verbal threats, and raising his fist every shift. Resident 79's admission note for SNF 2, dated 3/16/18, at 12:42 pm, noted Resident 79 was aggressive towards staff, almost hit staff member this shift. Resident 79 wanders into others rooms and attempts to leave facility. Frequent monitoring required. A review of Resident 79's care plans dated 3/17/18, indicated there were no behavioral interventions documented for the known history of aggressive/abusive behaviors. The social service progress note, dated 6/19/18, indicated, Resident is up daily. Ambulates independently throughout facility. Resident 79 at times will push other resident's in their wheelchairs . does not initiate conversation and when he speaks will ramble . does not remember where to go 1. Resident to resident altercation #1 occurred on 6/25/18. A review of Resident 79's nursing progress notes, dated 6/25/18 at 3:45 pm, indicated a CNA (Certified Nurse Assistant) called a nurse to Resident 79's room. The resident was standing with an empty glass in his hand. His roommate (Resident 49) had juice on his face and hair and blood on his left forehead. The roommate told staff that Resident 79 hit him. The note indicated that the residents were immediately separated and Resident 79 was moved to another room (across the hall from Residents 50 and 63). During a concurrent interview and record review on 7/10/18 at 2:43 pm, the interim Director of Nursing (DON) stated the Interdisciplinary Team (IDT, a group of disciplines that discuss resident's healthcare needs) should have met to discuss the root cause of the first resident-to-resident altercation that occurred on 6/25/18. The DON confirmed there were no new resident specific interventions to prevent future resident-to-resident altercations from happening. During an observation on 7/10/18 at 2:35 pm, Resident 49 was in his room, climbed into roommate's bed without staff supervision. The observation lasted for five minutes. A CNA was notified due to the risk of falling and potential for aggressive behavior. The IDT notation, dated 7/10/18 (15 days after altercation #1), indicated both residents had dementia and did not have recollection of the incident after 10 minutes. The root cause indicated that the resident must have been provoked by his roommate which caused him to throw juice and hit him (given the roommates history). IDT recommended to continue with 72 hour monitoring (licensed nurse narrative charting every shift regarding follow-up) of resident for any signs and symptoms of emotional distress. There were no IDT recommendations to increase supervision for Resident 79. On 6/25/18 at 9:38 pm, the nursing progress notes indicated resident aggressive towards staff during redirecting, throwing glass (of) water to CNA while redirecting resident. Frequent redirecting. There was no documentation found in Resident 79's record which indicated that routine monitoring was being done by nursing staff or social service staff until after the first known incident on 6/25/18 occurred in this facility. On 6/28/18 at 1:58 pm, Social Services progress notes (SSN), indicated, Did have episode of swatting at staff today per nursing note. 2. Resident Altercation #2 occurred on 7/6/18. Resident 79's nursing progress notes, dated 7/7/18 at 1:43 am, indicated, At approximately 2345 (11:45 pm on 7/6/18) a CNA responded to her room following a call for help. The CNA witnessed Resident 79 repeatedly striking Resident 50 in the head with a book. CNA called for help and I (Licensed Nurse) responded, removing (Resident 79) from the room and walking him to his room and assisting him to bed. (Resident 79) was very agitated and cussing. (Resident 79) placed on 15-minute checks and stayed in bed until approximately 2:45 am. He is now up and staff is redirecting him back to his room. He is still agitated but states no memory of incident, just upset that we will not allow him to walk into other Pts (patients) rooms. The nursing progress notes indicated the administrator, Assistant Director of Nursing (ADON), and Responsible Party (RP) were notified. Nursing progress notes indicated there was no apparent injury to Resident 50. Resident 79's IDT meeting progress notes, dated 7/9/18, at 5:09 pm, indicated Resident was confused, able to ambulate, had hallucinations, and episodes of wandering aimlessly and going into other resident's rooms significantly intruding into other's privacy. The root cause indicated the IDT members believe resident wandered during the night and found a pair of shoes in another resident's room which caught his attention but his presence woke the resident in that room and 'spooked' her and started yelling to him to get out of the room which triggered him to react by hitting her with the bible. MD was notified of the incident with order for [MEDICATION NAME] 50 milligrams (mg) BID (two times a day) for [MEDICAL CONDITION] with aggressive behavior towards staff and peers. The IDT recommended tele psych (mental health evaluation) referral and to Continue each (Q) 15 minutes monitoring for his whereabouts. A review of Resident 79's care plan, created by the Activities Director on 7/9/18, (three days after incident), indicated he was seen hitting another resident on forehead. The care plan's goal included no further aggressive behaviors towards others and had interventions that included alert charting for 72 hours, immediately separated residents and required notifications, medication management, non-pharmacological interventions for behaviors (entered by the DSS, and included music, conversation, warm milk/snack, activity, verbal encouraging, redirection/diversion, reassurance, removal of stimuli, massage/back rub, walk around, nature walk, space, provide quiet environment, toileting needs met, rule out pain, rule out infection). During a concurrent interview and record review on 7/10/18 at 2:43 pm, the interim DON stated the IDT had met for the second resident-to-resident altercation but had not put the meeting notes in the computer yet. The DON stated that the MD had ordered [MEDICATION NAME] (a medication used to treat mental disorder such as aggressive behavior). The DON stated there were no non medication interventions attempted prior to recommending an antipsychotic medication ([MEDICATION NAME]). A review of the forms titled every 15 minute checks for location and safety and progress notes dated 7/07/18 through 8/17/18 for Resident 79 indicated: On 7/11/18, no 15 min check documentation from 1 pm through 2 pm and 11 pm through 11:45 pm; On 7/12/18, no 15 min check documentation from 10:45 pm through 11:45 pm; On 7/13/18,no 15 min check documentation from 12:15 am through 2:15 pm (14 hours). On 7/14/18, no 15 min check documentation from 12:15 pm through 2:15 pm (three hours); On 7/15/18, the15 min check documentation was left blank for four hours and 30 minutes (from 5:30 am through 6:15 am, from 9:30 am through 10:15 am, from 12:15 pm through 2:15 pm, and from 10:45 pm through 11:45 pm). On 7/16/18, no 15 min check documentation for seven hours (from 7:15 am through 2:15 pm). On 7/17/18 at 1:35 pm, the nursing progress notes indicated, Wanders about and needs frequent redirection to keep him from entering others rooms or taking their belongings- this is his usual behavior. On 7/18/18 at 12:54 pm, the nursing progress notes indicated, Continues to wander and attempt to get into others' belongings- frequent redirection and 15 minute checks continue. On 7/23/18 at 12:55 pm, the nursing progress notes indicated, res (resident) redirected away from other resident's rooms. On 7/24/18 at 1:06 pm, the nursing progress notes indicated, he is redirected from entering others rooms. On 7/24/18 at 7:01 pm, the nursing progress notes indicated, he is redirected from entering others rooms. On 7/26/18 at 12:11 pm, Social Services progress notes read seen by tele-psych today and indicated Psychological Treatment: Continue current redirection and monitoring of behavioral symptoms. Encourage patient to participate in activity programs. On 7/18/18, no 15 min check documentation for three hours and 45 minutes (from 10:45 am until 2:30 pm). On 7/19/18, no 15 min check documentation for 12 hours and 45 minutes (from 6:45 am until 10:30 am and from 1:30 pm until 10:30 pm). On 7/20/18, no 15 min check documentation for nine hours (36 lines were blank from 5:30 am until 2:30 pm). On 7/21/18, no 15 min check documentation for 11 hours and 30 minutes (46 lines were blank from 11 am until 10:30 pm). On 7/24/18,no 15 min check documentation for five hours and 15 minutes (from 5:15 pm until 10:30 pm); On 7/26/18, no 15 min check documentation for one hour and 45 minutes (from 8:45 pm until 10:30 pm); On 7/27/18, no 15 min check documentation for three hours and 45 minutes (from 8 pm until 11:45 pm); On 7/28/18, no 15 min check documentation for six hours and 15 minutes (from 12:15 am until 6:30 am); On 7/30/18, no 15 min check documentation for 45 minutes (from 11:15 pm until midnight); On 7/31/18, no 15 min check documentation for five hours (from 5:30 pm until 10:30 pm); On 8/1/18, no 15 min check documentation for 30 minutes (from 10 pm until 10:30 pm); On, 8/3/18, no 15 min check documentation for seven hours and 45 minutes (from 6:45 am until 2:30 pm); On 8/3/18 at 12:01 pm, the nursing progress notes indicated, Redirected from others rooms. On 8/4/18, no 15 min check documentation for five hours and 15 minutes (from 6:45 am until 10:45 am, and from 1:15 pm until 2:30 pm); On 8/5/18, no 15 min check documentation for five hours (from 1:15 pm until 2:45 pm, and from 7 pm until 10:30 pm); On 8/7/18 at 10:12 pm, the nursing progress notes indicated, resident up and walking around unit. Was in TV room watching TV. Staff reported he was not in there any longer and not in his bed. Unit searched and resident found in room [ROOM NUMBER] in bed sleeping, assisted resident to his own room and bed. On 8/8/18, no 15 min check documentation for five hours and 30 minutes (from 1:45 am until 6:30 am, and 9:45 pm until 10:30 pm); On 8/10/18, no 15 min check documentation for one hour and 15 minutes (from 9:15 pm until 10:30 pm); On 8/11/18, no 15 min check documentation for four hours and 15 minutes (from 11 am until 2:30 pm, and from 11:15 pm until midnight); On 8/12/18, no 15 min check documentation for six hours and 30 minutes (from 12 am until 6:30 am); On 8/13/18, no 15 min check documentation for six hours and 30 minutes (from 12 am until 6:30 am); On 8/14/18, no 15 min check documentation for two hours and 45 minutes (from 9:15 pm until midnight); On 8/15/18, no 15 min check documentation for six hours and 30 minutes (from 12 am until 6:30 am); 8/16/18 for four hours and 15 minutes (from 6:45 am until 11 am); On 8/17/18, no 15 min check documentation for six hours and 30 minutes (from 12 am until 6:30 am); On 8/27/18 at 3:40 pm, during an interview, Licensed Nurse (LN) BB remembered the incident that occurred on 7/6/18. LN BB heard screaming coming from Resident 50's room. When he got to the room, he witnessed Resident 79 repeatedly striking her with her bible. LN BB stated Resident 50 was distraught and shaken at the time and Resident 79 was very agitated. LN BB stated Resident 79 was removed from the room and placed on every 15 minute checks (for location and safety), which have been continuous since that time. On 8/27/18 at 4:15 pm, during an interview, Resident 50 remembered the incident that occurred on 7/6/18. Resident 50 explained that Resident 79 came into her room, was beside her roommate's bed (closest to the window) and touching a pair of shoes that were on the bed. Resident 50 was not sure what his intentions were, and was afraid he would hurt her roommate. Resident 50 stated she told Resident 79 this was not his room, and he needed to leave. Resident 79 came over to her bed, which really scared her, and picked up her address book (one of her most important belongings). When Resident 50 told him to put the book down and to leave the room, he got mad and started hitting her on the forehead with the book, and she started screaming for help. Resident 50 stated she felt bad about the way she handled it, since she did not put her call light on to get assistance from staff. Resident 50 stated it really shook her up, and at the time, she could not think what to do. She just knew she wanted Resident 79 to get out of the room and stop hitting her. Resident 50 stated staff responded to her screaming and removed Resident 79 from the room. When asked if she felt safe with Resident 79 across the hall, she stated she felt safe and if it happened again, she would put her call light on. Resident 50 then added that if other residents wanted him to move, I would vote for that. 3. Resident to Resident Altercation #3 occurred on 8/18/18. On 8/18/18 the every 15 minute checks for location and safety documentation was left blank for 13 hours and 30 minutes (from 2:15 am until 6:30 am, and from 2:45 pm until midnight) and on 8/19/18 for (from 12 am until 6:30 am, and from 7:15 am until 10:30 pm) The IDT meeting notes (attended by the DSS, AD, and the DON), dated 8/21/18, indicated the IDT reviewed resident-on-resident incident from 8/18/18 (time not indicated). The IDT note indicated, Both residents involved and other resident's roommate were interviewed by SS (social service). The notes indicated that upon interview, multiple conflicting accounts of events were given. LN (Licensed Nurse) reported that (Resident 63) came out of the room stating that (Resident 79) came to her room. When (Resident 63) asked (Resident 79) to leave, he struck her on the chest. Resident 63 previously reported she left her room to investigate an argument she heard in the hall. She (Resident 63) then claims other res (Resident 79) stopped her from interfering by placing his hand on her chest. There was no witness to this version of the event. Resident 79 now has no recall of the event. Resident 63 also has no recall of the event. Roommate reported that Resident 79 was entering the room repeatedly to use the bathroom. Roommate then reported she had a partial view, obstructed by the divider curtain, and claims that Resident 79's arms appeared to be batting at something. It is unclear if res-on-res contact was actually made. Resident 63 was assessed by LN (Licensed Nurse) with no signs of injury or distress. No root cause was documented. IDT Recommendations were to place resident on every 15-minute checks for 72 hours. On 8/18/18, the Fall Risk Assessment indicated, Wandering; verbally abusive; physically abusive; socially inappropriate, e.g. is noisy, screams, disrobes, self-abusive, rummages, hoards, etc. On 8/18/18 at 1:59 pm, the nursing progress notes indicated, Continued to be confused, wandering around rooms. On 8/19/19 every 15 minute check documentation showed 5:15 pm -5:45 pm awake/combative. The checks were left blank for nine hours and 30 minutes (from 12 am until 6:30 am, and from 7:15 pm until 10:15 pm) On 8/19/18 at 7 pm, the CNA narrative charting indicated, Resident became very agitated and combative when attempting to complete vitals (temperature, heart rate, respirations, and blood pressure) . he was kicking, screaming and crying. He sat out in the hall and was calm until 9:30 pm when he was incontinent of urine and became agitated again. Another aid (CNA) assisted and he was combative. He slept after that. On 8/19/18 at 9:08 pm, the nursing progress notes indicated, Try to hit staff. On 8/20/18 the 15-minute checks form was left blank for one hour and 15 minutes (from 10:45 until midnight). On 8/20/18, behavior documentation on the Medication Administration Record [REDACTED] On 8/21/18 the 15-minute checks form was left blank for five hours and 45 minutes (from 12 am until 1 am, from 1:15 am until 6:30 am, and from 8 pm until midnight). A care plan, created by the Director of Social Service on 8/21/18, (three days after the incident) indicated resident was observed batting at another resident, unclear if contact was made between residents. The care plan's goal remained the same. The interventions were not assessed for effectiveness and did not included any new interventions to prevent further altercation or abuse. On 8/22/18, the every 15 minute check form indicated On Station 1 combative at 6:30 pm. The form was left blank (after the combative behavior) for two hours and 45 minutes (from 7:45 pm until 10:30 pm). On 8/23/18 at 1:40 pm, the nursing progress notes indicated, Struck out at CNA x 1 during care today . redirected away from others' rooms as needed. The Summary of Investigation, dated 8/24/18 and signed by the Administrator, indicated that since the nurse on duty (stated Resident 79 and Resident 63 exchanged words in the hallway, but no physical contact occurred) contradicted the incident as described by Resident 63's roommate (Resident 79 came into their room, would not leave, and hit Resident 63, who then went to the doorway to call for help), and after a complete head to toe assessment (on 8/20/18, two days after the incident) there was no bruising or redness noted, the summary concluded that the IDT does not believe that physical contact was made between the two residents. The summary indicated Resident 79 was put on every 15-minute checks and that neither resident has had any change of daily activity and were not fearful. After indicating the IDT did not believe Resident 40's eyewitness account of the incident (as described above), the summary indicated Resident 40 was instructed to notify staff if anyone unwanted entered her room in the future. A review of Resident 79's 15 minute check forms for location and safety were left blank on 8/25/18, for seven hours and 45 minutes (from 2:45 pm until 10:30 pm) and on 8/26/18 for two hours and 45 minutes (from 3:45 am until 6:30 am). Resident 40's record was reviewed which indicated she was able to make own decisions, and had no memory impairment. On 8/27/18 at 11:55 am, during an interview, CNA AA explained she was a regular on Station II, and was completing documentation at the nurse's station on 8/18/18 when she heard a commotion, then heard Resident 63 repeatedly yelling, get him out of here! When she got to the room, both residents were agitated/upset and near Resident 63's doorway. She stated other staff were assigned to these residents and took over their care at that point. On 8/27/18 at 12:05 pm, during an interview, with Resident 40, Resident 63's roommate and witness to the incident, Resident 40 stated, Resident 79 had come into their room three times that night. The first time he came into the room, he was trying to go into their bathroom, she told him to leave, but he would not, so one of the CNA's had to come get him. The second time she was able to get him to leave. The third time, Resident 40 told him this isn't your room, your bathroom is across the hall. Resident 40 stated that Resident 63 was standing at the foot of her bed, when Resident 79 came into their room and walked towards the bathroom. Resident 40 pressed the call light to get help, but before staff came to assist, Resident 79 was hitting Resident 63 in the chest and Resident 63 was yelling for help. Resident 40 explained she saw him swinging his arm repeatedly at Resident 63. Then Resident 79 was leaving the room and Resident 63 went to the doorway to try and get somebody to come help us. Resident 40 stated, he had been coming in here all the time. On 8/27/18 at 3:40 pm Licensed Nurse BB (LN BB) stated he was a regular caregiver for Resident 79. LN BB explained that Resident 79 was very confused and would strike out at others so he was on every 15 minute watches for that (documented by the resident's CNA). LN BB explained caring for Resident 79 included frequent redirection to keep him from wandering into other resident rooms. When asked which residents he bothered the most, LN BB stated the residents located across the hall from his room. When asked about any recent resident-to-resident altercations, LN BB recalled Resident-to-Resident altercations #1 and #2, but was not aware of the incident that had occurred on 8/18/18. After checking the 24 hour report documentation (identified incidents requiring 72 hour alert charting), LN BB explained he had been on vacation until the 8/24/18 (the day after the alert charting ended), so was not aware of the last incident that had occurred. On 8/27/18 at 4 pm, during an interview CNA CC confirmed he was currently assigned to Resident 79's care. When asked about Resident 79's care needs, CNA CC stated he had never cared for Resident 79 before so didn't know a lot about him. When asked about Resident 79's behaviors, CNA CC stated he had not been told about any behaviors. When asked if Resident 79 had had any aggressive behaviors or previous resident to resident problems, CNA CC stated he was not aware of any. When asked how he learned about resident care issues, CNA CC explained CNA to CNA walking rounds (CNA going off duty, gives report to oncoming CNA while walking by each resident room and explaining care needs) were done prior to starting his shift. When asked how he would find out about important care needs that were not communicated during report, CNA CC stated additional information (other than what was reported by off-going CNA) was not available to CNA staff. During a concurrent interview, LN BB confirmed no resident care directives or care planning information was available to CNA staff. LN BB explained this information is only available to licensed staff (in computer), CNA staff have computerized kiosks where documentation of resident care occurs, but no care directives are included in the kiosk information. LN BB confirmed the facility practice was for CNA to CNA walking rounds reporting to occur. During a concurrent interview, CNA CC confirmed he was not told about Resident 79 being on every 15 min checks, was not told he had aggressive behaviors, was not aware he had hit another resident, was not aware he had hit two ladies across the hall and was as not aware Resident 79 required close monitoring to keep other residents safe. On 8/28/18 at 11 am during an interview CNA DD was a regular caregiver on Station 2 (Resident 79's location). CNA DD explained he (Resident 79) mostly acts up in the evenings, and was often combative with staff. CNA DD explained that last week he threw his soda on her, hit her in the stomach and spit on her. CNA DD stated she had seen him throwing medications at the nurse when he did not want to take them. CNA DD stated Resident 79 was very confused, had delusions (thinks things are there that are not), and even while he was being closely monitored, he still managed to wander in and out of peoples rooms. CNA DD stated that Resident 79 got agitated easily and was frequently combative when redirected. When asked if Resident 79 had been found in other resident rooms, CNA DD stated a couple days ago he was not in the hallways and staff were looking for him and he (Resident 79) was found down on Station 1 in someone's bed. On 8/28/18 at 3 pm, during an interview, the Admin and the DON confirmed the resident to resident altercations as described above, and acknowledged Resident 79 was able to ambulate independently, and required redirection to keep him out of other resident rooms. The Admin and DON acknowledged that the third resident to resident altercation had occurred while Resident 79 was on every 15 minute check supervision. The Admin and DON acknowledged that communication between Resident 79s CNA's (during report) had not been adequate to ensure the every 15 minute check supervision was being done, and that no measures were in place, to protect other residents from abuse, between the every 15 minute checks. On 8/29/18 at 3:45 pm, during an observation and interview, Resident 63 was alert, oriented and able to accurately recall short and longer-term events. When asked if residents ever wandered into her room, Resident 63 recalled a detailed description, without any cueing, of the incident that occurred on 8/18/18. Resident 63 explained that the resident from the room across the hall (Resident 79) had come into her room. When her roommate asked him to leave, he did not leave and kept coming in and to her side of the room. Resident 63 stated she told him to get out of the room and was yelling for help, but instead of leaving, he got mad and punched her in the stomach (pointed to her upper abdomen/lower chest area). Resident 63 stated it was painful for quite a few days after he hit her. Resident 63 was asked if she felt comfortable being near Resident 79 after this incident, she stated she avoids him now, if she sees him in the hallway, she will not go out until he is gone. Would not feel comfortable passing close by him. When asked if she felt safe with Resident 79 across the hallway, she stated, yes I feel safe. When asked what made her feel safe, Resident 63 stated that she was a tuff lady, and if he tried it again, she would be ready for him this time. No documentation of the incident on 8/18/18, between Resident 79 and Resident 63 were found in the nursing progress notes. The physician history and physical assessment, dated 8/29/18, indicated Resident 79 included an assessment/plan that indicated, . He can have spontaneous aggression and physical violence without provocation. The [MEDICATION NAME] has helped some but he is now 1:1 (one staff with Resident 79 at all times) . I recommend that he be assessed in a geriatric specific inpatient psychiatric facility, but we have put measures in place that will ensure his and the other residents safety.

Based on observation, interview, and record review, the facility failed to prevent two avoidable falls for one of three sampled residents (Resident 1) and failed to implement care plan interventions to prevent falls for two of three sampled residents (Residents 2 and 3) when: 1. a. Resident 1 was not assessed for fall risk or have a care plan developed to reduce the risk for falls within 24 hours of admission, per facility protocol. Resident 1 had no fall precautions in place and the facility allowed Resident 1 to get up to the bathroom without assistance, resulting in an avoidable fall on 3/15/17, and b. Resident 1 did not receive adequate supervision resulting in an avoidable fall on 3/24/17. 2. Resident 2 did not receive assistance devices to prevent accidents when the care planned interventions to reduce the risk for falls indicated the use of a bed alarm and a mat on the floor, were not implemented. 3. Resident 3 did not receive assistance devices to prevent accidents when the care planned intervention to reduce the risk for falls indicated the use of a sign to remind the resident to Use the call light, was not implemented. These failures resulted in Resident 1 sustaining a right ilium (pelvis) fracture (broken bone) on 3/15/17. Resident 1 had constant right hip pain of seven to eight out of 10 (a scale of zero to ten, where zero is no pain and 10 is the worst pain), and goes up to eight or nine out of 10 with muscle spasms, which required transfer to an acute care hospital for IV (administered into a vein) pain control and physical therapy, and an odontoid (neck bone) fracture on 3/24/17, requiring the long-term use of a neck brace. This had the potential to result in avoidable falls and subsequent injuries for Residents 2 and 3. Findings: A review of the facility's policy titled, Fall Management Program, revised 11/7/16, indicated that a Resident's risk for fall is assessed by a Licensed Nurse (LN) by using the Admission Assessment form . The Licensed Nurse and/or Interdisciplinary Team (IDT) will develop a Plan of Care according to the identified risk factors 1. a. A review of Resident 1's clinical record indicated that he admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was transferred to the acute care hospital on [DATE], after a fall at the facility. The Minimum Data Set (MDS, a standardized resident assessment), dated 3/15/17, indicated that Resident 1 required limited assistance of one person and he was not steady moving from a seated to standing position or from surface to surface. He was only able to stabilize with staff assistance. A review of Resident 1's first Fall Risk Assessment, signed 3/15/17 at 10:26 am, seven hours after his first fall, indicated that Resident 1 had No History of falls within the last six months and he was at a moderate risk for falls. During an interview, on 7/25/17 at 2:45 pm, Resident 1's Responsible Party (RP) stated that when Resident 1 was admitted , she told the nurse that he was a fall risk. RP stated that she was concerned because there were no fall precautions in place, and the facility allowed Resident 1 to get up to the bathroom without assistance. A review of Resident 1's Care Plan titled, The resident is at high risk for unavoidable falls, dated 3/21/17, indicated that a plan of care was not developed to reduce the risk for falls prior to his first fall on 3/15/17. During a concurrent interview and record review, on 7/25/17 at 3 pm, the Director of Nursing (DON) confirmed that Resident 1's fall risk was not assessed and a care plan was not developed prior to his first fall on 3/15/17. During an interview on 9/20/17 at 10:40 am, the Facility Administrator (FA) stated that it is the facility's expectation that a fall risk assessment and subsequent care plan to reduce the risk for falls are to be completed within 24 hours of admission. A review of Resident 1's Progress Notes, dated 3/15/17 at 7:18 am, indicated that Resident 1 had an unwitnessed fall, when he was found sitting on the floor at 3:30 am, after he attempted to transfer himself and slid off of the bed. At 4:30 am, Resident 1 Complained of pain in his right hip and pelvic area with shooting intensity. Resident 1 was transferred to the emergency room by paramedics. A review of the Ambulance report, dated 3/15/17 at 5:23 am, indicated that Resident 1 sustained a fall resulting in a traumatic injury. There were no obvious deformities to the right hip or leg, but Resident 1 reported constant pain of seven to eight out of 10 and goes up to eight or nine out of 10 with muscle spasms. The report indicated a Past medical history of [REDACTED]. A review of the acute care hospital, History and Physical Report, dated 3/15/17, indicated that Resident 1 sustained a traumatic (caused by trauma) displaced (moved out of alignment) right ilium fracture after a fall. The report indicated The patient will be unlikely able to control his pain at the skilled nursing facility and will need physical therapy and likely IV pain medications. b. A review of Resident 1's clinical record indicated that he was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated that Resident 1 required extensive assistance of one person and he was not steady moving from a seated to a standing position or from surface to surface. He was only able to stabilize with staff assistance. During an interview, on 7/25/17 at 1 pm, the FA stated that upon readmission on 3/20/17, Resident 1 was put into a new room for increased supervision because of his increased fall risk. During an interview, on 7/25/17 at 1:25 pm, LN B stated that Resident 1's room was around the corner and it was very difficult to monitor Resident 1. LN B stated that she knew that Resident 1 had a history of [REDACTED]. LN B stated that nursing staff are not allowed to move Residents. LN B stated that Resident 1 was not put into a new room, for increased supervision, upon readmission. During an interview, on 7/25/17 at 1:50 pm, LN A stated The closer to the Nurse's Station, the better, as far as supervision. A review of Resident 1's Progress Notes, dated 3/24/17 at 10:45 pm, indicated Patient found out of bed laying on mat beside of bed . Patient placed back in bed and instructed to call staff when getting out of bed The progress note did not indicate that Resident 1's physician or RP were notified of an unwitnessed fall or that Resident 1's neurological status was monitored after the unwitnessed fall. During an interview, on 7/25/17 at 3:30 pm, LN E confirmed that she authored the Progress Note dated 3/24/17 at 10:45 pm. LN E stated that she was training with LN A when Resident 1 was found on the floor. LN E stated that LN A told her that If a resident is found on the mat and did not get hurt, then it is not a fall. LN E stated that she did not feel right about that and asked LN A for a policy that would indicate that this incident was not a fall. LN E stated that LN A was unable to provide her with the policy. A review of the facility's policy titled, Fall Management Program, revised 11/7/16, indicated that following each resident fall, the Licensed Nurse will revise a plan of care, complete the Neurological Flow sheet for an unwitnessed fall, notify the attending physician, responsible party, and the Director of Nursing or Administrator as soon as possible. The policy did not describe any situation where a resident found on the floor is not considered a fall. A review of Resident 1's Progress Notes, dated 3/25/17 at 2:35 pm, indicated Patient has been lethargic (sluggish) today, refusing to eat meals. The physician was notified and a new order was received to remove a Fentanyl (a strong narcotic pain reliever) patch. During an interview, on 7/25/17 at 2:30 pm, LN C stated that she observed a change of condition of Resident 1. LN C stated that she notified the physician of the change of condition. LN C stated that she did not know of Resident 1's fall on 3/24/17. A review of the emergency room Report, dated 3/25/17, indicated that Resident 1 had been Complaining of a headache in his occipital (the back of the head) area for the last couple days. Resident 1 was unable to provide details about his neck pain due to lethargy (a state of sleepiness or deep unresponsiveness) and the history was provided by his RP, who presented with him. The report indicated that Resident 1 Last fell about nine days ago. Resident 1 was diagnosed with [REDACTED]. A review of the Consultation Report, dated 3/25/17, indicated that Resident 1 has had multiple hospital admissions for multiple fractures after falls. The physician indicated that fixing this type of fracture would be technically very difficult and risky surgically. The physician recommended a hard neck brace. The physician suspected it will never heal completely and told the RP that Resident 1 may need to be in a neck brace indefinitely. A review of Resident 1's Progress Notes, dated 3/26/17, indicated that Resident 1 was transferred to the acute care hospital on [DATE] for a headache with possible reaction to the Fentanyl patch. During a chart review conducted by the IDT, it was noted that Resident 1 had a fall on 3/24/17. The physician and RP were notified on 3/26/17 when the nurse's note was discovered. 2. A review of Resident 2's record indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident 2 had severe cognitive (ability to think and reason) impairment, required extensive assistance of two people to turn in bed, transfer between surfaces, and he was always incontinent (involuntary loss of control) of bowel and bladder. A review of Resident 2's Care Plan, dated 8/25/17, indicated that he was discovered next to his bed leaning against the bed on 8/25/17. The care plan instructed staff to use a bed alarm and fall mats on either side of the bed. During a concurrent observation and interview, on 9/20/17 at 9:04 am, Certified Nurse's Assistant (CNA) D confirmed that Resident 2 did not have a bed alarm or fall mats on either side of the bed. 3. A review of Resident 3's record indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident 3 had severe cognitive impairment, required extensive assistance of two people to turn in bed, transfer between surfaces, and he was always incontinent of bowel and bladder. A review of resident 3's care plan, dated 9/15/17, indicated that Resident 3 was discovered with his knees on the floor mat on 9/14/17. The care plan instructed staff to add signage to Resident 3's room to remind him to Use call light. During a concurrent observation and interview, on 9/20/17 at 9:04 am, CNA D confirmed that Resident 3 did not have signage in his room to remind him to Use call light.

Based on interview and record review, the facility failed to ensure Resident 1 received adequate supervision and care to prevent an accident when she was in the care of Physical Therapist (PT) A, who was intoxicated and impaired while on duty, and Resident 1 fell to the floor. This resulted in Resident 1 having a fall with injury, a broken left femur (leg bone) and left wrist skin tear and pain, requiring hospitalization and surgical repair of her broken femur. Resident 1 returned to the facility and declined in her ability to transfer, could not bear weight on her left leg, and tearfully verbalized ongoing fearfulness of falling. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview and record review with the Administrator (Admin) on 4/16/15 at 12:50 pm, she stated Resident 1 was in the care of PT A on 8/19/14 when the resident fell . Resident 1 was transferred to the hospital on [DATE] and was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Admin confirmed that, after the resident fell , PT A provided a toxicology screen (blood or urine test to check for intoxicants) that indicated a was positive result for an intoxicating substance (THC, the active substance in marijuana). Admin stated the facility no longer employs anyone from the company that was providing PT services at the time of the incident. During an interview with Rehabilitation Aid (RA) on 4/16/15 at 1:15 pm, he stated he was called in to assist after Resident 1 fell . RA described PT A stating he, appeared impaired and was not dressed in his normal attire (PT A was wearing a sports jersey, sweat pants, and sandals). RA stated that he was told Resident 1 fell in some manner but was unable to clarify if the resident fell or was assisted to the floor. During an interview with the Speech Therapist (ST) on 4/16/15 at 1:22 pm, she stated she was present on the day Resident 1 fell . ST stated PT A was dressed oddly and she had overheard PT A was unable to remember his computer password. ST stated, after Resident 1 had fallen, PT A appeared impaired and she observed him bump into the wall when he tried to exit the room. During an interview with Licensed Nurse (LN) A on 4/16/15 at 2:10 pm, she stated she was the nurse that took care of Resident 1 after she fell . LN A stated she was told by other staff that Resident 1 had fallen, but was told by PT A that Resident 1 did not fall, rather he slowly lowered her to the ground. LN A stated, after she assumed care of Resident 1 from PT A, Resident 1 began to complain of pain and reported she had fallen. When LN A told Resident 1 that PT A reported she had not fallen, but rather was lowered to the ground, LN A stated Resident 1 told her, He must have been drunk because I did fall. LN A was asked about the resident's ability to recall the event. LN A stated, Resident 1 was very alert and aware at that point, and LN A thought Resident 1 was reliable in her report. During an interview and record review with the Assistant Director of Nurses (ADON) on 4/16/15 at 2:45 pm, she reviewed the Fall Risk Assessment, dated 7/30/14, and confirmed Resident 1 had a fall score of ten, which placed her at a moderate risk for falls. The ADON reviewed the physician's orders [REDACTED]. The ADON stated she was unable to access the documentation from PT A at the time of the incident. During an interview with the Admin on 4/21/15 at 10 am, she stated she was unable to provide a copy of the toxicology screening for PT A, but confirmed that it was positive. The record for Resident 1 was reviewed on 4/21/15. The Fall Care Plan, dated 7/31/14, indicated Resident 1 was a moderate fall risk, had generalized weakness, and balance problems. The Physical Therapy Plan of Care, dated 7/31/14 to 8/27/15, indicated, Resident 1 was referred to PT due to generalized weakness and difficulty walking. The plan of care identified that Resident 1 was fully oriented but had poor safety awareness and was a fall risk. An Interdisciplinary Progress Note, dated 8/21/15, indicated, Was called to therapy gym for assist to floor. Resident (Resident 1) was already in a chair when this nurse entered the room. Was told by the therapist that resident was standing with walker, stated she was dizzy, and he assisted her to the floor. Resident is now complaining of pain and a skin tear to left wrist. The hospital Emergency Report, dated 8/20/14, indicated, Left femur fracture . showing displaced supracondylar femur fracture (broken leg bone with the fragments out of alignment). The hospital's Report of Operation, dated 8/20/14, indicated Resident 1 required surgical intervention to treat a comminuted fracture of the left distal femur (broken leg bone with fragmenting of bone) . The patient did have significant osteoarthritis . but did not indicate that Resident 1 had osteoporosis (medical condition that causes bones to become brittle and fragile). The Postoperative Report indicated Resident 1 would be unable to bear weight for 12 weeks and would need to remain in a device to immobilize her knee at all times for two weeks. Physical Therapy Daily Treatment Notes throughout the month of 9/2015 (after Resident 1's fall in the care of PT A and after hospitalization ) contained several entries that indicated Resident 1 was so fearful of falling that she became tearful and required additional staff to assist in her care. The following was documented: On 9/1/14, Currently on regular mattress. While rolling began crying and in tears reports fear of falling. On 9/4/14, Resident 1 required, max a (maximum assistance) x 2 staff for safety due to patient fear. On 9/8/14, Resident 1 required 2 staff to assist her in transfers, due to her fear of falling. On 9/10/14, Prior to transfers patient in tears due to fear of falling. On 9/15/14, Patient denies pain with movement however patient in tears due to fear. On 9/21/14, Due to patient fear of falling, requires two staff to assist. On 9/28/14, Patient appears to be fearful while working on bed mobility . patient in tears.

Based on observation, interview, and record review, the facility failed to conduct complete, ongoing skin assessments and develop and maintain interventions to prevent the development of two avoidable heel pressure ulcers (skin wounds which develop due to unrelieved pressure or decreased circulation which destroys tissue); a Stage III (Full thickness tissue 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) left heel pressure ulcer and an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined) right heel pressure ulcer for one of 24 sampled residents (Resident 9) by failing to ensure: A thorough assessment of the resident's skin was completed upon readmission to the facility; A completed Admission Skin Assessment and Pressure Ulcer Risk Assessment by the treatment or charge nurse upon readmission; A completed weekly Pressure Ulcer Risk Assessment after re-admission; The IDT evaluated Skin and Pressure Ulcer Assessments upon re-admission and developed an individualized plan of care based on determined risk factors; and The charge nurse completed a weekly skin evaluation on the Weekly Skin Review. These failures contributed to Resident 9 developing two avoidable pressure ulcers; a Stage III pressure ulcer on his left heel and an unstageable pressure ulcer on his right heel. Findings: The record for Resident 9 was reviewed. The Minimum Data Set (MDS, a standardized resident assessment), dated 9/25/14, indicated Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident 9 was unable to walk, needed extensive staff assistance for transfers, hygiene and bed mobility, was at risk for developing pressure ulcers, and had two pressure ulcers on the trunk of his body (scrotum and buttock) when he was admitted to the facility. Review of physician's orders [REDACTED]. The MDS assessment, dated 3/23/15, indicated Resident 9 was unable to walk and had a limitation of function of both of his lower extremities (hip, knee, ankle and foot) which interfered with daily functions. Resident 9 was at risk for development of pressure ulcers. Resident 9's record indicated, from 3/28/15 to 4/1/15, he was out of the facility visiting family, and returned to the facility on [DATE] at 10:26 pm. On 4/2/15 at 12:05 am, just after midnight, a health status note (nursing progress note) indicated the Licensed Nurse (LN) attempted to do a skin check. but (Resident 9) would not allow (the) nurse to assess his entire body because he became Physically resistive. The LN documented they were able to assess Resident 9's feet, hands, and face, no open areas were noted and they would, Notify the AM nurse to attempt skin check. Two weekly summaries (licensed nurse weekly review), dated 4/2/15 at 6:57 pm and 4/9/15 at 3:24 pm, indicated Resident 9's skin was desensitized to pain/pressure and he had pressure areas. No documentation was present to identify the location, wound bed/edges or any detailed assessment of pressure areas. The facility's Pressure Ulcer Risk Assessment policy, dated 11/2012, provided guidelines for assessment and identification of pressure ulcer development risk, including routine assessment and documentation of resident skin condition, per the facility's wound and skin care program. Skin assessment was to be performed at least weekly, or more frequently as needed, to identify skin changes or signs of developing pressure ulcers. The policy stated, Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly, to attempt to prevent pressure ulcers. The size and location of any red or tender area was to be documented. The facility's policy titled, Skin and Wound Management Program, dated 6/13/06, instructed, Each resident is assessed to determine the presence of or potential for skin integrity alteration. A plan of care addressing skin integrity alterations, risk factors, and co-morbidities is developed and implemented by the Interdisciplinary Team (IDT) with ongoing reassessment to ensure optimum outcome. The policy directed staff to conduct a thorough assessment of the resident's skin upon admission, re-admission, quarterly, and when a change of condition occurs: The Admission Skin Assessment is to be completed by the treatment or charge nurse. The Pressure Ulcer Risk Assessment is competed weekly for the first four weeks after admission or re-admission. The IDT will evaluate the completed Admission Skin Assessment and Pressure Ulcer Risk Assessment, within 72 hours of admission or re-admission. Body checks will be performed by CNA's, daily and observations reported to the charge nurse, and charge nurses will perform weekly skin evaluation and document findings on the Weekly Skin Review. The facility will take all measures available to prevent the development of pressure ulcers. All nursing progress notes (daily notes-separate from the weekly summary) from 4/2/15 at 12:05 am, when the LN documented a partial skin check, through 4/11/15, when two pressure areas were identified on Resident 9's right and left heels, were reviewed and no documentation was present to indicate a complete skin assessment had been performed. On 4/11/15 at 1:35 pm, a LN assessment indicated Resident 9 was found to have an unstageable pressure sore on his right heel described as Dark eschar (dead tissue) surrounding tissue and measured 4 centimeters (cm) in length by 1.5 cm wide and another pressure sore on his left heel which was an open area that measured 1.0 cm by 0.5 cm. During an interview and concurrent record review on 4/16/15 at 10 am, the wound care nurse (WCN) stated Resident 9 had been admitted on [DATE] with a pressure sore on his scrotum and another on his buttocks but those had both resolved mid-January and Resident 9 had no other pressure areas until 4/11/15, therefore, no weekly pressure ulcer assessments had been completed from 1/13/15 to 4/11/15. On 4/14/15 at 3 pm and 4/15/15 at 7:55 am, Resident 9 was observed in bed lying on his left side. On 4/15/15 at 11:40 am and 3:00 pm, Resident 9 was observed sitting in a manual wheelchair with the back portion of his heels, wrapped in gauze and with heel protectors on, resting directly onto the metal footrests with his toes pointed toward the ceiling. On 4/16/15 at 9 am, during an observation and interview with Certified Nurse Assistant (CNA) I, Resident 9 was observed lying in bed on his left side. CNA I stated, on 4/11/15, she found two new pressure ulcers on Resident 9; one on his right heel and one on his left heel. CNA I stated she did not know how he got them. During an interview on 4/16/15 at 9:15 am with LN F, she stated Resident 9 has no movement or sense of feeling in his legs (could not detect pressure or discomfort due to pressure on his heels). LN F stated Resident 9 has pressure ulcers on the bottom of his feet which the RP stated are from his manual wheelchair, because his feet rest on the foot rests and he cannot move them to relieve pressure. LN F further explained Resident 9 has two wheelchairs, a manual which he likes to use but does not have the ability to be adjusted to relieve pressure, and an electric chair which reclines in the back and elevates his feet to take pressure off his feet/heels. During an interview and concurrent record review on 4/16/15 at 10 am, the wound care nurse (WCN) acknowledged Resident 9's pressure ulcers could be a result of his feet continuously resting on the foot rest of his manual wheelchair. WCN stated no referral to occupational therapy had been made to assess Resident 9's seating and leg positioning in his manual wheelchair until 4/16/15 (five days after the facility discovered the Stage III and unstageable pressure ulcers on his heels). The National Pressure Ulcer Advisory Panel (NPUAP), an international pressure ulcer foundation describes a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure and/or shear. A Stage III pressure ulcer as, Full thickness tissue loss. Fatty tissue under the skin may be visible but bone, muscle and tendon are not exposed. An unstageable pressure ulcer as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough or eschar is removed to expose the base of the wound, the true depth and Stage cannot be determined. The NPUAP recommends facility's use a structured risk assessment to include relevant risk factors and complete a comprehensive skin assessment to develop and implement a risk based prevention plan. Skin assessment should be ongoing based on the individual's degree of risk, head-to-toe with particular focus on skin overlying bony prominences, including the heels, and documented. A review of the facility's care plans for Resident 9 indicated a pressure ulcer care plan was initiated on 11/11/14 for an unstageable right plantar (bottom of the foot) pressure ulcer. The care plan indicated Resident 9 would be encouraged to use his electric wheelchair with recline function to offload pressure. The care plan was Cancelled (not current) on 11/20/14. There were no current care plans in Resident 9's record to address pressure ulcer development risk or impaired skin integrity risk for Resident 9 from 3/20/15 to 4/11/15. Current care plans for pressure ulcer development risk or impaired skin integrity risk were requested for review from the Assistant Director of Nurses (ADON), but were not provided by the date of survey exit of 4/17/15. During an interview and concurrent record review with the ADON on 4/17/15 at 12:45 pm, the ADON stated she did not know what pressure areas were being referred to in the weekly summaries of 4/2/15 and 4/9/15. ADON confirmed no care plan for risk of pressure ulcers from 3/20/15 to 4/11/15 could be located. ADON confirmed a lack of assessments and appropriate interventions may have contributed to Resident 9's development of pressure ulcers in the facility. An interview was conducted on 4/17/15 at 3:15 pm with Resident 9's RP who had taken him on pass outside the facility on 3/28/15 and returned him to the facility on [DATE]. RP stated she had told the facility when he was admitted to the facility in 9/2014 that Resident 9 had a previous history of pressure ulcers on both heels from his manual wheelchair.

Based on observation, interview, and record review, the facility failed to protect three of eight sampled residents (Residents 1, 7, 8) and one resident outside the sample, (Resident 9), from abuse when: Resident 2 made verbal insults towards Resident 1, punched Resident 1 in the face, and squeezed her hand resulting in redness, bruising, and psychological trauma. When the police came to speak with Resident 2, he told them "he didn't f---ing care and he would do it again." The facility continued to allow Resident 2 to move through the hallway unsupervised, which resulted in another interaction where Resident 2 made verbal insults and threatened physical harm to Resident 1. The facility then failed to ensure documentation of and follow-up treatment and services for the incident. Resident 2 made verbal insults and threats of physical harm to Resident 8. Confidential Resident 9 was fearful and didn't feel safe, due to Resident 2's violent talk. Resident 2 was verbally abusive to Resident 7 who was fearful and didn't feel safe when around Resident 2. On 3/25/15 at 5:10 pm, the facility's Administrator (Admin) and Director of Nursing (DON) were notified of an immediate jeopardy (IJ) situation due to the facility's failure to protect residents from Resident 2's verbal and physical aggression and abuse. On 3/26/15 at 2:15 pm, the facility provided an acceptable immediate corrective action plan to keep residents safe and free from abuse by Resident 2, which included one to one supervision of Resident 2, and the facility's Admin and DON were notified the IJ was abated. Refer to F225, F278, F 279, F319, and F514 for additional information. Findings: The facility's policy titled, "Abuse Prevention, investigation and reporting," last revised 3/2013, indicated, "each resident has the right to be free from verbal, sexual, physical, and mental abuse .... Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents... ." The policy indicated employees would be trained upon hire and bi-annually on the recognition, prevention, and reporting requirements for abuse. The policy indicated "abuse will not be tolerated in this facility." The policy's direction for the protection of residents from abuse indicated "If a resident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps: Provide a safe environment for residents as indicated by the situation; If suspected perpetrator is another resident: the residents will be separated so they do not interact with each other until circumstances of the reported incident can be determined. The policy's direction for the investigation of suspected abuse indicated all incidents of suspected or alleged abuse will be investigated by the assigned staff who will be informed of the nature of the incident and continue the investigation progress. The policy's direction for reporting abuse indicated all mandated reporters were required by law to report incidents of known or suspected abuse. The policy indicated a form (SOC form 341, used for reporting incidents) would be sent to the ombudsman's office and to the department (The CA Department of Public Health-CDPH) if required. The policy indicated an incident and injury report would be completed and event reported to the director of nurses and the administrator immediately for necessary follow up. a. On 3/20/15 at 7:20 am, the CDPH received a report from the facility which included an allegation of abuse that occurred on 3/19/15 at 6:30 pm. The report indicated a Certified Nursing Assistant (CNA) observed a male resident (Resident 2), strike a female resident (Resident 1) on the right side of her face. The report indicated the CNA went out to separate the residents and the male resident was then grabbing Resident 1's right hand. Resident 1's record was reviewed. Resident 1, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a resident assessment), dated 3/3/15, indicated Resident 1 had significant memory impairment. The MDS indicated Resident 1 required extensive assistance from staff to transfer out of bed and minimal assistance with wheelchair locomotion. Resident 1's record indicated she was able to communicate effectively and to make her needs known. Resident 1's care plan, dated 2/20/15, indicated she was dependent on staff for activities, cognitive stimulation, and social interactions due to her physical limitations and cognitive deficits (memory problems). Resident 1's care plan, to address the 3/19/15 incident described above (when Resident 2 hit Resident 1), did not include any interventions to ensure her safety from Resident 2. Resident 2's medical record was reviewed. Resident 2, a [AGE] year old male, was admitted to the facility on [DATE] for rehabilitation after hospitalization and surgery for [REDACTED]. Resident 2's [DIAGNOSES REDACTED]. The specific type of mood disorder was not indicated. The record indicated Resident 2 was homeless at the time of the accident. The consultation physician's report of Resident 2's neurological function while in the hospital, dated 8/14/13, indicated, "other than being a belligerent jerk to pretty much everyone," he was neurologically intact. Resident 2's behavior care plan, initiated on 5/27/14, indicated he was being monitored for frequent angry and aggressive outbursts. The care plan indicated triggers for the outbursts included when other residents get in his way or disturb him for cigarettes. The MDS, dated [DATE], indicated Resident 2 was alert, oriented and able to communicate effectively without memory impairment. Resident 2's Medication Administration Record [REDACTED]. Resident 2's behavior monitoring was tallied on his MAR. Resident 2's MAR, for the 23 day period from 3/1/15 through 3/23/15, indicated 45 aggressive outbursts had occurred. Resident 2's care plan, to address the 3/19/15 incident described above, did not include any interventions to ensure the safety of other residents. During an observation and interview on 3/20/15 at 3:30 pm, Resident 1 was sitting in the hallway across from the nurse's station. When asked how everything was going for her, Resident 1 stated, "ok, except for that guy that beat me (her) up." When asked who beat her up, she pointed down the hall in the general vicinity of Resident 2's room. During an observation of Resident 2 on 3/20/15 at 4:10 pm, while in his room sitting in a wheelchair and watching TV, he agreed to a short interview. Resident 2 explained an interaction with the "silver haired witch" (and indicated he was referring to Resident 1) down the hall." Resident 2 explained that he told Resident 1 "nobody in here f---ing cares about you, you gray haired witch." Resident 2 stated he "thought it was so funny what happened because Resident 1 had pulled his hand, when he was near her and his hand hit her in the face." When asked why he thought it was funny, Resident 2 stated, "because I hate that f---ing gray haired witch." When asked why he didn't like her, Resident 2 responded that she was "always sitting there in the hallway and was in the way." Resident 2 explained that he was "pissed about all kinds of things in this g-- damn place." Resident 2 stated that he would be fine if people would just leave him alone. Resident 2 stated that "if they don't leave me alone I'll just take care of them." When asked what he would do, Resident 2 stated he would "just hit them, or kick them, or punch them in the face." When asked if he had done this before, Resident 2 stated, "yes." When asked who he had done this to, Resident 2 did not reply and indicated the interview was over by turning his attention towards watching TV. On 3/23/15 at 5:35 pm, Resident 2 was observed coming into the facility from the smoking patio and was self-propelling down the hallway towards his room. Resident 1 was observed sitting in the hallway just past the nurses' station. LN C was observed standing at a medication cart with her back to Resident 1, approximately five feet away. When Resident 2 got close to Resident 1, he yelled out "You f---ing b--ch! Someday I ' ll get a chance to bury you in a g-d damn grave! You f---ing bald faced b--ch! I'm gonna punch you!..." LN C was observed to intervene by standing between the residents and encouraging Resident 2 to continue going towards his room. After Resident 2 continued down the hallway, LN C returned to the medication cart. LN C then stated "I don't think he would actually harm a fly, but anyway." Observed another staff ask Resident 1 how she was doing, to which Resident 1 replied, "Ok, I guess, I was just called a b--ch." On 3/24/15 at 5:45 pm, LN C stated she had followed up with both residents after the incident described above. LN C confirmed during the verbal exchange on 3/23/13, Resident 2 was verbally abusive to Resident 1. LN C stated she was surprised to hear he had hit someone and was not aware it had happened until after the verbal exchange the day prior. During an interview on 3/24/15 at 10:45 am, CNA A stated she had observed and intervened in the incident described above. CNA A explained while walking down the hallway past the windows and door to the smoking patio, she saw Resident 2 use his closed fist to punch Resident 1 in the face. CNA A stated when she was pulling Resident 1's wheelchair to get her away from Resident 2, Resident 2 was holding on to and squeezing Resident 1's hand and did not want to let go. CNA A stated during this encounter, while she was separating the residents, Resident 2 was cussing and threatening Resident 1 saying, "just wait until next time I see you in the hallway ... you cock s---ing b--ch!" CNA A stated she reported the incident to Licensed Nurse (LN) B. CNA A stated she was a long term regular caregiver for Resident 2. CNA A explained Resident 2 cusses a lot when in a bad mood. He will say he wants to beat people of, or that he's tired of the sons of b--ches. When she told him the hallway was for everyone and everyone had a right to be in the hallway, Resident 2 said, "then they just need to be shot in the face." CNA A explained if he was in a bad mood, he will go on about everything including the news, people in his way, or just cussing to the air. When asked what he was like when in a good mood, CNA A stated he would usually be quiet the whole time and not say anything. CNA A added Resident 2's moods can change in a "split second." When asked how he reacted to people being in his way in the hall, CNA explained "he'll cuss them out when he is upset. He called them cock s---ing b--ches. When asked why he seems to target Resident 1, CNA A explained when he goes by her cussing, she will say "you've got a dirty mouth or watch your mouth" and Resident 2 will react by cussing her out. When asked who else he cusses out, CNA A stated Resident 8. When asked if the words Resident 2 used to cuss Resident 1 were verbally abusive towards Resident 1, she stated, "yes." On 3/24/15 at 12:15 pm, during a telephone interview, Resident 2's family member (FM E), the healthcare decision maker for Resident 2, explained until recently, he had been estranged from Resident 2 for most of his life. FM E explained that in talking to the woman who was married to Resident 2 the first five years of FM E's life, Resident 2 had mental issues all of his life. He explained "he (Resident 2) was always a little kid stuck in a man's body." When asked about Resident 2's careers, FM E stated he was never in the military, but Resident 2's stories included that he was in the marines, was a truck driver, was a cop or was a fire fighter but in truth he was none of these. FM E stated he had heard that Resident 2 had been incarcerated before, but was not sure when or what for. FM E stated he was very upset that Resident 2 hit a lady and hoped he would be moved to a facility better equipped to deal with his issues. On 3/24/15 at 2:50 pm, during an interview, the Administrator (Admin) was asked if Resident 2 had ever hit anyone before the incident which occurred on 3/19/15. The Admin reviewed the facility files and explained on 2/17/15, he had hit a resident in the upper arm because she was taunting him and she had taunted him before. The Admin explained he stays to himself, but if someone gets on him, he responds. When asked if he had hit anyone prior to 2/17/15, Admin explained that one other time he had rammed a wheelchair and yelled profanities at another female resident on 5/26/14. During an interview on 3/25/15 at 9:45 am, LN B explained, after the incident described above was reported to her, she assessed the residents and notified the police who came out and met with Resident 2. LN B stated that Resident 1 had sustained redness and bruising to her skin. LN B explained that when the police talked to Resident 2 about the incident, Resident 2 told them, "he didn't f---ing care and would do it again." On 3/25/15, the CDPH received a report that Resident 2 had not had any further aggressive behaviors since the incident that occurred on 3/19/15. On 3/25/15 at 4:25 pm, during an interview and concurrent record review, the Admin and the DON confirmed Resident 2's verbal aggression that occurred on 3/23/15 at 5:35 pm to Resident 1 had not been documented in his record. The Admin and DON confirmed that documentation of the incident would have started alert charting (requires frequent checks by staff on location and status of involved residents) and triggered a review by the interdisciplinary team. The Admin and DON confirmed the incident should have been documented and follow up care should have been done. b. On 3/20/15 at 3:20 pm, an interview took place with Resident 4. (Resident 4's record indicated she was alert and oriented, without memory impairment. Resident 4 was capable of making her own healthcare decisions.) When asked if she knew of any residents that were violent or threatening, who might hit or kick other residents, Resident 4 stated Resident 2 had just hit another resident, he tried to get away with it but a CNA caught him hitting her (was referring to incident on 3/19/15). When asked if he bothered other residents, Resident 4 explained Resident 2 picked on Resident 8 all the time out in the hallway. She stated, Resident 2 would come up to Resident 8 and say mean things to him like, "I'm gonna kick your a--." Resident 4 explained Resident 2 called Resident 8 many words that she didn't want to repeat, uses the "F" word a lot and other expletives. Resident 4 stated the staff all hear and see it. The staff talks to Resident 2, but it doesn't do any good. Resident 4 stated she was not sure how often in happened. Resident 4 went on to explain that Resident 2 came up behind her one time, lifted his feet and pushed her in the back, to try to move her out of his way. On 3/23/15 at 2:15 pm, Resident 4 stated she did not feel safe when she was around Resident 2 and tries not to pass him in the hallway. Resident 4 stated Resident 2 had a bad attitude, a chip on his shoulder. She was told he kicked the facility cat and really hurt it, further stating, "He is a violent person." Resident 8's record was reviewed. Resident 8, an [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's MDS, dated [DATE], indicated he had severe memory impairment and his speech was unclear. Resident 8's care plan, dated 1/16/15, gave direction to redirect the resident when he attempted to wander into other residents rooms. The care plan indicated Resident 8 had a wander guard (alarmed device that goes off if he tries to exit the facility). On 3/24/15 at 10:45 am, during an interview when asked about Resident 2's behavior towards Resident 8, CNA A explained Resident 8 is very confused, self-propels around the facility in his wheelchair and doesn't seem to be aware if he is in someone's way or in the wrong room. CNA A stated that Resident 8 had wandered into Resident 2's room in the past. Even if Resident 8 is in the hallway anywhere near his room, Resident 2 will yell out "you better get that son of a b--ch out of here before I f-ck-n kick his a--! I'll f-ck-n hit him!" When she tells Resident 2 "that's not OK," he has stated, "I don't give a f-ck, I don't like him!" When asked how often Resident 2 was verbally aggressive like that, CNA A stated, "pretty much every day." CNA A explained "the other day Resident 8 was wandering in the hallway when Resident 2 grabbed the back of his wheelchair and attempted to push Resident 8 away from him by kicking and pushing him in the back. When CNA A intervened so that no contact was made, Resident 2 was yelling at Resident 8 and said "you son of a b--ch! You better get the f-ck out of here." Then to CNA A he stated, "he can't f-ckin be back here!" When asked who knew about Resident 2's behaviors, CNA A stated, "Everyone that has ever seen him in the hallway would know about his behaviors. It's impossible not to know. All staff are aware." CNA A confirmed that Resident 2 was verbally abusive to other residents on a regular basis. When asked what measures were in place to protect residents from Resident 2, CNA A stated that if she hears him in the hallway, she immediately tries to move other residents out of the hallway. CNA A confirmed that if Resident 2 was unsupervised in the hallway and other residents were there, those residents would not be safe from the potential for abuse by Resident 2. CNA A stated they "called the cops" and Resident 2 told them "he didn't give a f-ck and what the hell were they gonna do about it." On 3/24/15 at 11:40 am, during an interview, LN D stated she was a regular caregiver for Resident 2. LN D explained that Resident 2 did not like Resident 8. When asked why he didn't like him and what words he used when interacting with Resident 8, LN D stated that Resident 8 was very confused and Resident 2 goes off if he gets in his way. Resident 2 has said, "you get that piece of sh-t out of here right now!" When asked how this seemed to affect Resident 8, LN D explained that Resident 8 did not respond and continues on as if it didn't even happen. LN D confirmed that Resident 2 was verbally abusive to other residents. LN D confirmed that they could not be sure other residents were safe if Resident 2 was unsupervised when out of his room. LN D stated that she was very surprised that Resident 2 had hit Resident 1 because she didn't think he would hit anyone. c. On 3/20/15 at 1:45 pm, during an interview, confidential Resident 9 was asked how residents were getting along with each other in the facility, to which she replied, "terrible." When asked why, she stated, "Because there are some violent people here." When asked if she felt safe in facility, Resident 9 stated, "No, I'm terrified." When asked who she was terrified of, she stated, "I can't tell you because they'll hurt me." When asked if they target anyone in particular, she stated, "yes." When asked if she ever witnessed them being physically violent with anyone, she stated, "no." When asked how she knew they were violent, she stated, "because of violent talk, they say they've hit or kicked or punched other people in the mouth." When asked who their violent talk was directed at, she stated she was afraid to say who. When asked if she felt safe in her room, she stated, "yes." When asked where she felt unsafe, she stated where ever the violent residents were; Sometimes during smoke break and sometimes in the hallway. When asked if the staff heard the violent talk, she stated, "yes." When asked what staff did about it, she stated, "nothing." When asked if she changed what she did or where she went because of the violent residents, she stated, "yes, I try to stay away from them as much as possible, sometimes don't go on smoke break and sometimes do, and feel scared." Resident 9 stated she had never felt terrified anywhere else until here. When asked why she felt terrified, she stated, "Because I don't have any way to defend myself." When asked who she had told about this, she stated, "the staff know who the violent people are and don't do anything to protect her or make her feel safe. When asked her to identify staff or residents, she stated, "this conversation is over." On 3/20/14 at 4:50 pm, during an interview, Resident 9 stated she had been terrified for the rest of the day after our earlier interview because she was afraid of retaliation from the violent residents. Resident 9 eventually stated Resident 2 was the violent resident she was worried about. Resident 9 stated though Resident 2's violent talk had not been directed towards her, she was convinced he was capable of violence and would hurt her if he knew she had reported him. On 3/23/15 at 1:15 pm, during an observation of a supervised smoking break, Resident 2 was seated a full table away from the closest resident who was Resident 9. No eye contact or verbal interaction between residents was noted. d. On 3/23/15 at 2:15 pm, during an interview, Resident 4 stated Resident 2 threatens and name calls during supervised smoke breaks. When asked what words he used, Resident 4 stated he calls them b--ches and wh-res. When asked to whom these words were directed, Resident 4 stated, towards (Resident 1) and (Resident 7). Resident 4 stated she heard Resident 2 call them "f---ing wh-re, silver headed b-tch ... every name in the book." Resident 4 explained that if people were talking together, he (Resident 2) will say "you can keep your f---ing mouth shut!" Resident 4 stated the staff hear everything he says and tell him to stop, but he doesn't care, it doesn't do any good. Resident 4 said that Resident 2 was in the Marines and the way he carries himself, she believes it. Resident 4 explained that Resident 2 "acts like everyone is supposed to be intimidated by him." e. Resident 7, a female resident under [AGE] years of age, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's MDS, dated [DATE], indicated she was alert, oriented, able to communicate effectively and without memory impairment. Resident 7 was capable of making her own healthcare decisions. On 3/23/15 at 3:10 pm, during an interview, Resident 7 was asked if there were any violent residents in the facility. Resident 7 stated Resident 2 was a vicious person and was the one that threatens to "tear your head off." Resident 7 stated Resident 2 was a rude, crude and socially unacceptable human being. Resident 7 explained from the minute she arrived in the facility, he aimed his rants at her. He has called her "b-tch, wh-re, sl-t, c-nt, bubblehead, and stupid," and usually preceded those words with the "F" word. Resident 7 explained she tried to tune him out as she enjoyed socializing with other residents during smoke breaks until one day, he threw an ashtray at her and almost hit her head. At the time, he was cussing and swearing and she was ignoring him. He would call her a "g-d damn f---ing wh-re" and many other expletives. The supervising staff told him "don't you ever talk to a woman that way" and other reprimands, but this did not work. She misses the other residents she used to socialize with, but it is not worth being in his presence. Resident 7 stated, "how they still let him go out there, I don't understand." Resident 7 stated, "he doesn't follow the rules, he brags about being a marine and acts all tough and threatening, the residents are afraid of him. Any women out there alone with him would be afraid." Resident 7 stated Resident 2 "gets by with whatever he wants." All the staff are aware and do not keep residents safe from him. Resident 7 stated she is nervous when she goes out to smoke because Resident 2 is an independent smoker and could show up anytime. When asked what she does when he comes out to the smoking patio while she is there, Resident 7 stated, "if he comes out there, I leave immediately because I don't know what he might do." Resident 7 stated she did not feel safe when near Resident 2. When asked how she would feel if she did not have a choice but to smoke in Resident 2's presence, even if supervised, Resident 7 stated, "if I didn't have a choice but to smoke with Resident 2, I don't know what I would do, I would be so afraid I might quit smoking. It would be terrible. Staff are aware of his behaviors and don't keep residents safe." On 3/24/15 at 11:40 am, during an interview, LN D stated she was a regular caregiver for Resident 2. LN D explained Resident 2's mood varies from moment to moment and from day to day. Many things set him off, "could be something or nothing at all. His behavior is erratic. When he has angry outbursts Resident 2 will yell, "I'm gonna smash their head up against the wall." When LN D hears him in the hallway, she gets up and moves residents out of his way. LN D stated his behaviors that she observes usually happen in the hallway when he is on his way to smoke. LN D stated he doesn't like to be bothered when in the hall. When asked what Resident 2's behaviors are like, in general, LN D stated that he does threaten harm and has hit people. When asked if CNA's have reported his verbal aggressive behaviors towards Resident 1, LN D stated that she didn't remember specifically, but he is verbally aggressive towards almost everybody, its who he is." When asked if he was verbally abusive to other residents, LN D stated, "well, ya." When asked how they keep other residents safe from him, LN D stated they keep an eye on him and if they see anyone in his way they move the resident out of his way. On 3/24/15 at 3:50 pm, during an interview, Housekeeping Staff F (HS F) stated he had been supervising residents smoking for the past five years. When asked about behaviors that occur during supervised smoke breaks, HS F explained many of the residents don't get along with each other. HS F confirmed that Resident 2 was verbally aggressive and abusive especially towards women. HS F stated he reported all behaviors to the nursing staff. When asked if he had any special training to deal with resident verbal behaviors, HS F stated "no." HS F confirmed that he felt the facility expected him to deal with social issues that occurred during the smoke breaks. When asked who knew about Resident 2's aggressive outbursts, HS F stated, "all staff" knew about his behaviors. On 3/25/15 at 9:45 am, during an interview, LN G stated that she was a regular care giver for Resident 2. When asked about Resident 2's behaviors, LN G explained his behavior was very erratic but predictable in the way that if people were in his way or if he had to wait at all to get coffee, he predictably responds with verbal aggression. When asked if he was unsupervised in the hallway, could she be sure that other residents were safe, LN G stated, "I would be lying if I said I could." On 3/25/15 at 4:25 pm, during an interview and concurrent record review, the Director of Nurses stated during Resident 2's stay in the facility (from 9/10/13 through 3/25/15), two psychiatric evaluations were conducted by a psychiatric nurse practitioner. Review of the psychiatric notations, dated 6/7/14 and 6/17/14, indicated a mental evaluation of Resident 2 was conducted, based on his behavior towards the nurse practitioner on the day of her visits. The DON confirmed there was no indication that a comprehensive evaluation of Resident 2's mental/psychosocial adjustment difficulties during his stay in the facility had been done. The IDT meeting progress notes to address behavior management (conducted on a quarterly and as needed basis), dated 3/17/15, indicated Resident 2 was taking [MEDICATION NAME] for his episodic mood as evidenced by aggressive outbursts. The notes indicated an evaluation of Resident 2's behaviors for a three month period from 12/1/14 through 2/28/15. The notes indicated there were 56 documented behaviors during the month of 12/2014 (up from 29 during 11/2014), 48 for 1/2015, and 48 for 2/2015. The notes indicated no recommendations were made for revision to Resident 2's care plan. On 3/25/15 at 5:10 pm, the facility's Administrator (Admin) and Director of Nursing (DON) were notified of an immediate jeopardy (IJ) situation due to the facility's failure to protect residents from Resident 2's verbal and physical aggression and abuse. On 3/26/15 at 2:15 pm, the facility provided an acceptable immediate corrective action plan to keep residents safe and free from abuse by Resident 2, which included one to one supervision of Resident 2, and the facility's Admin and DON were notified the IJ was abated. The nursing notation regarding Resident 2's behavior, dated 3/28/15 at 1:01 am, indicated that he approached staff and stated, "look at me I'm Mr. Hollywood now. If I knew I'd get all this special attention, I'd have slapped the sh-t out of that (named Resident 1) b--ch sooner." The notes indicated the nurse advised Resident 2 it wasn't appropriate to talk badly or to hit someone, and he just laughed. Resident 2's psychology consult progress notes, dated 3/28/15 at 8:13 pm, indicated that during an interview with the psychologist, Resident 2 stated the recent incident (on 3/19/15 when Resident 2 hit Resident 1) was not his fault. Resident 2 claimed that he did not intentionally try to strike the female resident (Resident 2), but was quick to add that she deserved to be hit. Resident 2 complained about a male resident (Resident 8) who wandered in his wheelchair near Resident 2's room and stated he would just push him away. The notes indicated that Resident 2 did not want to share a room and did not want anyone going into his room. Resident 2 stated he did not want family or anyone else in his business. The notes indicated Resident 2's mood was moderately depressed. Resident 2 was mildly agitated, but cooperative since the psychologist agreed to meet with him during his smoking break. Resident 2 was alert and reluctantly cooperative with the interview. The notes indicated that Resident 2 suffered mood swings, low frustration tolerance, irritability, agitation and aggressive behaviors toward both staff and other residents. Resident 2 appeared to like having 1:1 staff attention, a single room, and prevention of contact with other residents. Some of his behaviors may be exhibited intentionally in order to maintain that status as some of his remarks in the chart notes would indicate. The psychology recommendations included: "Agree with recent increase in dose of mood stabilizer. Also agree with current trial on anti-psychotic medication for agitation and aggressive behaviors related to [MEDICAL CONDITION] Disorder. Agree with search for a more appropriate placement in which Resident's behaviors are not such a danger to other residents that he is able to gain special treatment because of the safety issues and level of care at this facility." On 4/7/15 at 4:35 pm, during a telephone interview, Resident 2's physician (MD G) was asked about Resident 2's ability to be willful. MD G stated "oh yes, he is very capable of being willful. He knows what he is doing ... can be willful with manipulation."

Based on observation, interview, and record review, the facility failed to prevent, address, and report willful acts of verbal abuse by Resident 2 towards residents for four of eight sampled residents (Residents 1, 4, 7, and 8), one resident outside the sample (confidential Resident 9), and potentially any resident in close proximity of Resident 2. The facility was aware of Resident 2's verbally abusive behaviors towards other residents and allowed Resident 2 to move throughout the facility, unsupervised, placing residents at risk for continued abuse and for the abuse to go unrecognized, unaddressed, and unreported. On 3/25/15 at 5:10 pm, the facility's Administrator (Admin) and Director of Nursing (DON) were notified of an immediate jeopardy situation (IJ) due to the facility's failure to protect residents from Resident 2's verbal and physical aggression and abuse. On 3/26/15 at 2:15 pm, the facility provided an acceptable immediate corrective action plan to keep residents safe and free from abuse by Resident 2, which included one to one supervision of Resident 2, and the facility's Admin and DON were notified the IJ was abated. Findings: The facility's policy titled, "Abuse Prevention, investigation and reporting," last revised 3/2013, indicated the following: "Each resident has the right to be free from verbal, sexual, physical, and mental abuse .... Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents... employees will be trained upon hire and bi-annually on the recognition, prevention, and reporting requirements for abuse ... abuse will not be tolerated in this facility." The policy's direction for the protection of residents from abuse indicated, "If a resident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps: Provide a safe environment for residents as indicated by the situation; If suspected perpetrator is another resident: the residents will be separated so they do not interact with each other until circumstances of the reported incident can be determined." The policy's direction for the investigation of suspected abuse indicated all incidents of suspected or alleged abuse will be investigated by the assigned staff who will be informed of the nature of the incident and continue the investigation. The policy's direction for reporting abuse indicated all mandated reporters were required by law to report incidents of known or suspected abuse. A form (SOC form 341, used for reporting allegations of abuse, neglect, or mistreatment) would be sent to the ombudsman's office and to the department (The CA Department of Public Health-CDPH), and an incident and injury report would be completed and event reported to the director of nurses and the administrator immediately for necessary follow up. On 3/20/15 at 1:45 pm, during an interview, confidential Resident 9 was asked how residents were getting along with each other in the facility, to which she replied, "terrible." When asked why, she stated, "Because there are some violent people here." When asked if she felt safe in facility, Resident 9 stated, "No, I'm terrified." When asked who she was terrified of, she stated, "I can't tell you because they'll hurt me." When asked if they target anyone in particular, she stated, "yes." When asked how she knew they were violent, she stated, "because of violent talk, they say they've hit or kicked or punched other people in the mouth." When asked who their violent talk was directed at, she stated she was afraid to say who. When asked if she felt safe in her room, she stated, "yes." When asked where she felt unsafe, she stated where ever the violent residents were; Sometimes during smoke break and sometimes in the hallway. When asked if the staff heard the violent talk, she stated, "yes." When asked what staff did about it, she stated, "nothing." When asked if she changed what she did or where she went because of the violent residents, she stated, "yes, I try to stay away from them as much as possible, sometimes don't go on smoke break and sometimes do, and feel scared." Resident 9 stated she had never felt terrified anywhere else until here. When asked why she felt terrified, she stated, "Because I don't have any way to defend myself." When asked who she had told about this, she stated, "the staff know who the violent people are and don't do anything to protect her or make her feel safe". When she was asked to identify staff or residents, she stated, "this conversation is over." On 3/20/15 at 3:20 pm, an interview took place with Resident 4. (Resident 4's record indicated she was alert and oriented, without memory impairment. Resident 4 was capable of making her own healthcare decisions.) When asked if she knew of any residents that were violent or threatening, who might hit or kick other residents, Resident 4 stated Resident 2 had just hit another resident, he tried to get away with it but a CNA caught him hitting her (was referring to incident on 3/19/15). When asked if he bothered other residents, Resident 4 explained Resident 2 picked on Resident 8 all the time out in the hallway. She stated, Resident 2 would come up to Resident 8 and say mean things to him like, "I'm gonna kick your a--." Resident 4 explained Resident 2 called Resident 8 many words that she didn't want to repeat, uses the "F" word a lot and other expletives. Resident 4 stated the staff all hear and see it. The staff talks to Resident 2, but it doesn't do any good. Resident 4 stated she was not sure how often in happened. Resident 4 went on to explain that Resident 2 came up behind her one time, lifted his feet and pushed her in the back, to try to move her out of his way. During an observation and interview on 3/20/15 at 3:30 pm, Resident 1 was sitting in the hallway across from the nurse's station. When asked how everything was going for her, Resident 1 stated, "ok, except for that guy that beat me (her) up." When asked who beat her up, she pointed down the hall in the general vicinity of Resident 2's room. During an observation of Resident 2 on 3/20/15 at 4:10 pm, while in his room sitting in a wheelchair and watching TV, he agreed to a short interview. Resident 2 explained an interaction with the "silver haired witch" (and indicated he was referring to Resident 1) down the hall." Resident 2 explained that he told Resident 1 "nobody in here f---ing cares about you, you gray haired witch." Resident 2 stated he "thought it was so funny what happened because Resident 1 had pulled his hand, when he was near her and his hand hit her in the face." When asked why he thought it was funny, Resident 2 stated, "because I hate that f---ing gray haired witch." When asked why he didn't like her, Resident 2 responded that she was "always sitting there in the hallway and was in the way." Resident 2 explained that he was "pissed about all kinds of things in this g-- damn place." Resident 2 stated that he would be fine if people would just leave him alone. Resident 2 stated that "if they don't leave me alone I'll just take care of them." When asked what he would do, Resident 2 stated he would "just hit them, or kick them, or punch them in the face." When asked if he had done this before, Resident 2 stated, "yes." When asked who he had done this to, Resident 2 did not reply and indicated the interview was over by turning his attention towards watching TV. On 3/20/14 at 4:50 pm, during an interview, Resident 9 stated she had been terrified for the rest of the day after our earlier interview because she was afraid of retaliation from the violent residents. Resident 9 eventually stated Resident 2 was the violent resident she was worried about. Resident 9 stated though Resident 2's violent talk had not been directed towards her, she was convinced he was capable of violence and would hurt her if he knew she had reported him. Resident 1's record was reviewed. Resident 1, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/15, indicated Resident 1 had significant memory impairment. The MDS indicated Resident 1 required extensive assistance from staff to transfer out of bed and minimal assistance with wheelchair locomotion. Resident 1's record indicated she was able to communicate effectively and to make her needs known. Resident 1's care plan, dated 2/20/15, indicated she was dependent on staff for activities, cognitive stimulation, and social interactions due to her physical limitations and cognitive deficits (memory problems). Resident 1's care plan, to address a 3/19/15 incident (when Resident 2 hit Resident 1), did not include any interventions to ensure her safety from Resident 2. Resident 2's medical record was reviewed. Resident 2, a [AGE] year old male, was admitted to the facility on [DATE] for rehabilitation after hospitalization and surgery for [REDACTED]. Resident 2's [DIAGNOSES REDACTED]. The specific type of mood disorder was not indicated. The record indicated Resident 2 was homeless at the time of the accident. The physician's report of Resident 2's neurological function while in the hospital, dated 8/14/13, indicated, "other than being a belligerent jerk to pretty much everyone," he was neurologically intact. Resident 2's behavior care plan, initiated on 5/27/14, indicated he was being monitored for frequent angry and aggressive outbursts. The care plan indicated triggers for the outbursts included when other residents get in his way or disturb him for cigarettes. The MDS, dated [DATE], indicated Resident 2 was alert, oriented and able to communicate effectively. Resident 2's Medication Administration Record [REDACTED]. Resident 2's behavior monitoring was tallied on his MAR. Resident 2's MAR, for the 23 day period from 3/1/15 through 3/23/15, indicated 45 aggressive outbursts had occurred. Resident 2's care plan, to address the 3/19/15 incident described above, did not include any interventions to ensure the safety of other residents. On 3/23/15 at 2:15 pm, Resident 4 stated she did not feel safe when she was around Resident 2 and tries not to pass him in the hallway. Resident 4 stated Resident 2 had a bad attitude, a chip on his shoulder. She was told he kicked the facility cat and really hurt it, further stating, "He is a violent person." On 3/23/15 at 3:10 pm, during an interview, Resident 7 was asked if there were any violent residents in the facility. Resident 7 stated Resident 2 was a vicious person and was the one that threatens to "tear your head off." Resident 7 stated Resident 2 was a rude, crude and socially unacceptable human being. Resident 7 explained from the minute she arrived in the facility, he aimed his rants at her. He has called her "b-tch, wh-re, sl-t, c-nt, bubblehead, and stupid," and usually preceded those words with the "F" word. Resident 7 explained she tried to tune him out as she enjoyed socializing with other residents during smoke breaks until one day, he threw an ashtray at her and almost hit her head. At the time, he was cussing and swearing and she was ignoring him. He would call her a "g-d damn f---ing wh-re" and many other expletives. The supervising staff told him "don't you ever talk to a woman that way" and other reprimands, but this did not work. She misses the other residents she used to socialize with, but it is not worth being in his presence. Resident 7 stated, "how they still let him go out there, I don't understand." Resident 7 stated, "he doesn't follow the rules, he brags about being a marine and acts all tough and threatening, the residents are afraid of him. Any women out there alone with him would be afraid." Resident 7 stated Resident 2 "gets by with whatever he wants." All the staff are aware and do not keep residents safe from him. Resident 7 stated she is nervous when she goes out to smoke because Resident 2 is an independent smoker and could show up anytime. When asked what she does when he comes out to the smoking patio while she is there, Resident 7 stated, "if he comes out there, I leave immediately because I don't know what he might do." Resident 7 stated she did not feel safe when near Resident 2. When asked how she would feel if she did not have a choice but to smoke in Resident 2's presence, even if supervised, Resident 7 stated, "if I didn't have a choice but to smoke with Resident 2, I don't know what I would do, I would be so afraid I might quit smoking. It would be terrible. Staff are aware of his behaviors and don't keep residents safe." On 3/23/15 at 5:35 pm, Resident 2 was observed coming into the facility from the smoking patio and was self-propelling down the hallway towards his room. Resident 1 was observed sitting in the hallway just past the nurses' station. LN C was observed standing at a medication cart with her back to Resident 1, approximately five feet away. When Resident 2 got close to Resident 1, he yelled out "You f---ing b--ch! Someday I'll get a chance to bury you in a god damn grave! You f---ing bald faced b--ch! I'm gonna punch you!..." LN C was observed to intervene by standing between the residents and encouraging Resident 2 to continue going towards his room. After Resident 2 continued down the hallway, LN C returned to the medication cart. LN C then stated, "I don't think he would actually harm a fly, but anyway." Observed another staff ask Resident 1 how she was doing, to which Resident 1 replied, "Ok, I guess, I was just called a b--ch." During an interview on 3/24/15 at 10:45 am, CNA A stated she had observed and intervened in an incident of physical abuse that occurred on 3/19/15 where she saw Resident 2 use his closed fist to punch Resident 1 in the face. CNA A stated Resident 2 was holding on to and squeezing Resident 1's hand and did not want to let go, and while she was separating the residents, Resident 2 was cussing and threatening Resident 1 saying, "just wait until next time I see you in the hallway ... you cock s---ing b--ch!" CNA A stated she reported the incident to the Licensed Nurse (LN). CNA A stated she was a long term regular caregiver for Resident 2. CNA A explained Resident 2 cusses a lot when in a bad mood. He will say he wants to beat people up, or that he's tired of the sons of b--ches. When she told him the hallway was for everyone and everyone had a right to be in the hallway, Resident 2 said, "then they just need to be shot in the face." CNA A explained if he was in a bad mood, he will go on about everything including the news, people in his way, or just cussing to the air. When asked what he was like when in a good mood, CNA A stated he would usually be quiet the whole time and not say anything. CNA A added Resident 2's moods can change in a "split second." When asked how he reacted to people being in his way in the hall, CNA explained "he'll cuss them out when he is upset. He called them cock s---ing b--ches. When asked why he seems to target Resident 1, CNA A explained when he goes by her cussing, she will say "you've got a dirty mouth or watch your mouth" and Resident 2 will react by cussing her out. When asked who else he cusses out, CNA A stated Resident 8. When asked if the words Resident 2 used to cuss Resident 1 were verbally abusive towards Resident 1, she stated, "yes." When asked if the Resident 2's verbal abuse had been reported, CNA A stated she had reported it to Licensed Nurse (LN) B, but did not report to an official agency. On 3/24/15 at 2:50 pm, during an interview, the Administrator (Admin) was asked if Resident 2 had ever hit anyone before the incident which occurred on 3/19/15. The Admin reviewed the facility files and explained on 2/17/15, he had hit a resident in the upper arm because she was taunting him and she had taunted him before. The Admin explained he stays to himself, but if someone gets on him, he responds. When asked if he had hit anyone prior to 2/17/15, Admin explained that one other time he had rammed a wheelchair and yelled profanities at another female resident on 5/26/14. On 3/24/15 at 5:45 pm, LN C confirmed during the verbal exchange on 3/23/13 at 5:35 pm, Resident 2 was verbally abusive to Resident 1. LN C stated she was surprised to hear he had hit someone and was not aware it had happened until after the verbal exchange, the day prior. LN C confirmed the verbal abuse had not been reported to an official agency. During an interview on 3/25/15 at 9:45 am, LN B explained, after the 3/19/15 incident of Resident 2 abusing Resident 1, she assessed the residents and notified the police who came out and met with Resident 2. LN B stated when the police talked to Resident 2 about the incident, Resident 2 told them, "he didn't f---ing care and would do it again." On 3/25/15 at 4:25 pm, during an interview and concurrent record review, the Admin and the DON confirmed Resident 2's verbal aggression that occurred on 3/23/15 at 5:35 pm to Resident 1 had not been documented in his record or reported (in accordance with facility policy). The Admin and DON confirmed that documentation of the incident would have started alert charting (requires frequent checks by staff on location and status of involved residents) and triggered a review by the interdisciplinary team. The Admin and DON confirmed the incident should have been documented and follow up care should have been provided. The DON confirmed the incident as described constituted verbal abuse. The DON confirmed that verbal abuse should be reported, per facility policy. On 3/25/15 at 4:25 pm, during an interview and concurrent record review, the Director of Nurses stated during Resident 2's stay in the facility (from 9/10/13 through 3/25/15), two psychiatric evaluations were conducted by a psychiatric nurse practitioner. Review of the psychiatric notations, dated 6/7/14 and 6/17/14, indicated a mental evaluation of Resident 2 was conducted, based on his behavior towards the nurse practitioner on the day of her visits. The DON confirmed there was no indication that a comprehensive evaluation of Resident 2's mental/psychosocial adjustment difficulties during his stay in the facility had been done. The IDT meeting progress notes to address behavior management (conducted on a quarterly and as needed basis), dated 3/17/15, indicated Resident 2 was taking [MEDICATION NAME] for his episodic mood as evidenced by aggressive outbursts. The notes indicated an evaluation of Resident 2's behaviors for a three month period from 12/1/14 through 2/28/15. The notes indicated there were 56 documented behaviors during the month of 12/2014 (up from 29 during 11/2014), 48 for 1/2015, and 48 for 2/2015. The notes indicated no recommendations were made for revision to Resident 2's care plan. On 3/25/15 at 5:10 pm, the facility's Administrator (Admin) and Director of Nursing (DON) were notified of an immediate jeopardy (IJ) situation due to the facility's failure to protect residents from Resident 2's verbal and physical aggression and abuse. On 3/26/15 at 2:15 pm, the facility provided an acceptable immediate corrective action plan to keep residents safe and free from abuse by Resident 2, which included one to one supervision of Resident 2, and the facility's Admin and DON were notified the IJ was abated. The nursing notation regarding Resident 2's behavior, dated 3/28/15 at 1:01 am, indicated that he approached staff and stated, "look at me I'm Mr. Hollywood now. If I knew I'd get all this special attention, I'd have slapped the sh-t out of that (named Resident 1) b--ch sooner." The notes indicated the nurse advised Resident 2 it wasn't appropriate to talk badly or to hit someone, and he just laughed. Resident 2's psychology consult progress notes, dated 3/28/15 at 8:13 pm, indicated that during an interview with the psychologist, Resident 2 stated the recent incident (on 3/19/15 when Resident 2 hit Resident 1) was not his fault. Resident 2 claimed that he did not intentionally try to strike the female resident (Resident 2), but was quick to add that she deserved to be hit. Resident 2 complained about a male resident (Resident 8) who wandered in his wheelchair near Resident 2's room and stated he would just push him away. The notes indicated that Resident 2 did not want to share a room and did not want anyone going into his room. Resident 2 stated he did not want family or anyone else in his business. The notes indicated Resident 2's mood was moderately depressed. Resident 2 was mildly agitated, but cooperative since the psychologist agreed to meet with him during his smoking break. Resident 2 was alert and reluctantly cooperative with the interview. The notes indicated that Resident 2 suffered mood swings, low frustration tolerance, irritability, agitation and aggressive behaviors toward both staff and other residents. Resident 2 appeared to like having 1:1 staff attention, a single room, and prevention of contact with other residents. Some of his behaviors may be exhibited intentionally in order to maintain that status as some of his remarks in the chart notes would indicate. The psychology recommendations included: "Agree with recent increase in dose of mood stabilizer. Also agree with current trial on anti-psychotic medication for agitation and aggressive behaviors related to [MEDICAL CONDITION] Disorder. Agree with search for a more appropriate placement in which Resident's behaviors are not such a danger to other residents that he is able to gain special treatment because of the safety issues and level of care at this facility." On 4/7/15 at 4:35 pm, during a telephone interview, Resident 2's physician (MD G) was asked about Resident 2's ability to be willful. MD G stated "oh yes, he is very capable of being willful. He knows what he is doing ... can be willful with manipulation." Resident 2's willful acts of verbal abuse towards other residents were not been reported by the facility or its staff, mandated reporters, to the CDPH.

Based on interview and record review, the facility failed to operationalize their Abuse Prevention and Investigation and Reporting policy and procedure by failing to: 1. Ensure that employees were suitable for hire and prevent the verbal and physical mistreatment for one of 24 sampled residents when they failed to take into consideration Certified Nursing Assistant (CNA) AA's previous employment history of resident neglect, mistreatment, and unprofessional misconduct, and rehired CNA AA. Refer to F 223. 2. Properly screen Certified Nursing Assistant (CNA) BB for a criminal background. 3. Ensure that a resident to resident altercation involving one of 24 sampled residents (Resident 9) and one resident outside the sample (Resident 35) was reported to the appropriate authorities. These cumulative failures resulted in the verbal and physical mistreatment of Resident 22 and had the potential for all residents to be subjected to abuse and mistreatment. Due to the systemic failure, lack of implementation of the Abuse Policy and Procedure, as well as a lack of a plan of action to prevent similar occurrences, on 2/4/14 at 5:55 pm, an Immediate Jeopardy was declared in the presence of the Administrator. The Immediate Jeopardy was abated on 2/4/14 at 6:24 pm, with the Regional Director of Operations after the facility implemented a corrective plan of action which ensured resident safety. CNA AA was terminated. CNA BB was screened for criminal history. Findings: A review of the facility policy, undated, titled, "Application/New Hire Process," the Rehire Process section indicated that an employee's file would be reviewed for rehire eligibility. 1. Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 22 was alert, oriented, and able to make her needs known. Resident 22 needed total assistance from the staff for dressing and personal hygiene. During a review of the facility abuse policy and procedure, revised 1/2010, an allegation of abuse made by Resident 22 was disclosed. A review of a document, dated 7/26/13, titled, "Report of Suspected Dependent Adult/Elder Abuse" disclosed that CNA AA put her hands over Resident 22's mouth when the resident requested to wear her new clothes. A review of an undated interview, obtained by Social Services from Resident 22's roommate read, "Resident stated that CNA (AA) was rude and mean and should not be taking care of people." A review of CNA AA's personal file disclosed that CNA AA was originally hired on 3/19/07, went to an on-call status, and was let go on 7/12/12 due to not working for 60 days. CNA AA was rehired on 5/28/13. Further review of CNA AA's file disclosed multiple disciplinary action forms to include failure to report resident abuse per facility policy, unsatisfactory customer service, and reports from families of being rude. The disciplinary action forms contained the following: 1/26/11 - Unsatisfactory customer service. Unsatisfactory performance when approaching a confused resident. 7/11/11 - Unsatisfactory customer service. Unsatisfactory performance. Resident found in soiled briefs. Bedside commode in need of attention. 12/8/11 - Unsatisfactory customer service. Unsatisfactory performance. Resident found on floor, soaked in urine. No oral care. 2/24/12 - Insubordination. Unsatisfactory customer service. Unsatisfactory performance. Failure to follow instructions. CNA AA did not follow nurses request to take resident's vital signs. 7/26/13 - Suspension 7/26 - 7/28/13. Resident stated CNA AA refused to dress her in her new clothes. Resident stated that CNA AA put her hand over resident's mouth. 7/31/13 Final warning. Suspension 7/27 - 7/30/13. Unsatisfactory customer service. Unprofessional behavior. A document written by the prior Administrator (Admin) KK, dated 7/29/13, read, "Investigative findings: Inappropriate conduct toward a resident. Will continue administrative suspension." A review of an undated facility policy titled, "Application/New Hire Process," the Rehire Process section indicated that an employee's file would be reviewed for rehire eligibility. A review of the Abuse Policy, dated 1/2010, read, "It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident." In an interview on 2/4/14 at 4 pm, the Interim Admin stated that the employee files were to be reviewed, prior to rehire. CNA AA's employee file was reviewed with the Interim Admin at that time. She stated that with CNA AA's poor performance history, she should not have been rehired. She stated that the facility policy and procedure for Abuse Prevention, Investigation, and Reporting was not followed. She confirmed that all the residents were at risk for abuse, neglect, and mistreatment. 2. Facility employee files were reviewed. CNA BB was hired on 10/2/06. No information was available to verify that a pre-employment screening was completed to include a history of abuse, neglect, or mistreating residents. A review of the facility Policy, titled, "Abuse Prevention, Investigation and Reporting," dated 1/2010, contained a section titled, "Screening." Number 1 read, "All CNAs will be properly screened for criminal background." In an interview on 2/4/14 at 3 pm, the Human Resources (HR) designee stated that screening for criminal background checks should be completed on all new employees. She reviewed CNA BB's file and was unable to find the information for screening of criminal background. She confirmed that the criminal background check for CNA BB was not completed, which placed the residents at risk for abuse, neglect, and mistreatment. 3. A review of the facility investigation, dated 12/22/13, of a resident to resident altercation was completed. The allegation indicated that one resident "punched" another resident in the eye. A review of two documents, both titled, "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341 a form used to report elder abuse), dated 12/22/13, showed the reports were incomplete; there was no documentation that the Ombudsman, Law Enforcement, or the Department of Public Health were notified. A review of the facility Policy titled, "Abuse Prevention, Investigation and Reporting," dated 1/2010, Section G read, "All mandated reporters are required by law to report incidents of known or suspected abuse... by telephone immediately or as soon as practically possible (within 24 hours) to the local Ombudsman or the local law enforcement agency and to the Department of Public Health." The Policy directed the staff to send the completed SOC 341 to the Ombudsman and the Department of Public Health within two working days. In an interview on 2/4/14 at 3:40 PM, the Interim Admin verified that their was no documentation on the SOC 341 to show that the Ombudsman, Law Enforcement, and the Department of Public Health were notified, per policy, and stated the Abuse Policy and Procedure was not followed.

Based on interview and record review, the facility failed to ensure that the facility's Immunization Program policy and procedure was operationalized when the facility had no knowledge of, or tracking/logging records of the flu and pneumonia status of each resident who currently resided in the facility. Flu and pneumonia vaccines had not been offered to all residents and/or not given to residents who had requested them. Residents who had refused a flu or pneumonia vaccine had no reasons for refusal documented. Education had not been provided to residents or their responsible parties in order for them to give an informed consent, prior to receiving flu or pneumonia vaccines. Eight of 24 sampled residents were affected. (Resident's 1, 3, 5, 6, 7, 9, 14, and 20) These failures practices placed all residents in immediate jeopardy of contracting the flu virus and/or pneumonia. "Flu season," according to the Center for Disease Control (CDC) website, is October 1st through March 31st, and the CDC recommends that flu vaccines be given as soon as possible due to the increased flu related deaths this year and the vaccine can take up to 2 weeks to develop antibodies (a protein produced by the body's immune system against the flu). On 1/28/14 at 10 am, a record of the flu and pneumonia status of each resident who was currently residing in the facility was requested from the Regional Clinical Director (RCD) A. On 1/29/14 at 2 pm, RCD A stated that resident flu and pneumonia information was not available and that she had no knowledge of which residents had consented to, refused, or received a flu shot this season and had no knowledge of resident pneumonia vaccine status, therefore, a "whole house" audit would have to be conducted. On 1/30/14 at 3:50 pm, RCD A provided the survey team with the results from the audit which disclosed that 30 residents out of 148 had actually received a flu vaccine, 21 had signed consents but never got the vaccine, 20 residents were not offered, and 64 residents refused the vaccine but the facility had no reasons documented. RCD A stated that the flu and pneumonia vaccines were going to be addressed and given immediately. On 1/31/14 at 2:50 pm, an interview was conducted with the interim Director of Nurses (DON). The DON stated that since the resident flu and pneumonia status audit, on 1/30/14, the facility had only given 2 residents a flu vaccine. The DON stated that she and the Director of Staff Development (DSD) were "working" on a system to get the flu vaccines done but, "no plan was in place yet." On 1/31/14 at 4:25 pm, the interim Administrator was notified that an immediate jeopardy situation had been determined by the survey team due to the lack of an effective and operational immunization program and the lack of the facility's action to use their resources to ensure that residents were immunized. The facility currently housed 148 residents and had the potential to house 184, and only 30 residents had received a flu vaccine which left a large population of residents unprotected from flu, at the peak of flu season. The Administrator confirmed that the facility's resident immunization program was not being operationalized, per policy and procedure, and that there was currently "no system in place." On 1/31/14 at 6:47 pm, an immediate action plan was accepted and the immediate jeopardy was abated with the interim Administrator and RCD B. Findings: 1. Resident 5's record was reviewed. The admitting physicians orders, dated 10/10/11, included orders for annual flu vaccine after consent, and pneumonia vaccine after consent (if not done past five years). A review of the facility Vaccination Checklist (undated), showed that Resident 5 had not received his annual influenza vaccination until 2/2/14, after his unvaccinated status was brought to the facility's attention by the Department. The Vaccination Checklist showed that the facility was not able to determine Resident 5's pneumonia immunization status. 2. Resident 9's record was reviewed. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, a resident assessment), dated 12/13/13, showed that he was cognitively intact (able to understand, recall, reason and make healthcare decisions), had not received this year's influenza vaccine during the current flu season, and that his pneumonia vaccine was not up to date. The MDS showed that he had been offered the flu vaccine and declined. On 1/30/14, Resident 9's record included flu and pneumococcal immunization consents, dated 5/9/13 (date of admission), that did not have either box selected to give permission to administer the vaccines or decline. On 1/30/14, Resident 9's physicians orders did not include orders for immunizations. On 1/30/14 at 10:20 am, Resident 9 was interviewed and asked if he was interested in receiving education about and being immunized against this season's flu. Resident 9 stated that he would like staff to speak to him about it. On 1/30/14 at 10:30 am, Licensed Vocational Nurse (LN) X confirmed Resident 9's immunizations were not ordered. A review of the facility provided Vaccination Checklist (undated), showed that Resident 9 had not received his annual influenza vaccination until 1/31/14, after his unvaccinated status was brought to the facility's attention by the Department. The Vaccination Checklist showed that the facility was not able to determine Resident 9's pneumonia immunization status and would offer the vaccine to him. On 2/4/14 at 10:02 am, Resident 9 confirmed that he had not been previously educated about or informed about receiving the flu shot, during this year's flu season. On 2/5/14 at 8:25 am, Administrator (Admin) concurrently reviewed the facility's documentation of the one dose of [MEDICATION NAME] (vaccine for pneumonia) they had ordered during 2013, on 5/13/13. Admin confirmed that the facility had only ordered the one dose of [MEDICATION NAME] in 2013. 3. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/14, Resident 1's health record was reviewed. On 11/22/13, a physician ordered an annual influenza (flu) vaccine be administered to Resident 1 after consent was obtained. A Minimum Data Set (MDS, a resident assessment), dated 12/31/13, documented that Resident 1 was cognitively impaired (impaired mental processes), and that he was incapable of making decisions regarding his health care. Resident 1's brother was the Responsible Party (RP) MM designated to legally make decisions regarding Resident 1's healthcare. The 12/31/13 MDS indicated that a flu vaccine had not been given with the reason documented as, "None of the above", which did not document the reason the vaccine had not been given. It also indicated that a pneumococcol vaccination ([MEDICATION NAME]) was "offered and declined." During an interview on 1/30/14 at 4:15 pm, RP MM stated that about three weeks prior, someone from the facility telephoned him to say that there was a [MEDICAL CONDITION] outbreak in the facility and asked him not to visit at that time. RP MM further stated that a day or two later he received a letter from the facility that offered, for the first time, the flu vaccine and [MEDICATION NAME] to his brother, Resident 1. Resident 1's record contained consent forms for the flu vaccine and [MEDICATION NAME] for Resident 1 that were signed by RP MM on 1/15/14. On 2/3/14, a facility document titled, "Vaccination Checklist," was submitted to this survey team for review. Regarding Resident 1, the document indicated that on 1/4/14 the [MEDICATION NAME] was "refused," and that the plan was to "re-offer and document refusal." There was no documentation in Resident 1's record that the [MEDICATION NAME] had been re-offered and there were no signed consent forms, prior to 1/15/14. The document stated that the flu vaccine was administered to Resident 1 on 2/2/14. 4. Resident 3's record was reviewed. Resident 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 had been transported by the facility, three or more times a week for hemodyalisis (HD, the mechanical process of cleansing the blood of accumulated waste and excess fluids) treatments at a contracted HD treatment clinic. On 2/18/14, the current Director of Nursing (DON) faxed this surveyor information that she had requested an influenza vaccination report, for Resident 3, from the HD treatment clinic. A document titled, "Vaccination Report," from the HD treatment clinic, was reviewed. The report indicated that Resident 3 had received an annual influenza vaccination at the HD treatment clinic on 9/18/13. The facility's "Vaccination Checklist," indicated that the facility had administered an additional annual influenza vaccine to Residents 3 on 10/29/13. 5. Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7 was alert and severely impaired. The record contained a consent for the current year's influenza vaccination that was signed by Resident 7's RP on 9/12/13. During an interview with Licensed Nurse (LN) W on 1/28/14 at 2:05 pm, she stated that the influenza vaccination was now over and they are only offering vaccinations to new admission residents if they have not received them yet. On 1/28/14 at 4 pm, during a concurrent interview and record review with Licensed Nurse (LN) X, she confirmed that there was no documentation in Resident 7's record to indicate whether or not Resident 7 had received the influenza vaccination. 6. a. Resident 14's record was reviewed. Resident 14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's record contained two documents, titled, "Influenza Immunization Informed Consent", dated 11/17/13 and 1/10/14. The Medication Administration Record, [REDACTED]. b. Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20 was unable to make her needs known. The Medication Administration Record [REDACTED]. No consent was obtained for influenza immunization. In an interview on 1/31/14 at 9:30 am, the interim DON confirmed that Residents 14 and 20 received the flu shots, prior to obtaining consents from their RPs. 7. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6 was unable to make her own decisions. Resident 6's RP gave the facility permission to administer the influenza vaccine by signing the influenza immunization informed consent form on 12/30/13. During a concurrent interview and record review with LN W on 1/30/14 at 9:20 am, she confirmed there was no electronic or paper record to indicate that the influenza vaccine was given to Resident 6. A review of the facility's policy and procedure titled, "Influenza (FLU) Vaccination of Residents, Staff, and Volunteers" dated 10/30/06, was conducted and directed the following: "1. All residents, staff and volunteers of our facility should receive the influenza vaccine annually, unless there is a documented contraindication (reason not to administer)..... 3. Every year, a log documenting how many people (residents, staff, and volunteers) received the vaccine, as well as the number who refused and did not receive the vaccination, will be maintained and made available to State Department of Health-or entity responsible for reporting of immunization status. A. Current and newly admitted residents, all staff, and volunteers will be offered the influenza vaccine from October of each year through the end of March the following year. B. Each resident's, staff's, and volunteer's immunization status will be determined prior to vaccination, and will be documented in either the resident's medical record or staff/volunteer's immunization record. C. Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination. (In the case of residents, this may be with their authorized representative when appropriate. If signed consent is required according to state law, it would occur at this procedural step.) D. Residents, staff, and volunteers may refuse vaccination. Vaccination refusal and reasons why (e.g., allergic, contraindicated, did not want vaccine, etc.) should be documented by the facility." A review of the facility's policy and procedure titled, "Pneumococcal Disease, Preventing Transmission To Residents & Staff", dated 3/2009, was reviewed and directed the following: "1. Upon admission, residents who are at risk of contracting pneumococcal diseases will be offered the pneumococcal vaccine, per physician's orders [REDACTED].e., allergy or prior vaccine given in the last 5 years). The resident or their responsible party will sign for acceptance or denial on the vaccine consent form.... 4. The facility will maintain a resident immunization record for, in addition to documenting the dose was given on the resident's medication record, which will be completed upon administration of vaccines, and will be kept in the resident's active clinical record throughout the course of the stay at the facility." On 1/28/14 at 10 am, a record of the flu and pneumonia status of each resident who was currently residing in the facility was requested from the Regional Clinical Director (RCD) A. On 1/29/14 at 2 pm, RCD A stated that resident flu and pneumonia information was not available and that she had no knowledge of which residents had consented to, refused, or received a flu shot this season and had no knowledge of resident pneumonia vaccine status. RCD A stated that there had been no tracking or record keeping of resident flu and pneumonia immunizations for the past year. RCD A stated that the facility was currently conducting a "whole house" chart audit to determine each resident's current flu and pneumonia status and that, "the facility's system is broken." On 1/29/14 at 3 pm, RCD B submitted a plan of correction (POC) to the survey team, in recognition of the facility's failure to implement immunizations, and disclosed that the resident flu vaccines were going to be immediately given and the nurses were going to be re-educated on the facility's immunization program. On 1/30/14 at 3:50 pm, RCD A provided the survey team with the results from the resident flu and pneumonia status audit. The audit was reviewed with the RCD A and disclosed that 30 residents had received a flu vaccine, 21 residents had signed consents for a flu vaccine but never got one, 20 residents were not offered, and 64 residents had declined the flu vaccine. RCD A stated that the reasons for refusals of the flu and pneumonia vaccines had not been documented. On 1/31/14 at 2:50 pm, an interview was conducted with the interim Director of Nurses (DON). The DON stated that since the resident flu and pneumonia status audit that was completed on 1/30/14, the facility had only given 2 residents a flu vaccine. The DON stated that she and the Director of Staff Development (DSD) were "working" on a system to get the flu vaccines done but, "no plan was in place yet." On 1/31/14 at 3:55 pm, the DSD was interviewed. The DSD stated that she had only been responsible for the staff immunizations in the past and that the resident immunization program was managed by the Assistant DON until 1/2014, then he went out on a leave of absence. The DSD stated that at 1 pm today, a corporate consultant told her that she was now in charge of the resident immunization program and that she needed to "come up with a plan to fix it" and that she "may get some help eventually." The DSD tearfully stated that the consultant had not provided her with any direction and, "I'm still trying to figure out how to fix this." The DSD added that the consultant had left the facility to fly back home. On 1/31/14 at 4 pm, RCD B was interviewed. RCD B stated that she had no knowledge of what had been implemented during the past week to get the resident's flu vaccines administered. RCD B stated that, "this will take some time, it won't be fixed overnight." On 1/31/14 at 4:25 pm, the interim Administrator was notified that an immediate jeopardy situation had been determined by the survey team due to the lack of an effective and operational immunization system that the facility created and allowed to continue, and the lack of facility action and sufficient use of resources to ensure that residents were immunized against flu and pneumonia. The facility currently housed 148 residents and had the potential to house 184, and only 30 residents had received a flu vaccine which put a large population of residents at risk for contracting the flu virus at the peak of the flu season. The Administrator confirmed that the facility's resident immunization program was not being operationalized, per policy and procedure, and that there was currently "no system in place." On 1/31/14 at 5:05 pm, RCD B presented an unacceptable immediate action plan and the immediate jeopardy was not abated. At 5:30 pm, RCD B presented a second unacceptable immediate action plan and the immediate jeopardy was not abated. At 6:25 pm, RCD B presented a third unacceptable immediate action plan and the immediate jeopardy was not abated. At 6:47 pm, the fourth immediate action plan included immediate education, administration, and documentation of refusals of resident flu and pneumonia vaccines, and was accepted and the immediate jeopardy was abated. On 2/4/14 at 8:55 am, the Medical Director (MD) C was interviewed. MD C stated that he has been the facility's Medical Director for nearly [AGE] years and "every year I have to remind the facility to do those flu shots, there's a delay every year." MD C stated there was ineffective communication between himself and the previous Administrator and stated, "she never acted on my concerns or suggestions."

Based on interview and record review, the facility failed to ensure that the Consultant Pharmacists (RPH) Medication Regimen Review (MRR) recommendations were acted upon by the physicians of 2 of 24 sampled residents (Residents 1 and 5), and failed to maintain all resident MRR recommendations and physician responses in a complete, readily available, and systematically organized manner when: 1. Resident 5 fell and sustained serious injuries while taking excessive doses of Seroquel (an antipsychotic) and his physician neglected to respond to the RPH's repeated MRRs to lower the dose. 2. Resident 1 continued to receive Risperdal (an antipsychotic) for four months after the RPH recommended a gradual dose reduction (GDR) and the physician neglected to respond to the MRRs. 3. The facility was unable to produce requested MRRs for the past year, 1/2013 to 1/2014. MRRs had to be reprinted by the Pharmacy because they were not all found in the facility; four months of MRRs (2/2013, 4/2013, 6/2013, and 8/2013) were missing and could not be found. Many of the physician responses to the recommendations made by the facility's RPHs were not in the residents' medical records. The facility could not produce physician responses to the MMRs. These failures resulted in harm to Resident 5 when he fell and sustained a head laceration requiring stitches and had low blood pressure, and placed Resident 1 and other residents at risk of adverse outcome from receiving unnecessary drugs and to suffer serious injury, impairment, discomfort, or death. On 2/6/14 at 5:05 pm, the interim Administrator and RCD B were informed that an Immediate Jeopardy (IJ) situation had been determined, due to Resident 5 sustaining harm from a fall which was directly related to his physician's neglect in responding to repeated MRR recommendations, and all residents had the potential to suffer serious injury, impairment, discomfort or death, because the facility had created an unorganized manner in which the MRR recommendations and physician responses were maintained, allowed it to continue, and had no knowledge of whether or not resident medication regimens were safe and appropriate. Findings: 1. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's record included a physician's orders [REDACTED]." There was a current physician's orders [REDACTED]." The facility pharmacist's (RPH) Consultation Report, dated 5/8/13, for Resident 5 read, "1) Flomax for "urinary incontinence"= inability to hold--> please correct to URINARY RETENTION." There was no evidence that the Medical Doctor (MD) E (Resident 5's primary physician) had responded or addressed the pharmacist's recommendation. Resident 5's September 2013 physician's orders [REDACTED]. The facility pharmacist's (RPH) Consultation Report, dated 3/7/13, suggested lowering Resident 5's twice daily (bid) 450 milligrams (mg) of Seroquel (antipsychotic) dose to 400 mg bid, in order to reduce side effects and because he only had behaviors for five of 28 days during February/2013. Resident 5's physician, MD E, declined the RPH's recommendation. The facility RPH's Consultation Report, dated 7/7/13, recommended a gradual dose reduction of Resident 5's Seroquel to 250 mg (milligrams) bid (twice daily), due to the possibility of abnormal heart rhythms and because his AIMS score (abnormal involuntary body movements), could be adverse effect of the drug. There was no evidence that MD E had responded or addressed the pharmacist's recommendation. The facility pharmacist's (RPH) Consultation Report, dated 8/7/3, for Resident 5 read, "REPEATED RECOMMENDATION from 7/7/2013: Please respond promptly to assure facility compliance with Federal regulations. Flomax for "urinary incontinence"=inability to hold--> please correct to URINARY RETENTION as the indication needing treatment * this medication increases urinary outflow." There was no evidence that the MD E had responded or addressed the pharmacist's recommendation. The facility RPH's Consultation Report for Resident 5, dated 9/11/13, read, "receives Seroquel for PSYCHOSIS M/B (manifested by) STRIKING OUT AT STAFF USING FOUL LANGUAGE BUT DOES NOT HAVE A HALLUCINATION/DELUSION AS DEFINED BY CMS. SEE SURVEYOR ANTIPSYCHOTIC TOOL SHEET. Resident has dementia." The report recommended that MD E evaluate the indications for continued use of the Seroquel and complete a neurological exam, as suggested by the AIMS tool sheet. The report showed that the indications for use did not meet the requirement of being a "danger to self or others." There was no evidence that MD E had responded or addressed the pharmacist's recommendations. The facility RPH's Consultation Report, dated 10/9/13, repeated her previous recommendation of 9/11/13, that read, " receives Seroquel for PSYCHOSIS M/B (manifested by) STRIKING OUT AT STAFF USING FOUL LANGUAGE BUT DOES NOT HAVE A HALLUCINATION/DELUSION AS DEFINED BY CMS (Centers for Medicare and Medicaid). SEE SURVEYOR ANTIPSYCHOTIC TOOL SHEET. Resident has dementia." The report recommended that MD E evaluate the indications for continued use of the Seroquel and complete a neurological exam, as suggested by the AIMS tool sheet. The report showed that MD E's indications for use for Resident 5's Seroquel did not meet the requirement of being a "danger to self or others." There was no evidence that MD E had responded or addressed the pharmacist's recommendations. The manufacturer's information for Seroquel indicates the need for monitoring of potential side effects such as dizziness, fast heart rate, heart rhythm irregularities, fainting, and postural low blood pressure (a sudden drop in blood pressure from lying to sitting to standing), all of which Resident 5 was at risk for due to his medical conditions. The manufacturer recommends that Seroquel dosing in patients who have heart disease or abnormal heart rhythms, such as Resident 5, should be limited to an initial dose of 25 mg twice daily, to reduce the risks for postural low blood pressure and fainting. Resident 5's Fall Risk Evaluations, dated 1/10, 2/21, 4/5, 7/11, 7/23, 7/26, and 8/21/13, all showed he was at risk for falls from taking four different medications that contribute to falls. Resident 5's Psychotropics Care Plan, dated 7/11/13, identified dizziness as a side effect of Seroquel. Resident 5's Fall Risk Evaluations and progress notes showed he had fallen on 1/10/13, 2/21/13, 4/5/13, 5/24/13, 7/11/13, 7/22/13 twice, 7/23/13, 7/26/13, 8/21/13, 9/15/13, 9/18/13, 10/5/13, 10/18/13, and 1/1/14. Resident 5's Fall Investigation Worksheets, for falls occurring on 5/24/13 and two on 7/22/13, included antipsychotic, antidepressants, and antianxiety medications as "current medications that may be causative." Resident 5's Progress Note, dated 9/22/13 at 7:30 pm (four days after his fall with injuries and tooth loss on 9/18/13), read, "Spoke with MD E by phone. Reported low blood pressures and that resident does not exhibit the extreme behaviors he has in the past with agitation and hyper movement. Reviewed all psych meds with MD. MD E decreased Seroquel to 300 mg BID..." On 2/5/14 at 2:30 pm, RPH stated that she had spoken to MD E many times about lowering residents' psychoactive medications and proper indications for the use of them. RPH stated she had brought these issues to the facility's quarterly meetings and done several in-services on psychotropic medication prescribing. 2. Resident 1 was admitted to the facility on [DATE] and was readmitted twice, the most recent on 11/12/13. He had [DIAGNOSES REDACTED]. The MRRs for Resident 1, for the previous 12 months, were requested from the facility for review. Documentation received was for only the months of 12/2013 and 1/2014, both of which referred the reader to, "See report for any noted irregularities." On 1/29/14, RPH MRR reports and physician responses for the past 12 months were requested from the facility. The facility presented seven MRR reports with recommendations to the prescribing physician, and only two of them, both dated 12/2013, included responses from the physician. In a MRR report, dated, 8/2013, RPH documented that Resident 1's medication, MiraLax (a laxative medication), was to be administrated with four to eight ounces of water; and recommended that the physician ensure that it is administered as such, "...to optimize medication therapy and comply with all CMS (Federal) regulations." In a MRR report, also dated 8/2013, RPH documented, "There are two orders for mild pain, Tylenol and Percocet one tablet. Please consider changing Percocet to...as needed for moderate pain," and "(order) states Ativan (a medication used to treat anxiety) is 1 mg every three hours as needed for anxiety but August MAR (medication administration record) is hand corrected to every 12 hours as needed. What is correct order...Please clarify ASAP to prevent any med errors." There was no documentation of a response from the physician. In an additional MRR report, dated 8/2013, RPH wrote, "(Resident 1) is currently receiving Risperdal 0.5 milligrams (mg) three times daily (TID) for dementia related to physical aggression since 6/18/13," with a recommendation, "For an initial attempt at gradual dose reduction (GDR), please consider reducing Risperdal to 0.5 mg twice daily, while concurrently monitoring for re-emergence of target and/or withdrawal symptoms." There was no documentation of a response to that report from the physician. In a MRR report, dated 11/2013, RPH wrote, "(Resident 1 receives an antipsychotic, Risperdal without an indication or behavior...Please consider reducing the dose...with eventual goal of discontinuation." There was no documentation of a response to that report to the physician. The Risperdal was continued, without a clear indication for use, at the same dose of 0.5 mg TID, for another four months, until the physician responded, on 12/24/13, to two reports dated 12/2013, that repeated the same recommendations. In a MRR report, dated 1/2014, RPH wrote, "(Resident 1) receives an antipsychotic Risperdone (generic Risperdal)...use requires one or more of following conditions...," with a recommendation to either reduce the dose, or list the specific diagnosis/indication, and symptom criteria or behavior indicating the use of Risperdal. There was no documented response from the physician. During an interview on 2/6/14 at 2 pm, the Administrator and DON both stated that they had no further documentation of RPH MRR reports or physicians' responses to such reports. 3. On 1/29/14 at 9 am, the survey team requested the RPH monthly MRRs for the past year, 1/2013 to 1/2014, from RCD A. These documents allow the survey team to determine if irregularities in the residents medication regimens have been identified by the RPH and acted upon by the residents physicians, to avoid the residents' experiencing adverse consequences or unnecessary medication On 1/29/14 at 5 pm, a large stack of loose MRRs were given to the survey team by the interim DON. The DON stated that four months of MRRs were missing; 2/2013, 4/2013, 6/2013, and 8/2013. The DON stated that most of the reviews had been reprinted by the Pharmacy because they were not all found in the facility and, "that's all we have for now." There were no records of the physician's responses to the MRRs. The survey team began the time consuming task of comparing those loose sheets of pharmacy recommendations to individual resident physician's orders [REDACTED]. The survey team identified that many of the physician responses to the recommendations were not in the residents medical records. The DON stated that the MRRs should have been systematically organized and maintained in a binder along with the physician's responses to the RPH's recommendations, to ensure that the physicians were addressing resident medication reviews. The DON stated that the recommendations and physician responses should have been readily available in the resident's medical records and confirmed that they were not. The DON stated that the missing MRRs and physician responses were still trying to be located. The facility's policy and procedure titled, "Medication Regimen Review" contained in the "Pharmacy Services and Procedures Manual," dated 12/1/07, was reviewed and specified: "5. The facility should independently review each resident's medication regimen directly from the resident's medical chart and with Interdisciplinary Care Team members, Resident, or Responsible Party, as needed. 6. Facility should ensure that Facility Physicians/Prescribers are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 8. Facility should provide the Medical Director with a copy of the MRRs and should alert the Medical Director where MRRs require follow-up. 9. Facility should maintain copies of MRRs on file in Facility, either as part of the resident's permanent medical record or in a special file, in accordance with Applicable Law." A review was conducted of the "Quality Improvement" summaries that RPH F had discussed with the facility's Administrator and DON in 7/2013, 8/2013, 9/2013, and 12/2013, and disclosed the following: In 7/2013: "Isolated issues" with Medication Regimen Review (MRR) recommendations being acted upon, "Please remind nursing staff that repeated recommendations will be grounds for citation." "Pattern" observed in unnecessary drugs, "Please clarify indications for use of the mentioned, especially the antipsychotics... Please see attached regulations for strict indications for use." "Isolated issues" with nursing monitoring behaviors and "Acceptable target behaviors are not being identified for antipsychotic use." In 8/2013: "Please update psych summary sheets as required per regulation,"transferred from another facility on this" won't qualify as a risk vs. benefit for psychotropic use, especially antipsychotics." "To better serve your facility in an effort to identify those at high risk for falls/change of condition/inappropriate antipsychotic use, consultant would like to request a falls list on future visits. Current falls evaluation sheet does not identify which are routine/quarterly assessments vs. true falls. Perhaps identify them when doing the evaluations, or separating the IDT assessments into sections instead of mixing weight, pressure ulcers, UTIs etc with falls." In 9/2013: "Isolated issues" with MRRs, "Could not locate responses from Dr. (the Medical Director)." "There is no process in place to monitor adverse drug reactions/drug interactions. Discussed with facility leadership." "Non-pharmacological interventions; can not answer this question, could not locate where this is being documented." "Please ensure the MD's respond to GDRs (gradual dose reductions). Some are overdue from no responses." "Pattern observed" "Behavior monitoring; Agitation is not an approved indication for use, psychosis without a hallucination/delusion has been cited at other facilities." "Informed consents-many months reminder and still not obtained. "PRN pain meds without clear pain parameters..." "Antipsychotics: unapproved indications is being used." "Psych summary sheets needs to be available & UPDATED per facility policy...please ensure behaviors/[DIAGNOSES REDACTED]. Duplicate orders; antidepressants needs risk vs. benefit from MD that one is not sufficient to control depression." In 12/2013: "Pattern observed" Unnecessary Drugs: Discussed with facility leadership to consider an audit to make sure each routine med on the doctor's order sheet has the [DIAGNOSES REDACTED]. Would you please have your doctors address each of our recommendations as soon as possible? Please do an audit for informed consent and AIMS tests for each resident on antipsychotic med? Would you please also implement checking for orthostatic hypotension monthly for each resident on antipsychotic med? Please have nurses write Morphine liquid orders more specifically in the future. The order should include the concentration of the liquid...Please have each of your fingerstick blood sugar orders specify when to call the doctor for below what level and above what level. There are a number of prn pain meds used here and it would be nice if nurses would request more routine orders as appropriate..." On 2/5/14 at 8:45 am, the survey team again, requested the missing MRRs from 2/2013, 4/2013, 6/2013, and 8/2013, and physician responses to the MRRs. On 2/6/14 at 5 pm, RCD B stated that no physician responses were found and, "if it is not in the chart then we don't have it." RCD B stated, "these things take time, we can't fix it in two days, we need more resources." On 2/6/14 at 5:05 pm, the interim Administrator and RCD B were informed that an immediate jeopardy situation had been determined due to Resident 5 sustaining harm from a fall that was directly related to his physician's neglect in responding to repeated MRR recommendations, and all residents had the potential to suffer serious injury, impairment, discomfort or death, because the facility had created an unorganized manner in which the MRR recommendations and physician responses were maintained and allowed it to continue and had no knowledge of whether or not resident medication regimens were safe and appropriate. The RCD B stated that the facility's process by which MRRs were organized and verification of how recommendations were being followed up on was, "a broken system." An immediate corrective action plan was requested. On 2/6/14 at 5:45 pm, an unacceptable corrective action plan was submitted by RCD B and the Immediate Jeopardy was not abated. On 2/7/14 at 8:40 am, an acceptable action plan was submitted by RCD B and the Administrator and the Immediate Jeopardy was abated.

Based on observation, interview, and record review, the facility failed to maintain an effective weight management program when four of 24 sampled residents (Resident's 7, 9, 12, and 17) had avoidable significant weight loss when: 1. Resident 12's weight loss was not addressed per the facility's weight management program. The facility failed to do a admission weight, interdisciplinary team meetings (IDT-a meeting consisting of at least different departments) were not done, there was no reevaluation of weight management interventions and supplement and meal percentage were not adequately monitored and assessed. 2. Resident 7's severe weight loss was not addressed per the facility's weight protocol policy and Resident 7 was served food items not ordered by the physician. 3. Resident 17's severe insidious (gradual, unintended, progressive) weight loss, was not addressed by the facility when they failed to implement measures and address recommendations from the Registered Dietitian (RD). 4. Resident 9 was not re-weighed by the facility to confirm a severe weight loss. These failures contributed to residents continued weight loss and potential to not meet their highest level of physical well being. Findings: Review of the facility's policy titled "Weight Management System" revised 11/2012, indicated the following: # 4 "comparable substitutes will be offered to residents who consume less than 50% of the meal offered." # 2 "weekly weights will be obtained on all new admissions,(and) residents who experience a significant weight change...for a minimum of 4 consecutive weeks" # 6 "supplements are documented as % consumed" Review of the facility's policy titled, "Weight Protocol" revised 7/2013, indicated the following; #4 "criteria for significant weight change:" 5% weight loss in 30 days, 7.5% weight loss in 90 days and 10% weight loss in 180 days." # 5 "all significant weight changes or 5 pounds weight changes in a resident who weighs greater than 100 pounds... are assessed and charted, plan of care is updated." #7 "Residents with insidious weight change will be reviewed quarterly and addressed by IDT" It further defines insidious weight loss as " a slow, undesirable,or unplanned weight loss over three months or more." Review of the facility's policy titled "Weight Committee" revised 7/2013, indicated the following. # 1 IDT will review residents with insidious weight change over 3 months or more. # 3 IDT will "plan interventions" to prevent further weight change. IDT guidelines included: #2 obtain food preferences, # 7 review unintended weight loss as an IDT and as a team will develop interventions, # 9 at subsequent weight variance committee meetings will "determine if current interventions are effective." The facility's policy titled "Calculating percentages at meal times," dated 7/2013, indicated "All alternate foods are documented by nursing staff...indicating whether the substitute was offered and consumed." The policy also indicated "Coffee and tea provide 0% to meal percentage intake," but protein shakes (health shakes,) juice and milk are included in calculating meal percentage intake. The facility's policy titled "Nutrition and meals," dated 11/2012, indicated "4. If the resident refuses a meal or food item, or eats 75% or less, offer a meal replacement of similar nutritive value." The facility's policy titled "Nourishment and H.S. (bedtime) snacks," dated 11/2012, indicated "Liquid high protein supplements will be recorded as percentage on the Medication Administration Record [REDACTED]." 1. Resident 12 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool) dated 1/16/14, showed she had moderate cognitive impairment (inability to think, reason, and make decisions). During an observation and concurrent interview with Resident 12, on 1/30/14, at 9 am, she was in bed with a breakfast tray in front of her. No food items were observed to be gone from the tray. Resident 12 stated no one had come in during the meal time to assist her or offer her anything else. During an interview with Certified Nurse Assistant (CNA) HH, on 1/31/14, at 8:05 am, he stated he assists residents with morning and noon meals. CNA HH stated if a resident does not eat he returns the resident to their room after the meal and it is up to the residents assigned CNA to offer the resident something else to eat if they ask for something. There was not a system in place to ensure that the assigned CNA knows that the resident has been returned to their room and that they need to offer them a substitute. During an interview with Certified Nurse Assistant (CNA) II, on 2/5/14, at 8 am, she stated she regularly assists residents with morning and noon meals. CNA II stated her documentation of resident meal percentage intake does not include health shake or liquids, only solid foods. During an interview with Certified Nurse Assistant (CNA) JJ, on 2/5/14, at 8:05 am, she stated she regularly assists residents with morning and noon meals. CNA JJ stated her documentation of resident meal percentage intake does include health shake and solid foods, but no other liquids. During an interview with the Director of Staff Development (DSD), on 2/5/14, at 8:30 am,she stated she orients new employees and they are taught to document resident meal percentage intake figuring solids, health shakes and milk into the total percentage but no other liquids. During an interview with Resident 12's responsible party (RP-makes decisions for her), on 2/5/14, at 1:15 pm, he stated he visits Resident 12 about 2-3 times per week. Resident 12's RP stated he is frequently at the facility visiting during dinnertime and because of this, he is aware Resident 12 does not eat dinner well. He stated he had seen Resident 12 refuse many dinner meals because she did not care for the food they served so he brings her food from outside the facility. He stated the facility has been Resident 12's primary residence since 2004 and he was not aware any alternate/substitute food besides a cheese sandwich, which Resident 12 does not like, was available for Resident 12 to eat, if she did not like what was being served. During an interview with Licensed Nurse (LN) Y, on 2/4/14, at 10:30 am, she stated she was frequently the nurse for Resident 12. LN Y explained her signature on the MAR for the entry reading "Health shake" indicated the health shake was on Resident 12's tray, it did not imply any percentage was consumed by the resident. The record for Resident 12 contained the following: The Weight Summary Record indicated that on 4/1/13, Resident 12 weighed 163.8 pounds (lbs). On 1/19/14, she weighed 132.4 lbs. Over the period of time from 4/2013 to 1/2014 (9 months), she had lost 31.4 lbs (19% of her initial weight.) The Nutritional Quarterly Evaluation, dated 3/20/12, by the Dietary Services Supervisor (DSS),read that Resident 12 was on a fortified (added nutrients and calories) diet at that time. The Nutritional Evaluation of 3/12/13, indicated Resident 12 was still being maintained on a fortified diet. On 5/1/13, Resident 12's weight (wt) was 158.0 lb. It indicated a 5.8 lb loss from the previous month and a 12.2 lb loss over the past six months. The Nutritional Progress Note, dated 5/23/13, by the Registered Dietitian (RD), documented her height as 5 foot 3 inches and indicated Resident 12 was still on a fortified diet. Her estimated calorie (kcal) needs were 1,500-1,600 kcal per day and protein needs were 59-73 grams per day. It indicated no new interventions were developed. On 7/1/13, Resident 12's wt was 152.3 lbs representing an insidious loss of 7.0 % (11.5 lb) loss in 3 months. No quarterly interdisciplinary (IDT) notes or weight committee notes were present or provided by the facility which indicated a review of this insidious weight loss per the facility's Weight Protocol policy. On 8/2/13, Resident 12's wt was 151.4 lbs, representing a loss of 12.4 lbs in the past 4 months (mo) and a loss of 4.2% in the previous 3 mo. No quarterly IDT notes were present to review this insidious weight loss per the facility Weight Protocol policy. A document titled,"Amount eaten (ADL charting)," dated 9/5/13-9/30/13, indicated Resident 12 had no snack or supplement intake. It also indicated that out of a total of 75 meal intakes documented in that time frame, Resident 12 had 0% intake on 4 of 75 meals, and an intake of 0-25% on 16 of 75 (21% of meals). On 9/5/13, Resident 12's wt was 137.6 lbs, representing a severe weight loss of 9.1 % (13.8 lbs) in 30 days, 9.1% (13.8 lbs) in 90 days and 11.3 % (17.6 lbs) in 6 mo. On 9/14/13, the Registered Dietitian (RD) note defined the loss as "unplanned wt (weight) loss dt (due to) decrease in appetite", it included a plan to obtain weekly weights for 4 weeks. On 9/17/13, the first IDT since the insidious weight loss began in 5/2013 was held. The physician approved the RD/ IDT recommendation of increasing the residents health shakes to three times daily. A document titled,"Amount eaten," dated 10/1/13-10/31/13, indicated Resident 12 had no snack or supplement intake. It also indicated that out of a total of 78 meal intakes documented in that time frame, Resident 12 had 0% intake on 7 of 78 meals, and an intake of 0-25% on 30 of 78 (38% of meals). On 10/1/13, Resident 12's wt was 140.0 lbs which represented a continuing severe and significant insidious weight loss of 7.5% (11.4 lbs) in 3 mo and 11.4% (18 lbs) in 6 mo. No weight committee or IDT meeting or new interventions were done at this time by the facility according to their weight management policies to address the continued loss. On 10/11/13 Resident 12 was sent to the hospital. After spending 4 consecutive nights there she was readmitted to the facility on [DATE]. No weight was obtained on readmission and no weekly weights were initiated after readmission as the facility Weight Management policy instructed. On 10/22/13, a weight IDT meeting was conducted utilizing Resident 12's weight of 146 lbs which had been obtained prior to discharge as no readmission weight had been done. The IDT meeting notes indicated only one discipline (dietary) was present. The "Dietary nutritional progress note," dated 10/22/13, by the RD indicated Resident 12's po (by mouth) intake had decreased from her previous intake prior to her stay at he hospital and Resident 12 was now only taking "1-26 % (of her) meals." The same interventions to support nutrition placed before Resident 12 went to the hospital were reinstated, no new dietary recommendations were made. A document titled,"Amount eaten," dated 11/1/13-11/30/13, indicated Resident 12 had no snack or supplement intake. It also indicated that out of a total of 88 meal intakes documented in that time frame, Resident 12 had 0% intake on 10 of 88 meals (11% of meals), and an intake of 0-25% on 28 of 88 (32% of meals). On 11/10 13, Resident 12's wt of 139.2 lbs continued to represent a significant loss of 10.3 % (16 lbs) in the previous 6 mo. No new interventions were developed to address the continued wt loss. On 11/17/13, Resident 12's wt of 133.2 lbs continued to represent a significant loss of 8.3 % (12 lbs) in 1 mo and 14.2 % (22 lbs) in 6 mo. On 11/24/13, Resident 12's wt of 134.0 lbs continued to represent a significant loss of 7.7% (11.2 lbs) in 1 mo and 13.7 % (21.2 lbs) in 6 mo. On 11/7/13 the ST (speech therapist) ordered a Magic cup (nutritional supplement) added onto all trays. (Cross Reference F 281) On 11/21/13, a single discipline (dietary only) IDT meeting was held. The RD recommended and the physician subsequently ordered med pass (a liquid supplement) 60 milliliters three times a day which the facility record noted as being initiated on 12/1/13. A document titled,"Amount eaten," dated 12/1/13-12/31/13, indicated Resident 12 had no snack or supplement intake. It also indicated that out of a total of 89 meal intakes documented in that time, Resident 12 had O% intake on 3 of 89 meals, and an intake of 0-25% on 40 of 89 (45% of meals). On 12/15/13, Resident 12's wt was 140.8 lb signifying a significant weight gain of 5.7% (7.6 lbs) in 30 days. No weight committee or IDT meeting was held according to the facility's weight management policies to assess this significant 30 day change or to assess the effectiveness of prior interventions. A document titled,"Amount eaten," dated 1/1/14-1/30/14, indicated Resident 12 had no snack or supplement intake. It also indicated that out of a total of 90 meal intakes documented in that time frame, Resident 12 had 0% intake on 3 of 90 meals, and an intake of 0-25% on 48 of 90 (53% of meals). On 1/1/14 Resident 12's weight was 131.4 lbs indicating a 6.9% (9.8 lb) loss in 1 mo, 10 % (14.6 lb) loss in 3 mo and 13.2% (20 lb) loss in 6 mo. On 1/1/14 Resident 12's weight represented a 19.8 % (32.4 lb) weight loss over the previous nine months. On 1/7/14, an IDT meeting with two disciplines present planned to have Resident 12's breakfast served in her room instead of in the dining room with a certified nurse assistant present to assist. On 1/12/14 Resident 12's wt was 134 lbs indicating a 7.7% (11.2 lb) loss in 3 mo and 11.5% (17.4 lb) loss in 6 mo. On 1/19/14 Resident 12's wt was 132.4 lbs indicating a 1.6 lb loss in one week, an 8.8% (12.8 lb) loss in 3 mo and a 12.5% (19 lb) loss in 6 mo which continued to represent an insidious and severe weight loss for the past 3 and 6 months. No weight management IDT meetings were held to evaluate the continued decline or assess the effectiveness of interventions. During an interview and concurrent Medication Administration Record [REDACTED]"Health Shake" and the one reading "med pass" were the same thing. She stated the order reading "Health Shake" is a duplicate of the med pass order, "it just got printed twice on the MAR." LN W stated she does not document the percent intake of liquid supplements taken by the resident, which was not according to the weight management policy. During an interview with the Dietary Services Supervisor (DSS), on 1/30/14, at 10 am, she stated she prepares the list of residents to be seen at the weight committee/IDT meetings. The DSS stated there was no re-evaluation for effectiveness of interventions implemented to stabilize weight and weekly weights were not necessarily taken after a resident has had a significant weight loss. These statements were contradictory to the above mentioned policies. During an interview with the RD, on 1/30/14, at 10:45 am, she confirmed the DSS prepared the list of residents to be seen at the weight committee/IDT meetings. She stated that prior to 1/2014 she did not receive all residents monthly weights and did not track residents including Resident 12 for insidious weight loss as she should. RD confirmed weekly weights were not always done after a significant weight loss as their policy stipulated because it was difficult to get staff to obtain them and they are "not always done." RD further stated health shakes should be documented by nursing as percent taken and her ability to determine adequacy of interventions is "a problem" because she does not have accurate or complete intake information and she does not know how to access any certified nurse assistant charting on the computer regarding residents intake since the facility began computerized charting in 9/2013. RD explained the computerized charting does not designate an actual percent intake, but a range of intake. For example an intake documented as 0-25% as many were on Resident 12, could reflect an intake of 0%. RD explained that for the weight IDT meeting, the expectation is a minimum of three disciplines be present. For dietary meetings the minimum expectation of persons who need to be in attendance are the RD, DSS, a licensed nurse and an activities worker. One goal of IDT meetings is to be able to get a well rounded look at the residents behaviors which may impact eating and likes and dislikes in order to adequately plan interventions appropriate to the specific resident being assessed. During an interview with the Director of Nursing (DON), on 1/30/14 at 2:40 pm, she confirmed the facility did not follow their policy when Resident 12's weight was not obtained on the day of readmission and weekly thereafter. The DON confirmed the facility was not documenting percentage of supplements taken as their policy stipulated. The DON reviewed the MAR for Resident 12 and confirmed the "Health Shake" and "med pass" were two different and separate supplements which should each be documented in percentage. The DON confirmed substitutes are to be offered and documented for each resident each time they have less than 50% intake and this had not been done for Resident 12. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated 1/7/14, indicated that Resident 7 was severely impaired and needed extensive assist in feeding. Resident 7 also had a history of [REDACTED]. Resident 7's record was reviewed on 1/28/14. The Weights and Vitals Summary Record indicated that on 8/1/13, Resident 7 weighed 106 pounds (lbs) and on 9/2/13, she weighed 106.2 lbs. In an interview with the DSS on 2/4/14 at 11:10 am, she stated that on the RNA (Restorative Nursing Assistant) weight sheet, Resident 7's weight on 9/13 was 99.4 lbs. Resident 7 was re-weighed at 101.4 lbs. with a total weight loss of 4.6 lbs (4.3%) in the month of 9/13. DSS stated that she did not know when Resident 7 was re-weighed. There was a difference of 5.2 lbs in Resident 7's weight from what was recorded in Resident 7's record and the weight recorded on the RNA weight sheet. During an interview with Certified Nursing Assistant (CNA) DD, on 2/4/14 at 11:40 am, he stated that when there is a difference of 3 to 5 pounds in a month, he re-weighs residents right away, within twenty-four hours and then gives the copy of the weight record to the DSS and DON. On 10/1/13, Resident 7's weight was recorded in her record at 98.8 lbs. This was a 7.4 lbs. weight loss from the previous month which was 6.9% loss in a month. On 10/31/13 there were notes that the Interdisciplinary team (IDT) met but did not address Resident 7's weight loss. During a concurrent interview and record review with the RD on 2/4/14 at 9:15 am, she stated that she did not know what happened with Resident 7's weight loss not being reviewed. She further stated that Resident 7 should be put on weekly weights immediately. She confirmed that the facility did not follow their policy on "Weight Protocol" when they did not do weekly weights after Resident 7's weight loss. Review of the physician's order dated 10/7/13 at 10:06 am, indicated to change diet texture to puree (pudding-like consistency) with thin liquids with allowance for peanut butter and jelly for lunch and dinner and magic cup (supplement) on all trays, three times a day. A physician's order dated 10/18/13 at 9:50 am, indicated to remain on puree with thin liquids, RCS (Reduced Concentrated Sweets) with regular peanut butter and jelly and magic cup on all trays to maximize nutrition and hydration. Roadside dining (name of dining room) all meals for max assistance. A physician's order dated 11/5/13, indicated Resident 7 was on a RCS, puree, fortified (essential nutrients added) diet with thin liquids. There was no peanut butter and jelly sandwich ordered. On 11/1/13, Resident 7's weight was recorded as 95.2 lbs. This was a 3.6 lbs (3.6%) weight loss from the previous month, 11 lbs. (10.4%) loss in two months according to the weight in the record or 6.2 lbs (6.1%) according to the RNA weight sheet. A weekly weight was obtained on 11/6/13 at 89 lbs. with a weekly weight loss of 6.2 lbs. (10.2%) in 3 months. No other weekly weights were documented in the record. The IDT Progress Notes dated 11/5/13 by the DSS indicated that Resident 7 triggered for a monthly and three month weight loss. It indicated Resident 7 lost 3.6 lbs in one month and 10.8 lbs (10.2%) in 3 months. IDT notes recommended to add small portions and sugar free healthshakes once a day. Offering smaller and more frequent meals can make it more appealing for the resident to improve their intake. There was no record of weekly weights being monitored. There was no physician order for [REDACTED]. On 12/3/13, Resident 7's weight was recorded at 87 lbs. with a total of 8.2 lbs. insidious weight loss from the previous month which represented a severe weight loss of 11.8 lbs (11.9%) in 3 months and 19.2 lbs (18.1%) in the past 6 months. The Dietary Progress Notes dated 12/12/13 by the RD did not reflect any new interventions at that time. A progress Notes by the RD dated 12/17/13, indicated Resident 7 had a Body Mass Index (BMI) of 17.4. A BMI under 18 indicates being underweight. The RD recommended ice cream twice a day between meals, weekly weights and await physician order to change to small portions. This was the second time the RD recommended small portions for Resident 7. A physician order dated 12/30/13 indicated small portions. No documentation of weekly weights were in the record. On 1/1/14, Resident 7's weight was 87.8 lbs, a weight gain of 0.8 lb in one month, which still represented a severe weight loss of 7.4 lbs (7.8%) in the past 3 months and 18.2 lbs (17.2%) in the past 6 month. A review of the RD notes dated 1/30/14, indicated significant weight loss for three and six months and the oral intake was 0-50% of meals. The RD recommended weekly weights until weight was greater than 100 lbs. No new interventions were done at this time. The care plan for difficulty swallowing, dated 11/1/13, for Resident 7 was reviewed. It included interventions to provide adaptive equipment, a nosey cup (have a cutout for the nose allowing to drink without tipping the head back) and a peanut butter and jelly sandwich with no crust on meal trays. On 1/31/14 at 7:55 am, in Roadside Cafe, Resident 7 was observed eating breakfast. Resident 7's diet tray card indicated she was on a reduced concentrated sweets diet (RCS), fortified (essential nutrients added), puree diet with small portions. Resident 7's tray contained a peanut butter and jelly sandwich with crust. Resident 7 was being assisted to eat by CNA EE. There was no current physician's order for the peanut butter and jelly sandwich (Refer to F367). The CNA documented 25% of breakfast consumed and there was no evidence that Resident 7 had been offered a substitute. During an interview with Licensed Nurse (LN) V, 1/31/14 at 8:20 am, she stated that if residents ate less than 50% of their meal intake, they have to offer a substitute. She stated that it was normal routine for Resident 7 to have meal intake of 25%. The facility did not follow their policy to "offer comparable substitutes to residents who consume less than 50% of the meal offered" when Resident 7 was not offered a substitute. On 2/3/14 a review of the Medication Administration Record [REDACTED]. Also the electronic record sheet titled "amount taken for snacks and supplements" were left blank from 9/2013- 1/2014. The facility did not follow their policy of documenting supplements as percent consumed. During an interview with the RD on 2/5/14 at 2:20 pm, she stated IDT will only see residents when they trigger the 5%, 7.5% and 10% weight loss. They will make recommendations but rely on nursing to implement them. RD stated she does not follow up on the interventions to see if they were implemented. The RD stated they only follow up on residents if they trigger again for significant weight loss. The RD stated she had no documentation or standard of practice to support why they do things this way. On 2/6/14 at 8 am, Resident 7 was observed being served a peanut butter and jelly sandwich with crust and without an adaptive device, nosey cup (have a cutout for the nose to allow to drink without tipping the head back). (Refer to F369) In an interview on 2/6/14 at 8 am, Director of Staff Development (DSD), who had served Resident 7's meal tray confirmed that peanut butter and jelly sandwich with crust was served and the tray did not have an adaptive device (nosey cup). She confirmed that the care plan for Resident 7 was not followed. (Refer to F279) 3. A review of the record for Resident 17 indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17 was alert, confused, and needed assistance with eating. A review of a document titled, "Weights and Vitals Summary," disclosed a weight loss of 6.2 pounds (lbs.) for Resident 17 from 6/2013 to 7/2013. A physician's order, dated 6/6/13, read "med pass (nutritional supplement) four ounces, three times per day." An IDT note dated 7/9/13, indicated that the med pass was ordered for low protein levels. A further review of the Weight Summary form disclosed the following weights for Resident 17: 9/5/13- 131.2 pounds (lbs.). 10/1/13- 134.6 lbs., a gain of 3.4 lbs. 11/1/13- 131.4 lbs., a loss of 3.2 lbs in one month. 12/3/13- 115 lbs., a 16.4 lbs. (12.5%) weight loss in one month; 12.5% loss indicates a severe weight loss. 12/8/13- 115.6 lbs., a gain of .6 lbs. 12/15/13,-114 lbs., a 1.6 lbs. weight loss in approximately 2 weeks. 1/1/14-112.4 lbs., a 2.6 lbs. (2.3%) weight loss in approximately one month, a loss of 19 lbs (14.4%) in two months. 2/4/14-110.2 lbs., a 2.2 lbs. weight loss in one month; a loss of 4.8 lbs (4.1%) in two months, 21.2 lbs. (16.1%) in three months which is a severe weight loss. From 9/5/13 to 2/4/14, Resident 17 gradually lost a total of 21 lbs. This constituted a severe weight loss of 16%. A review of a form titled, "Dietary/Nutritional Progress Note", dated 12/3/13, disclosed the RD recommendations to obtain weekly weights for Resident 17 and to "fortify" the current diet order. The IDT Progress Notes, dated 12/3/13, recommended "fortify diet and weekly weights." A review of a form titled, "Weight/Skin Committee", dated 12/3/13, recommended weekly weights and a fortified diet. A physician's order, dated 12/10/13, indicated the addition of a house supplement (nutritional supplement) four ounces, three times a day. The "Nutritional Risk Assessment" form, dated 12/16/13, listed weekly weights as an intervention. No weights were obtained between 12/12/13 through 1/1/14. No weekly weights were obtained for 1/2014. The recommendation of a fortified diet was not initiated. A review of an electronic form titled, "Amount Taken for Supplements", was blank from 12/2013- 1/2014 for the consumption of house supplements, for Resident 17. A review of the facility policy titled, "Nourishment and H.S. (bedtime) Snack", revised 11/2012, read, "Liquid high protein supplements will be recorded as percentage... on the Activities of Daily Living if given by nursing assistants." Review of the Dietary/Nutritional Progress Note, dated 1/21/14, written by the RD read, "no new recommendations, do not need to fortify diet at this point..." Review of the IDT notes dated 1/21/14 indicated no new recommendations at this time. During an interview on 2/5/14 at 2:20 pm, the RD stated that she only discussed residents in IDT meetings when they trigger a 5%, 7.5%, or 10% weight loss. She stated that she made her recommendations and did not review the resident's plan again unless they triggered again for a significant weight loss. She stated that there was no documentation or standard of practice that directed how to follow-up. The RD stated that she relied on nursing to implement interventions and recommendations, and that she did not follow up to ensure implementation. The RD stated that her usual practice was to fax the physician her diet recommendations. No documentation was available regarding physician notification for fortification of Resident 17's diet. The RD acknowledged that Resident 17 was not placed on a fortified diet in December as recommended. The RD confirmed that Resident 17 continued with a gradual weight loss. 4. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's MDS, dated [DATE], showed that he was cognitively intact (able to understand, recall, reason and make healthcare decisions). On 2/5/14, Resident 9's record showed his weights as: 225.8 pounds (lbs) on 12/3/13; 193.6 lbs on 1/1/14 (an apparent 32.2 lb weight loss in 29 days); 212.6 lbs on 1/19/14; 212 lbs on 1/26/14; and 212 lbs on 2/4/14. Resident 9's record included a Dietary/Nutritional Progress Note, dated 1/16/14, that showed that his weight loss of 32.2 lbs was unlikely as his eating patterns had not changed. Resident 9's Dietary/Nutritional Progress Note, dated 1/31/14, included a notation that it appeared the weight of 1/1/14 was a "scaling issue." There was no evidence found in Resident 9's record that showed the facility's RD had been contacted immediately after the 32.2 lb weight loss was discovered. On 2/5/14 at 2 pm, RCD B confirmed that facility staff should have re-weighed Resident 9 after the error was discovered, yet did not reweigh him until 18 days later, so the weight loss was not addressed timely and new intervention were not implemented timely.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for five of 24 sampled residents to meet or maintain their highest practical physical level of well-being (Residents 1, 2, 3, 4, and 18) when: 1. Resident 4 did not receive medications as ordered, in a timely manner to treat/relieve her severe pain and anxiety. Pain and anti-anxiety medications ordered by the physician were not given for almost seven hours. 2. Resident 2 had physician's orders [REDACTED]. 3. A complete interchange of information with the contracted [MEDICAL TREATMENT] (HD, the mechanical process of cleansing the blood of accumulated waste and excess fluid) clinic was not provided for Resident 3. 4. Intake and output of fluids were not sufficiently monitored for Residents 1, 3, and 18. These failures resulted in Resident 4 suffering untreated, severe pain resulting in a further decline of her physical and mental well-being, Resident 2 feeling "really" sick, vomiting, weak, sleepy, and tired, and had the potential of life-threatening bleeding and insufficient fluid balance (overload versus dehydration risk) for Residents 1, 3, and 18. Findings: 1. Resident 4, a [AGE] year old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED]. It read, "Use medication by any route, positioning, wound care and other measures to relieve pain and suffering." These were the comfort measures ordered by the physician. A review of the nursing notes, dated 1/28/14, disclosed that Resident 4 started complaining of shortness of breath, feeling anxious, and had continued abdominal pain. In a note timed 11:41 am, the nurse noted that Resident 4's physician had been called and the nurse was waiting for him to call her back. About two hours later, in a note timed at 1:31 pm, the nurse noted that Resident 4's physician had called and given orders (the physician's orders [REDACTED]. "Pharmacy notified." In an interview on 1/28/14 at 2:40 pm, Licensed Nurse (LN) U stated, "We are giving [MEDICATION NAME] ([MEDICATION NAME], a non narcotic pain reliever) but it doesn't seem to be doing it." LN U stated that Resident 4's family member and Responsible Party (RP) wanted her "kept comfortable." A review of the Medication Administration Record [REDACTED]. On 1/28/14 at 5:40 pm, one and one half hours after receiving [MEDICATION NAME], Resident 4 was observed in her wheelchair, rocking back and forth, moaning and holding her abdomen. In an interview on 1/28/14 at 6 pm, two hours after receiving [MEDICATION NAME], Resident 4 stated, "The pain is the worst I've had. The pain medication I received earlier didn't help." She described her pain as a 10 (pain scale of 1-10 where 1 is no pain and 10 is the most severe). A 1/28/14 nursing note timed at 6:20 pm, read, "Physician notified again about pain for (Resident 4). RX (pharmacy) called about pain and asked to contact the physician. I have not received authorization from RX to get into E-KIT (contained medications that can be given in case of an emergency)." A nursing note timed at 7:13 pm, by the nursing supervisor indicated that she had heard from Resident 4's physician then contacted the pharmacy who gave an authorization to remove the ordered medication from the E-kit. The following was also documented in this note, "(Resident 4) received medications immediately. States 10/10 pain." The facility policy titled, "New Orders for Schedule II Controlled Substances," last revision date of 1/1/13, was reviewed. It read, "New orders for Schedule II controlled substances require a written prescription prior to dispensing unless there is an Emergency Situation... For an emergency Schedule II controlled substance order, the authorized Physician should provide the following information to a licensed pharmacist: . . . . If the controlled substance is needed before the pharmacy can make the arrangements for a timely delivery, facility must fax a request to remove a controlled substance to the pharmacy." A fax was sent to the facility's pharmacy at 1:18 pm on 1/28/14, requesting the [MEDICATION NAME] and [MEDICATION NAME]. A controlled substance prescription from Resident 4's physician, as required by the facility's pharmacy and policy, was faxed at 6:43 pm, six and a half hours later. In an interview on 1/28/14 at 6:10 pm, Supervising Registered Nurse (RNS) stated that the pharmacy cannot send [MEDICATION NAME] without the physician's authorization. The RNS stated that the primary care physician had not yet returned their calls and that the Medical Director had not been contacted. This delay in treatment caused Resident 4, pain for six and a half hours, three of those hours in severe pain. 2. Resident 2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 1/10/14, described her as being cognitively intact (able to understand, recall, reason and make healthcare decisions). During initial observation tour on 1/28/14 at 8:40 am, Resident 2 was concurrently interviewed and stated that her diabetes had been out of control last night and that her blood sugar was over 500 mg/dl. She stated that her blood sugars had been high for the past four days and that this "takes a lot out of me." Resident 2's record included physicians orders, dated 1/4/14, that read, "FSBS (finger stick blood sugar, test) Q (every) AC (before meals) & HS (at bedtime). Call MD (medical doctor) if 60 or > (greater than) 400." Resident 2's January/2014 Medication Administration Record [REDACTED] 440 at 9 pm on 1/6/14; 482 at 9 pm on 1/8/14; 423 at 4:30 pm on 1/9/14; 463 at 9 pm on 1/9/14; 486 at 11:30 am on 1/10/14; 425 at 4:30 pm on 1/10/14; 484 at 9 pm on 1/10/14; 433 at 4:30 pm on 1/11/14; 482 at 11:30 am on 1/12/14; 410 at 11:30 am on 1/14/14; 405 at 9 pm on 1/15/14; 409 at 4:30 pm on 1/19/14; 433 at 4:30 pm on 1/22/14; 402 at 9 pm on 1/23/14; 417 at 9 pm on 1/24/14; 407 at 11:30 am on 1/25/14; 450 at 11:30 am on 1/26/14; and 544 at 9 pm on 1/27/14. There was no evidence found in Resident 2's record that her MD had been contacted and informed about any of the above blood sugars over 400 mg/dl. On 1/28/14 at 9 am, Registered Nurse (RN) L was interviewed about Resident 2's high blood sugars. She stated that nurses should call the MD to report blood sugars below 60 and above 400 mg/dl and note on the back of the MAR indicated [REDACTED]. On 1/29/14 at 2 pm, in an interview, the Director of Nurses (DON) confirmed that Resident 2's MD should have been notified about the blood sugars that were over 400 mg/dl. On 1/29/14 at 2:45 pm, in an interview and record review, DON confirmed there was no evidence or documentation that Resident 2's MD had been called for any of the 18 times her blood sugars had exceeded 400 mg/dl. On 1/29/14 at 3:30 pm, Resident 2 was asked to describe what she felt like when her blood sugars ran high and what she meant by the statement, "takes a lot out of me." She stated that when her blood sugars were too high, she felt sick, that she vomited, felt weak, slept a lot, was tired, and felt "really" sick. 3. a. Resident 3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/28/14, Resident 3's record was reviewed. Resident 3 had been transported by the facility, three or more times a week for HD treatments at a contracted service [MEDICAL TREATMENT] center. A document titled, "Policy and Procedure of Care and Assessment of Resident," dated 11/2012, specifies that, "The [MEDICAL TREATMENT] Center, by telephone or in writing, will notify the facility of the following...Changes in the resident's condition...The resident's vital signs and weight after [MEDICAL TREATMENT]...The Resident's fluid intake and output during treatment..." The document further specifies, "While at the facility: The facility has direct responsibility for the care of the resident, including...Assessment of the resident, including: Monitoring of vital signs post [MEDICAL TREATMENT]...inspect for drainage or bleeding..." A document titled, "[MEDICAL TREATMENT] Service Agreement," dated 3/1/04, specified under "Coordination of Services," that, "Information transmitted to the Provider by the Facility," and "Information transmitted to the Facility by the Provider," was to occur. Forms titled, "[MEDICAL TREATMENT] Communication Records," were dated for 26 of Resident 3's visits to the [MEDICAL TREATMENT] center for HD treatments from 10/17/13 through 1/28/14. Included on the form, was a top section for the facility to communicate to the [MEDICAL TREATMENT] center, Resident 3's vital signs (blood pressure, heart rate/pulse, respiration rate), the status of his access site (the vascular access site where the HD treatment is to be delivered), and any other information pertinent for the center's care of Resident 3. These assessments were to be done just prior to Resident 3's departure from the facility for each his HD treatments. A second section of the form was to be completed by the [MEDICAL TREATMENT] center and sent back to the facility post-[MEDICAL TREATMENT]. The second section specified entries for Resident 3's pre- and post-[MEDICAL TREATMENT] vital signs, weights, status of the access site, and any other pertinent information to be communicated to the facility. A third section of the form was to be be completed by facility staff upon Resident 3's return to the facility, and included vital signs assessment and the status of the access site. The assessment results to be entered in the third section, were also documented on Resident 3's Medication Administration Records (MARs). Of the 26 forms for Resident 3, the following was noted: Thirteen forms had no documentation from the [MEDICAL TREATMENT] center in the second section; Twelve forms had incomplete documentation from the [MEDICAL TREATMENT] center in the second section; One form was dated 11/11/13, for the first section, 11/12/13, for the second section, and 11/13/13, for the third section; One of the forms was dated 1/22/14, in section one and 1/23/14, in section two; One form was dated 11/19/13, in section one, dated 11/19/13, in sections two and three, and stated in section one from the facility pre-treatment, "redness and swelling to access site," with no related follow-up comments in sections two; One form was dated 10/18/13, and had a statement in section two from the [MEDICAL TREATMENT] center, "treatment terminated early due to bleeding," and had no post-treatment assessment documented by the facility in section 3; Forms dated during 10/2013, as well as Resident 3's MAR, dated 10/2013, lacked complete documentation that Resident 3's access site was accessed, and showed no documentation that his vital signs were assessed, upon his return from each HD treatment. The resource, Review of [MEDICAL TREATMENT] for Nurses and [MEDICAL TREATMENT] Personnel, Eighth Edition, published by Mosby, Inc., (with [MEDICAL TREATMENT] treatment outcome standards drawn from the National Kidney Foundation that include, in part, assessing the patients weight before and after HD treatment, assessing vital signs, particularly blood pressure, before, during and after HD treatment, and assessing the access site), explains the importance of these assessments in preventing life-threatening outcomes for the patient. Weight gained between [MEDICAL TREATMENT] treatments is due to fluid retention secondary to the dysfunction of the kidneys. High blood pressure may indicate fluid volume overload; low blood pressure may indicate dehydration. Significantly high or low blood pressure taxes the heart and can lead to stroke and/or heart failure. If not monitored and accessed, a patient could bleed to death from the HD access site. The health of the access site is critical for effective administration of the HD treatment, without which the patient will die. During an interview on 1/29/14 at 2:05 pm, the interim DON stated that the [MEDICAL TREATMENT] Communication Record forms should have been completed, and that exchange of information about Resident 3 and nursing staff's follow-up to inconsistencies with dates and form completion was lacking. She further stated that, for the well-being of the resident, it was the facility's responsibility to ensure continuity of care and communication between the facility and their contracted services. b. Review of the facility's "Vaccination Checklist," indicated that the facility had administered an additional annual influenza vaccine to Resident 3 on 10/29/13. On 2/8/14, the current Director of Nursing (DON) requested an influenza vaccination report for Resident 3 from the facility's contracted HD treatment clinic. A document titled, "Vaccination Report," from the HD treatment clinic, was reviewed. The report indicated that Resident 3 had received an annual influenza vaccination at the HD treatment clinic on 9/18/13, but the facility had not obtained this information from the HD clinic, prior to vaccinating Resident 3 at the facility, resulting in duplicate immunization. During an interview on 1/29/14 at 2:05 pm, the interim DON stated that the [MEDICAL TREATMENT] Communication Record forms should have been completed, and that exchange of information about Resident 3 and nursing staff's follow-up to inconsistencies with dates and form completion was lacking. She further stated that, for the well-being of the resident, it was the facility's responsibility to ensure continuity of care and communication between the facility and their contracted services. 4. A facility policy and procedure titled, "Monitoring of Intake and Output (I&O, fluid intake and output), dated 11/2012, was necessary when ordered, "to evaluate hydration, fluid restrictions, or assist in assessment and management of fluid needs." It further stated that all staff are responsible for recording intake and output for a resident in their care, that the licensed nurse is responsible for computing the subtotal intake and output at the end of each shift and recording it on the Intake and Output Record form, that the night-shift, or other designated charge nurse was to total the I&O for all three shifts, and that at the end of each seven day period, the nurse will complete the weekly evaluation section of the form. a. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/7/13, specified, "The resident has dehydration or potential fluid deficit related to poor intake." On 1/30/13, Resident 1's I&O Record forms, dated 11/12/13 to 11/24/13, were reviewed. The dates covered a total of 13 days and 29 shifts. Two days had no I&O amounts recorded for any shifts. Nine additional shifts on varying days had no I&O amounts recorded. Only six days had totals recorded for all three shifts. There was no documentation in the weekly evaluation section of the I&O form. During an interview on 1/31/14 at 6:10 pm, DON stated that it was a "problem" that the policy and procedure for recording I&O was not being followed. She further stated that there was a potential for Resident 1 to become dehydrated, which could seriously threaten his health. b. Resident 3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 3's record was reviewed. Resident 3 had been transported by the facility, three or more times a week for HD treatments at a contracted service [MEDICAL TREATMENT] center. On 1/28/14, a physician ordered that Resident 3's I&O be monitored and documented. There was no record of I&O monitoring. During an interview on 1/30/14, at 1:50 pm, the Regional Clinical Director (RCD) A stated that I&O monitoring had not been initiated and concurred that it was important for a resident with end stage [MEDICAL CONDITION], receiving [MEDICAL TREATMENT], to have his I&O monitored, in order to recognize potentially life-threatening fluid overload. c. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/31/14, Resident 18's I&O record forms, dated 10/14/13 to 11/29/13 were reviewed. It included six and one half weeks, with one weekly page, dated 11/11/13 through 11/14/13 (four days only), and a new weekly page started 11/16/13. Nineteen days lacked one or more shifts' documentation. Documentation indicated that ten days had figures for totals, with five of those being totals where shift entries were missing. There was no documentation in any of the weekly evaluation sections of the I&O forms. During an interview on 1/31/14 at 6:10 pm, DON stated it was a "problem" that the policy and procedure for recording I&O was not being followed particularly for a resident at risk with a history of high blood and [MEDICAL CONDITION].

Based on interview and record review, the facility failed to ensure that one of 24 residents (Resident 5) received adequate supervision and an assistive device to prevent accidents, when his bed alarm was not functioning on 9/18/13. This resulted in the resident falling and sustaining a head laceration (deep cut), bruises to both knees, and broken and loose teeth (that were later removed). Refer to F 329. Findings: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, a resident assessment), dated 12/27/13, showed he was not steady when moving from a seated to standing position and had fallen since the previous assessment. On 2/4/14, the facility's Falls Management policy, dated 11/12, showed that residents would be assessed for fall risk and interventions would be implemented to reduce the potential for falls. Recent falls will be reviewed to evaluate cause and determine additional strategies to prevent recurrence for each resident. On 2/4/14, Resident 5's January 2014 physician's orders [REDACTED]. Resident 5's Fall Risk Evaluations, dated 1/10, 2/21, 4/5, 7/11, 7/23, 7/26, and 8/21/13, all showed he was at risk for falls from taking four different medications that contribute to falls. Resident 5's Fall Investigation Worksheets, for falls occurring on 5/24/13 and two on 7/22/13, included antipsychotic, antidepressants, and antianxiety medications as "current medications that may be causative." Resident 5's Fall Risk Evaluations and progress notes showed he had fallen on 1/10/13, 2/21/13, 4/5/13, 5/24/13, 7/11/13, 7/22/13 twice, 7/23/13, 7/26/13, 8/21/13, 9/15/13, 9/18/13, 10/5/13, 10/18/13, and 1/1/14. Resident 5's Psychotropics Care Plan, dated 7/11/13, identified dizziness as a side effect of a medication Seroquel (antipsychotic). According to the 2014 LexiComp online drug guide, the Seroquel dose to treat dementia in the elderly (unlabeled use) is not to exceed 300 mg/day. Resident 5's September 2013 physician's orders [REDACTED]. Resident 5's September 2013 physician's orders [REDACTED]. Resident 5's transfer sheet, dated 9/18/13, showed he was transferred to the emergency room because he "fell -hit head, facial laceration, knocked out one tooth, loosened others." Resident 5's Interdisciplinary Progress Note, dated 9/18/13 at 11:08 am, showed he had fallen that morning at 2 am, sustained a laceration (deep cut) to his forehead, received 10 to 13 stitches to close it, knocked out a tooth, loosened several other teeth, gone to the emergency room and received stitches, and that his bed alarm was "not on at time of fall." Resident 5's Progress Note, dated 9/18/13 at 2:14 pm, showed he had low blood pressure and his left eye was "purple in color and swollen shut..." Resident 5's Progress Note, dated 9/19/13 at 6:59 am, showed that he continued to have a decrease in his blood pressure and alertness level, since the fall. Resident 5's Progress Note, dated 9/19/13 at 12:54 pm, showed that his right knee was bruised. Resident 5's Social Services Progress Notes, dated 9/25/13, read, "Dentist not wanting to do any treatment at this time feels resident had enough trauma to face and will follow up in 3 weeks." Resident 5's Progress Note, dated 9/26/13 at 3:04 pm, showed that his stitches were removed although fluid was still draining from the wound and the edges of the cut were no longer together, and the area around his left eye were still bruised purple and yellow (8 days after the fall). Resident 5's Progress Note, dated 10/5/13, showed he was found on floor face down, blood noticed on floor, had "hit head on floor causing large size lump to left forehead, and knocked scab off edge of old laceration (stitched together 9/18/13) which caused the 5-7 drops of blood on floor and on resident forehead." On 2/6/14 at 3:30 pm, Licensed Vocational Nurse (LN) QQ confirmed that she had been the nurse for Resident 5 at the time of the fall. LN QQ confirmed that the bed alarm had not been functioning because it was not connected at the port.

Based on interview and record review, the facility failed to ensure that two of 24 sampled residents (Residents 1 and 5) and two residents outside of the sample (Residents 25 and 26) had drug regimens that were free from unnecessary drugs when: 1. Resident 5 was administered excessive doses of [MEDICATION NAME] (an antipsychotic) without adequate indications for use (target behavior/symptoms) and fell , sustaining injuries. 2. Resident 25 was given [MEDICATION NAME] (an antipsychotic medication that controls mood and behavior), [MEDICATION NAME] (an anti-anxiety medication) and [MEDICATION NAME] (an antipsychotic medication) for "anxiety" in excessive doses and without adequate indications for use, and [MEDICATION NAME] (an anti-anxiety) IM (intramuscular) without adequate indications for use. 3. Resident 26 was given [MEDICATION NAME] (an antipsychotic) and Klonopin (a long acting anti-anxiety) for 7 days, without an adequate diagnoses, indication for use, or adequate monitoring. 4. Resident 1 continued to receive [MEDICATION NAME] (an antipsychotic) for four months after the Consultant Pharmacist recommended a gradual dose reduction (GDR) and the physician neglected to respond to the Medication Regimen Reviews (MRRs). 5. The Consultant Pharmacist (RPH) F had informed the facility through "Quality Improvement" summaries and by discussions with the Administrator and Director of Nursing (DON), that serious process failures were identified with the facility's use of [MEDICAL CONDITION] medication. The summaries, conducted over a six month period from 7/2013-12/2013, disclosed that the facility had a "pattern" of administering unnecessary drugs, "especially antipsychotics" in excessive doses, without adequate indications for use, monitoring, or dose reductions. Physicians were not responding to Medication Regimen Review (MRR) recommendations and/or responses "could not be located." There was "no process in place" to monitor adverse drug reactions and informed consents were not being obtained. These failures resulted in actual harm to Resident 5 when he fell and sustained a [MEDICAL CONDITION] and had low blood pressure, and Resident 25 whose behavioral health steadily declined and he was transferred to the hospital after 18 days of being given four different psychoactive medications, without proper assessment and monitoring. These failures increased the potential for Residents 1 and 26, and other residents who receive psychoactive medications, to suffer adverse consequences, and/or irreversible medication side effects. Refer to F279, F323, and F428. Findings: 1. Resident 5, a [AGE] year old , was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, a resident assessment), dated 12/27/13, showed he was not steady when moving from a seated to standing position and had fallen since the previous assessment. Resident 5's Fall Risk Evaluations, dated 1/10, 2/21, 4/5, 7/11, 7/23, 7/26, and 8/21/13, all showed he was at risk for falls from taking four different medications that contribute to falls. Resident 5's [MEDICAL CONDITION] Care Plan, dated 7/11/13, identified dizziness as a side effect of [MEDICATION NAME]. Resident 5's Fall Risk Evaluations and progress notes showed he had fallen on 1/10/13, 2/21/13, 4/5/13, 5/24/13, 7/11/13, 7/22/13 twice, 7/23/13, 7/26/13, 8/21/13, 9/15/13, 9/18/13, 10/5/13, 10/18/13, and 1/1/14. Resident 5's Fall Investigation Worksheets, for falls occurring on 5/24/13 and two on 7/22/13, included antipsychotic, antidepressants, and antianxiety medications as "current medications that may be causative." On 2/4/14, the facility's Psychoactive Medication Management policy, dated November 2012, read, "5. Medications should be prescribed within federal guidelines, unless doses outside these guidelines are clinically indicated to treat a psychiatric condition, or when the physician has justified the use by a risk vs. benefit analysis documented in the clinical record." The facility's Psychopharmacological Medication Use policy, dated 11/31/11 read, "Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services ("CMS"), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions...If Physician/Prescriber orders a psychopharmacological medication in the absence of a [DIAGNOSES REDACTED]." According the CMS requirements, the maximum dose for [MEDICATION NAME] is 150 mg/day. According to the 2014 LexiComp online drug guide, the [MEDICATION NAME] dose to treat dementia in the elderly (unlabeled use) is not to exceed 300 mg/day. Resident 5's September 2013 physician's orders [REDACTED]. Resident 5's Interdisciplinary Progress Note, dated 9/18/13 at 11:08 am, showed he had fallen that morning at 2 am, sustained a laceration (deep cut) to his forehead, requiring several (about a dozen) stitches to close it, knocked out a tooth, loosened several other teeth, and gone to the emergency room and received stitches. Review of the hospital's emergency physician's notes indicated Resident 5's [MEDICAL CONDITION] measured 5.5 x 6.0 centimeters, requiring stitches. Resident 5's Social Services Progress Notes, dated 9/25/13, read, "Dentist not wanting to do any treatment at this time feels resident had enough trauma to face and will follow up in 3 weeks." The facility pharmacist's (RPH) Consultation Report, dated 3/7/13, suggested lowering Resident 5's twice daily (bid) 450 milligrams (mg) of [MEDICATION NAME] (antipsychotic) dose to 400 mg bid, in order to reduce side effects and because he only had behaviors for five of 28 days during February/2013. Resident 5's physician, MD E, declined the RPH's recommendation. The manufacturer's information for [MEDICATION NAME] indicates the need for monitoring of potential side effects such as dizziness, fast heart rate, heart rhythm irregularities, [MEDICAL CONDITION], and postural low blood pressure (a sudden drop in blood pressure from lying to sitting to standing), all of which Resident 5 was at risk for due to his medical conditions. The manufacturer recommends that [MEDICATION NAME] dosing in patients who have [MEDICAL CONDITION] or abnormal heart rhythms, such as Resident 5, should be limited to an initial dose of 25 mg twice daily, to reduce the risks for postural low blood pressure and [MEDICAL CONDITION]. The facility RPH's Consultation Report, dated 7/7/13, recommended a gradual dose reduction of Resident 5's [MEDICATION NAME] to 250 mg bid, due to the possibility of abnormal heart rhythms and because his AIMS score (abnormal involuntary body movements), could be adverse effect of the drug. There was no evidence that MD E had responded or addressed the pharmacist's recommendation. The facility RPH's Consultation Report, dated 8/7/13, repeated the recommendation from 7/7/13, for a gradual dose reduction of Resident 5's [MEDICATION NAME] to 250 mg bid, due to the possibility of abnormal heart rhythms and because his AIMS score (abnormal involuntary body movements), could be adverse effect of the drug. MD E declined and did not reduce the [MEDICATION NAME]. The facility RPH's Consultation Report, dated 9/11/13, read, "receives [MEDICATION NAME] for [MEDICAL CONDITION] M/B (manifested by) STRIKING OUT AT STAFF USING FOUL LANGUAGE BUT DOES NOT HAVE A HALLUCINATION / DELUSION AS DEFINED BY CMS. SEE SURVEYOR ANTIPSYCHOTIC TOOL SHEET. Resident has dementia." The report recommended that the MD E evaluate the indications for continued use of the [MEDICATION NAME] and complete a neurological exam, as suggested by the AIMS tool sheet. The report showed that the indications for use did not meet the requirement of being a "danger to self or others." There was no evidence that MD E had responded or addressed the pharmacist's recommendations. The facility RPH's Consultation Report, dated 10/9/13, repeated the previous recommendation of 9/11/13, that read, "receives [MEDICATION NAME] for [MEDICAL CONDITION] M/B (manifested by) STRIKING OUT AT STAFF USING FOUL LANGUAGE BUT DOES NOT HAVE A HALLUCINATION/DELUSION AS DEFINED BY CMS. SEE SURVEYOR ANTIPSYCHOTIC TOOL SHEET. Resident has dementia." The report recommended that MD E evaluate the indications for continued use of the [MEDICATION NAME] and complete a neurological exam, as suggested by the AIMS tool sheet. The report showed that the MD E's indications for use did not meet the requirement of being a "danger to self or others." There was no evidence that MD E had responded or addressed the pharmacist's recommendations. Resident 5's Progress Note, dated 9/22/13 at 7:30 pm (four days after his fall with injuries and tooth loss), read, "Spoke with MD E by phone. Reported low blood pressures and that resident does not exhibit the extreme behaviors he has in the past with agitation and hyper movement. Reviewed all psych meds with MD. MD E decreased [MEDICATION NAME] to 300 mg BID..." On 2/5/14 at 2:30 pm, RPH F stated that she had spoken to MD E many times about lowering residents' psychoactive medications and proper indications for the use of them. RPH F stated she had brought these issues to the facility's leadership team at quarterly meetings and done several in-services on [MEDICAL CONDITION] medication prescribing. On 2/6/14 at 1:50 pm, Registered Nurse (RN) K was interviewed about Resident 5's [MEDICATION NAME] dose. RN K stated that Resident 5 had far less behavioral issues during the past year; she called MD E to request that Resident 5's [MEDICATION NAME] reduced. 2. Resident 25 was a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a resident assessment), dated 6/7/12, showed that Resident 25 had severe cognitive impairments (memory and reasoning abilities), exhibited verbal and physical behaviors toward others, and rejected care, less than daily. Resident 25's MDS reflected that he showed signs and symptoms of [MEDICAL CONDITION] (a temporary state of mental confusion, excitement, disorientation, and continual aimless activity that is usually reversible, once the underlying cause is detected), which had worsened since the previous MDS, dated [DATE]. A review was conducted of the Care Area Assessment Reports, dated 6/4/12, (CAAs are based on MDS responses and identify resident care areas that may require further evaluation and clarification to determine any complicating risk factors or referrals that may be needed). The MDS nurse had documented that the underlying cause for Resident 25's [MEDICAL CONDITION] was "metabolic [MEDICAL CONDITION]" and chose not to care plan that problem and/or any behaviors that may potentially be associated with [MEDICAL CONDITION]. According to the hospital's History and Physical (H&P), dated 5/1/12, Resident 25 was previously known to the physician who described him as "pleasant." An H&P, dated 6/11/12, disclosed that Resident 25 was living at home with his wife and still working part-time prior to his fall at home in April 2012. Resident 25's sudden onset of [MEDICAL CONDITION] was thought to be caused when Resident 25 abruptly stopped taking his Klonopin (a long acting anti-anxiety medication), which he used at bedtime. Resident 25 had no prior history of antipsychotic use or behavior problems. On 5/25/12 at 9:15 pm, Nursing Note documentation disclosed that when Resident 25's physician was notified that he fell at 6:30 pm, and again at 7:30 pm, [MEDICATION NAME] was ordered. Nursing documentation had not reflected if the [MEDICATION NAME] was ordered for a behavior or to prevent falls, as there was no nursing assessment for any underlying medical conditions or supportive behavior manifestations for the use of [MEDICATION NAME]. On 5/25/12 at 7:30 pm, Resident 25's physician ordered [MEDICATION NAME] 0.5 mg three times a day (TID) as needed (PRN), for the [DIAGNOSES REDACTED]. The order had not described what specific target behavior Resident 25 exhibited so that the nurses could accurately recognize and medicate him for his anxiety disorder. There was no evidence that Resident 25's physician had conducted a clinical assessment which justified the need to order a [MEDICATION NAME] dose that exceeded the Centers for Medicare and Medicaid's (CMS) recommendation of no more that 0.75 mg per day. Resident 25's MAR showed that on 5/28, 5/29, and 5/30/12, he was given [MEDICATION NAME] 0.5 mg twice a day, for a total of 1 mg, which exceeded the recommended daily dosage limit of 0.75 mg for the elderly, according to CMS guidelines. There was no monitoring for adverse side effects from [MEDICATION NAME] on the 5/2012 MAR, the reasons for giving Resident 25 [MEDICATION NAME], were undescribed "anxiousness, restlessness, and agitation" and the results of giving the medication were, "helpful." On 5/29/12 at 4:04 pm, a nurse faxed Resident 25's physician and requested an additional anti-anxiety medication, [MEDICATION NAME] 1 mg IM, because, "The DON (Director of Nursing) is requesting for when res won't take his pills po (orally)." On 5/29/12 at 8:55 pm, Nursing Note documentation disclosed that Resident 25 had one episode where he would not eat or take his medicine, but had ended up eating and taking the medications when his wife was present at 8 pm. Prior to that, there was no evidence that Resident 25 had refused his oral medications or that the [MEDICATION NAME], ordered four days ago, had been ineffective for behaviors that were still not clearly identified. Nurses had not conducted assessments for any underlying medical conditions or documentation of any on-going extreme/harmful behavior manifestations that warranted the use of [MEDICATION NAME] to be given IM. There was no documentation that any non-pharmacological interventions had been tried and failed. On 5/29/12, MD C returned the fax and wrote: "Pharmacist/OBRA (CMS) will not like two benzos (benzodiazepines another term for anti-anxiety drugs)." MD C ordered [MEDICATION NAME] (an antipsychotic) 2.5 mg twice a day (BID), for "anxiety" instead of [MEDICATION NAME] IM at that time. No specific [DIAGNOSES REDACTED]." A review of Resident 25's MARs for May and June 2012 disclosed that he was given 13 doses of [MEDICATION NAME] and a [DIAGNOSES REDACTED]. [REDACTED]." On 5/31/12, despite Resident 25 already having orders for [MEDICATION NAME] 2.5 mg BID and excessive doses of [MEDICATION NAME] 0.5 mg TID PRN, both for anxiety, nursing sent a fax to Resident 25's physician requesting more psychoactive medications for "sundowning" (a term used to describe behaviors that only occurred in the evening when the "sun went down"). Nursing had not described when or what behaviors Resident 25 experienced when he "sundowned." Nursing had not shown evidence to Resident 25's physician that he was a danger to himself or others or that they had tried non-pharmacologic interventions that did not work. Nursing also included in the fax that Resident 25 had nothing stronger than Tylenol ordered for pain and requested "something routine" for pain, but had not indicated whether or not Resident 25 was having pain or where his pain was. Resident 25 had "0" (no pain) recorded daily, according to the 5/2012 MAR, and had used [MEDICATION NAME] (Tylenol) 325 mg, two tablets, only once, however, an order was given by fax for [MEDICATION NAME] 5/500 mg, one tablet every 4 hours PRN moderate pain (4-6 on the pain scale of 1-10) and two tablets for severe pain (7-10). Beginning on 5/31/12, Resident 25 was given [MEDICATION NAME] 5/500 mg, one to three times every day for "pain" (undescribed) 6 out of 10, on the average, until he was transferred to the hospital on [DATE]. On 5/31/12 at 1 pm, Nursing Note documentation showed that Resident 25 was "very agitated and confused" and "resistant to care part of the time." There was no assessment or description of Resident 25's "agitation" or how he had "resisted care." There was no evidence that an assessment had been conducted to rule out potential underlying medical causes for his confusion and agitation, or that any non-pharmacological interventions had been attempted to relieve Resident 25's "agitation." On 5/31/12 at 5:45 pm, a different nurse documented, "Pt extremely agitated" and the physician was called and he gave an order for [REDACTED]. There was no documentation that Resident 25's condition was assessed, what interventions had been tried and how he responded, or why the already ordered [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]) were not effective. On 5/31/12, Resident 25's physician ordered the [MEDICATION NAME] 1 mg IM, BID PRN for "extreme agitation, restlessness, striking out" without a [DIAGNOSES REDACTED]. Resident 25's physician also ordered [MEDICATION NAME] 0.5 mg to "1 or 2 at HS (bedtime)" PRN, and discontinued the [MEDICATION NAME] 0.5 mg TID PRN. On 5/31/12 at 1:10 pm, MD C's faxed order was incorrectly transcribed on to the physician's orders [REDACTED]. [MEDICATION NAME] 0.5 mg PO q (every) 2 hours PRN anxiety AEB (as exhibited by) restlessness or agitation." Nursing staff had not recognized that the "HS" in the physician's orders [REDACTED]. A review of Resident 25's May and June 2012 MARs, showed that he was given [MEDICATION NAME] 0.5 mg PRN, one to three times every day. On 6/2, 6/3, 6/7, 6/8, and 6/11, Resident 25 was given a total of 1 mg of [MEDICATION NAME], more than the recommended daily dose limit. On 6/1, 6/4, 6/5, and 6/6, he was given a total of 1.5 mg of [MEDICATION NAME], twice the recommended daily dose limit. In addition to giving twice the recommended dose of [MEDICATION NAME] on 6/4/12, [MEDICATION NAME] 1 mg IM was also given. The MARs did not reflect what specific target behaviors the [MEDICATION NAME] and [MEDICATION NAME] were given for or show that non-pharmacologic interventions had been tried, prior to administering [MEDICAL CONDITION] medications. According to "Lexicomp Online" drug reference materials for healthcare professionals, in older adults, [MEDICATION NAME] increases the risk of impaired cognition, oversedation, [MEDICAL CONDITION], falls, fractures, and should not be used for agitation or [MEDICAL CONDITION]", both of which Resident 25 had, and "no more than 0.25 mg two to three times a day" was recommended. On 6/1/12, Resident 25's physician ordered a Neurology (a physician who specializes in diseases of the nervous system) consult and there was no evidence that Resident 25 had been seen by a Neurologist. On 6/7/12, Resident 25's physician reordered the Neurology consult and added, "ASAP!" There was no evidence that Resident 25 was seen by a Neurologist after his physician ordered the consult a second time. On 2/5/14 at 9 am, the interim DON confirmed that Resident 25 had not been seen by a Neurologist. On 6/5/12 at 11 am, Nursing Note documentation reflected that Resident 25 was confused, uncooperative, fidgety, and striking out at staff and that his physician was there to assess him. The nurse documented that MD C doubled the [MEDICATION NAME] to 5 mg BID, and that "safety measures were in place for staff and residents." There was no documentation of what safety measures were in place or evidence to support that Resident 25 was ever abusive toward other residents. On 6/5/12, a physician's orders [REDACTED]. CMS guidelines recommend a maximum daily dose limit of 7.5 mg of [MEDICATION NAME] per day, unless the physician has demonstrated through clinical assessment and risk versus (vs.) benefits, that a dose outside of that range is clinically necessary. There was no evidence that Resident 25's physician had conducted a clinical assessment or risks vs. benefits analysis. According to Lexicomp Online, [MEDICATION NAME] may be potentially inappropriate for use in older adults (greater than [AGE] years old), with dementia or [MEDICAL CONDITION] as an increased risk for mortality (death), [MEDICAL CONDITION], and falls have occurred. Elderly individuals have an increased risk of adverse response to side effects or adverse reactions to antipsychotics and lower initial doses are recommended. [MEDICATION NAME] may enhance the adverse/toxic effect of benzodiazepines ([MEDICATION NAME] and [MEDICATION NAME]). Lexicomp warned that, "Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk for death." On 6/6/12, a physician's orders [REDACTED]. On 6/7/12 at 11 pm, Nursing Note documentation disclosed that the [MEDICATION NAME] was discontinued and changed to [MEDICATION NAME] (another antipsychotic) 2 mg BID. There was no explanation for the medication change or what Resident 25's condition was. On 6/7/12, Resident 25's physician discontinued the [MEDICATION NAME] and ordered [MEDICATION NAME] 2 mg BID (4 mg in one day) without an adequate indication for use or [DIAGNOSES REDACTED]." CMS guidelines recommend no more than 2 mg of [MEDICATION NAME] per day. In the United States, a boxed warning (sometimes called a black box warning) is a type of alert that appears on the package insert for certain prescription drugs. The U.S. Food and Drug Administration (FDA) can require a pharmaceutical company to place a boxed warning on the labeling of a prescription drug, or in literature describing it. It is the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries significant risk of serious or even life-threatening adverse effects. [MEDICATION NAME], and [MEDICATION NAME] all have black box warnings. According to Lexicomp Online, "Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk for death." "Most deaths appeared to be either cardiovascular (sudden death heart failure), or infectious (as in pneumonia) in nature. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. [MEDICATION NAME] is considered to be potentially inappropriate for the elderly population. Lexicomp recommended that an extensive risk vs. benefits analysis should be performed and underlying reversible medical conditions assessed prior to using [MEDICATION NAME]. The IDT met on 5/25, 5/28, 5/29/ 5/31, and 6/4/12, and never addressed Resident 25's [MEDICAL CONDITION] drug use, specific behaviors or discussed interventions to reduce behavior symptoms or included Resident 25 in a "Behavior Management" program. The IDT did not recognize that Resident 25 had underlying medical conditions such as pain from fractured ribs, [MEDICAL CONDITIONS], nausea/vomiting, and subsequently a UTI, all of which may have contributed to his declining behavior and health problems. The IDT had not recognized that Resident 25's physician had ordered a Neurology consult twice, and it was never done. The IDT had not intervened when Resident 25 was being given [MEDICATION NAME] and [MEDICATION NAME] in excessive doses and without adequate indications for use and monitoring, or [MEDICATION NAME] IM for inadequate indications for use or justification to be given by injection. The IDT had not recognized that [MEDICATION NAME] 0.5 mg every TWO HOURS was a medication error and a serious excessive dose for the elderly. The IDT neglected to ensure that adequate care planning was being developed, reviewed and revised with individualized interventions for Resident 25. During an interview and concurrent record review on 2/7/14 at 9:10 am, the Social Service Director (MSW) stated that she was the "chairperson" for the IDT but she was not familiar with CMS regulations regarding unnecessary drugs, recommended drug dosage limits, or what clinical indications were required to justify the use of psychoactive medications. MSW confirmed that she was in attendance for the IDT meetings regarding Resident 25 and confirmed that the IDT had not addressed his [MEDICAL CONDITION] drug use, behaviors, or assessed his declining clinical condition. On 2/6/14 at 9:30 am, Resident 25's wife (RP) NN was interviewed. RP NN stated that over the 18 days her husband was in the facility he became more confused and his ability to do activities of daily living and therapy steadily declined. RP NN stated that Resident 25 had never taken antipsychotic medications prior to the nursing home admission and stated, "he was living a normal life at home and still working part-time." On 6/11/12, RP NN insisted that Resident 25 be transferred to the hospital because, "he was not getting better." RP NN stated that Resident 25 "completely cleared up" by the next day at the hospital when, "those medications were stopped." On 2/5/14 at 9 am, an interview and concurrent record and policy review was conducted with the interim Director of Nursing (DON). The DON confirmed that Resident 25 did not have supporting [DIAGNOSES REDACTED]. The DON stated that she was familiar with the CMS guidelines for acceptable indications for use and daily dosage limits for [MEDICAL CONDITION] medications in the elderly and confirmed that Resident 25's [MEDICATION NAME] and [MEDICATION NAME] doses had exceeded those recommended, and there was no documented clinical assessment or risk vs. benefit analysis by Resident 25's physician which justified those excessive doses. 3. Resident 26 was a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE], showed that Resident 26 had no mood or behavior problems, but had signs and symptoms of [MEDICAL CONDITION]. Resident 26's record was reviewed. On 6/10/13, Resident 26's physician ordered [MEDICATION NAME] (an antipsychotic) 0.5 mg each morning and 1 mg to be given at each bedtime for,"aggression and agitation" and Klonopin (a long acting anti-anxiety) 1 mg to be given at each bedtime for "aggression and agitation." The physician's orders [REDACTED]. A review of Resident 26's MARs for June 2013, disclosed that for the length of his stay at the facility from 6/10 to 6/17/13, he had received [MEDICATION NAME] 0.5 mg every morning and [MEDICATION NAME] 1 mg every bedtime, and no specific target behaviors were ever determined and "aggression" continued to be monitored. Klonopin 1 mg was given at every bedtime, and although the section dedicated for the behavior monitor was blank, on 6/12 and 6/13/13, two episodes of a "behavior" had been documented. A review of the facility's policy and procedure titled, "Psychoactive Medication Management," revised 11/2012, was conducted and directed the following: "1. Newly admitted residents receiving psychoactive medications will be evaluated within 14 days of admission for the clinical appropriateness of a dose reduction. 2. When a resident presents with symptoms or behavior that causes impairment in function, alteration in emotional well-being, or a danger to the resident or others, it is the responsibility of the IDT to determine if the emotional or behavioral symptoms may be caused by a transient medical condition, or reversible environmental and/or psychological stressor. This can be assessed through the MDS/RAP process or by a team evaluation documented in the IDT notes. 3. When psychoactive medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnosis, reasons for use (functional impairment), and have a care plan in place with medication use and non-drug interventions that had been attempted to alleviate the condition. The effectiveness of these medications and non-drug approaches should be regularly documented in the nurse's notes. 5. Medications should be prescribed within federal guidelines, unless doses outside these guidelines are clinically indicated to treat a psychiatric condition, or when the physician has justified the use by a risk vs. benefit analysis documented in the clinical record. 6. The Director of Nursing or designee, will be responsible for reviewing new psychoactive medication orders for clinical compliance with federal regulations as identified through the change-in-condition process, 24-hour reporting process, and review of new incoming orders. Referrals will be made to the IDT as indicated. 9. Medication effects will be monitored and documented on the medication administration record, to include targeted behavior monitoring, and monitoring for adverse side effects when the medications are used. 11. Residents receiving antipsychotic, anti-anxiety, and/or sedative/hypnotic medications will be evaluated per federal regulatory guidelines for on-going clinical appropriateness and consideration of a gradual dose reduction attempt." A review of the facility's policy and procedure titled, "Behavior Management", revised 11/2012, was conducted and directed the following: "3. Describe the symptoms, be specific. For example: if the resident is experiencing hallucinations, describe what the resident sees or hears. If the resident is combative describe how in precise terms. If the resident is agitated describe the agitation in precise terms." "Residents identified by the interdisciplinary team exhibiting problem behaviors will be candidates for a Behavioral Management program. 1. The interdisciplinary team assess residents on admission and on a continual basis to identify dysfunctional behaviors that present a problem or disruption to other residents. Findings of the interdisciplinary team assessment are documented in the interdisciplinary progress notes. 2. Behaviors requiring intervention are those which present a danger of harm to the resident or to others, disruption of the social environment, socially inappropriate behaviors or behaviors which interfere with the provision of direct care. Included are behaviors which predispose the resident to the risk of resident to resident incidents and/or abuse. 3. Upon identification of specific dysfunctional resident behavior, the interdisciplinary team determines precipitating factors of the behavior through: A. Observation and evaluation of events leading up to circumstances surrounding the behavior. B. Observation and evaluation of individuals and their interactions prior to and at the time of the behavior. C. Interviews with the resident and witnesses assess their perception of the events, circumstances and individuals connected with the behavior. D. Interview of the family, if available, to determine prior patterns of behavior and possible causal factors. 4. Based on the assessment of precipitating factors and behavior exhibited, the interdisciplinary team formulates a plan of care to manage, reduce or eliminate the behavior." On 2/5/14 at 9 am, an interview and concurrent record and policy review was conducted with the interim Director of Nursing (DON). The DON confirmed that Resident 26 did not have supporting [DIAGNOSES REDACTED]. 4. Resident 1 was admitted to the facility on [DATE] and was readmitted twice, the most recent on 11/12/13. He had [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to provide the necessary care and services for Resident 1, when: Licensed Vocational Nurse (LVN) D failed to report Resident 1's acute respiratory emergency and rapid deterioration to a physician and Registered Nurse (RN), which resulted in delayed emergency care for Resident 1. Resident 1 was found unresponsive and without movement by LVN E, who failed to evaluate and initiate CPR (cardiopulmonary resuscitation), (breathing and cardiac compressions) for Resident 1, and left the room to check on other residents. Emergency Medical Services (EMS) arrived to the facility and found Resident 1 unresponsive, pale in color, no pupil (eye) reaction (fixed and dilated), vomitus, and an electrocardiogram (a record of the heart rate and rhythm) to be "Asystole" (absence of heartbeat). Resident 1 was transported to the hospital where he was pronounced dead. Findings: Resident 1 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Notes dated [DATE] at 12:15 am, describe Resident 1 as alert, oriented and responsive. In addition, Resident 1 was noted to be pleasant and cooperative. Resident 1 was at the facility to receive and participate in multiple therapy programs (physical therapy, speech therapy and occupational therapy) for a limited period of time then return home. On admission to the facility, Resident 1 signed a form titled "POLST" (Physician order [REDACTED]. POLST is a physician based order that residents may sign to convey treatment in the event of an emergency. Resident 1 signed the POLST form which stated "in the event a person (he) has no pulse and is not breathing", "Attempt Resuscitation/CPR (provide breathing and chest compressions) and provide "Full Treatment" including intubation (tube in the lungs that assists with breathing) and defibrillation (a machine that applies shocks to the heart) and transfer to the hospital. By signing this form, Resident 1 is legally recognized as the decision maker and acknowledges that this request regarding resuscitative measures is consistent with the known desires of Resident 1, and with the best interest of the individual (Resident 1) who is the subject of this form. During a review of the clinical record for Resident 1, the physician's orders [REDACTED]." There was no specific physician order [REDACTED]. During an interview with LVN D on [DATE] at 2:45 pm, LVN D stated that on [DATE] she was assigned to care for Resident 1 and also orient LVN E. LVN D stated that Resident 1 seemed short of breath and anxious. LVN D stated, "A CNA reported an abnormal pulse oximetry (a device used to check the oxygen level in the blood) of 80% at 3:15 pm or 3:30 pm." LVN D stated she knew her responsibility was to call the physician if an oxygen reading was 92% or less but she did not. LVN D could not recall if she went to Resident 1's room to assess his status before 4:00 pm. A review of the nurse's notes, dated [DATE] at 4:00 pm, indicated LVN D had documented the following: "[DATE] 4:00 pm Resident checked/oxygen sat (saturation) 82% on room air, oxygen started at 2 liters with HHN (hand held nebulizer) treatment (a breathing treatment)." "[DATE] 4:15 pm "Resident oxygen sat continues to be ,[DATE]%, oxygen increased to 4 liters (metric measurement)." "[DATE] 5:00 pm Resident's oxygen sat's continues to be in the (low) 80's. HHN treatment repeated. Call light within reach." During an interview with LVN D on [DATE] at 2:45 pm, LVN D was asked, "Did you call Resident 1's doctor or report to the RN (Registered Nurse) when Resident 1's oxygen was dropping from 82% to ,[DATE]%?" LVN D stated she did not call Resident 1's physician. When responding to the question regarding reporting to a RN for further assessment when Resident 1 was experiencing respiratory distress, LVN D stated, "I feel like I am capable to do the job more so than the RN's. My skills are just as good if not better." LVN D stated, "Resident 1 was doing about the same or a little bit worse. I told him again he wasn't responding well and I don't know what he understood because there was a language barrier and he spoke Russian. I didn't suction him or send him out." LVN D stated, "I thought it was unusual he was a full code because usually if you are getting [MEDICAL CONDITION] (cancer treatment) and have a NG ([MEDICAL CONDITION]) tube, you are not realizing your status." According to the "Licensed Vocational Nurse Scope of Practice Standards," Chapter 5 defines "LVN's are not independent practitioners." The LVN must practice under the direction of a licensed physician or RN at all times. LVN's may not perform that part of the triage process that includes independent evaluation, interpretation of data, and determination of treatment priorities and levels of care. The "LVN may not independently determine that an oxygen deficit exists and proceed to administer oxygen when specific conditions and parameters for oxygen administration are not given by the physician." LVN D operated outside her scope of practice as an LVN in the State of California. Review of the facility's Policy and Procedure for "Oxygen", dated [DATE], indicated: 1."Oxygen may be administered at 2 liters/minute without a physician's orders [REDACTED]. Notify physician as soon as possible. If the resident has an urgent or life threatening need call "911", and then immediately notify physician. Continue oxygen and supportive care until emergency personnel arrive and take over the care of the resident in accordance with directives of resident or designated agent." 2."Notify physician immediately and follow physician's orders [REDACTED]." A review of the nurse's notes dated [DATE], indicated LVN D increased Resident 1's oxygen to 4 liters without a physician's orders [REDACTED]. Review of the facility's Policy and Procedure for "Change of Condition" dated [DATE] read, "It is the policy of this facility to identify, inform the physician and resident (or designated agent), and to intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner." During an interview with LVN E on [DATE] at 3:40 pm, LVN E was asked if he knew who found Resident 1 in [MEDICAL CONDITION] (no heart beat). LVN E stated, "I went to his room but his roommate was there. The patient was flat on his back with no movement, laying still. He looked different. His color was very different. Before it was normal but now was so much paler. I was looking at him and he didn't look right at all." When LVN E was asked what he did next, he said, "I left the room and went to check on other residents. During an interview with the Administrator (ADM) on [DATE] at 4:20 pm, she stated her expectations would be that the physician would be contacted. During a record review of the "Ambulance Run Report" on [DATE] from Emergency Medical Services (EMS), it indicated EMS received the call from the facility (911) at 5:36 pm. EMS was dispatched (sent off to a destination or for a purpose) at 5:37 pm with arrival to the facility recorded at 5:39 pm. On arrival to the facility, Resident 1 was found unconscious and unresponsive by the EMS staff. Resident 1 was placed on a monitor and noted to be in asystole. Resident 1 was transferred to the acute hospital with no changes enroute. Despite treatment given by EMS to Resident 1, including cardiac monitor (refers to continuous monitoring of the heart activity), CPR, Oral Airway (medical device used to maintain a patent open airway), and Oxygen, Resident 1 died . During a combined interview with the DON (Director of Nursing) and Nursing Supervisor on [DATE] at 3:05 pm, they stated that the LVN's would contact an RN to assess residents who are not doing well. In a joint interview with the DON and ADM on [DATE] at 4 pm, they confirmed that the RN should have been notified to reassess Resident 1, and the physician should have been notified when Resident 1's condition started to deteriorate. They also confirmed that the facility policies for oxygen administration, change of condition and initiation of CPR were not followed.

Based on interview and record review, the facility failed to ensure that care was provided in a manner that maintained dignity and respect for Resident 1, when he was awakened from sleep on 10/11/12 at approximately 11:00 pm and a urinary catheter procedure (a tube placed into the bladder to drain urine to an outside collection bag), was conducted by three licensed nursing staff (LNs C, D, and K) and two Certified Nurses Assistant staff (CNA A and B). Five staff teamed up to conduct a procedure despite Resident 8's objections, asking staff to "stop" and "go away." This failure resulted in avoidable psychosocial and physical harm to Resident 1 when he was awakened from sleep, confused, yelling, combative, and in pain during the procedure, and subsequently sustained severe trauma to his urethra, bled profusely from his penis, suffered severe pain, and had severe bruising and swelling of his penis, scrotum, and groin area. Resident 1 required two emergent transfers to an acute care hospital where he was treated for [REDACTED]. Refer to F281 and F309 for additional information. Findings: A record review revealed that Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS (minimum data set, a resident assessment tool), dated 7/28/12, showed that Resident 1 had severe memory impairment and was alert and oriented to person, but was disoriented to time and place, and was frequently incontinent of bowel and bladder (the inability to control the passage of urine and stool). Review of Resident 1's physician's orders [REDACTED]. The order showed that the reason for the catheter was for Resident 1's comfort and pain management (due to scrotal discomfort). There was no documented medical [DIAGNOSES REDACTED]. On 6/19/13 at 4:30 pm, during an interview, LN C explained that on 10/11/12, LN D explained to her that they needed to place a urinary catheter for Resident 1, prior the end of their shift since it had been ordered earlier in the day, and it would not be fair to leave it for the limited night shift staff. LN C explained that Resident 1 was combative, confused, and yelling during the procedure. LN C stated that she "tried to calm him down" by talking him through the procedure and "felt bad" for Resident 1 when this did not seem to be effective. When asked why she did not stop the catheterization procedure, LN C explained that she was a new employee, still on orientation, and did not know Resident 1. LN C stated that everyone else in the room did know Resident 1, so she thought this was his normal level of agitation that could not be relieved. LN C stated that LN D encouraged her to continue with the procedure and when they concluded that the catheter must be in the bladder; LN D reached over and inflated the balloon. LN C stated that in hind sight, she would do things much differently. LN C explained that if she were to do it over, she would not give in to "being intimidated" by the presence of other experienced staff, but instead would ask for Resident 1 to be medicated for pain and/or anxiety, prior to the procedure. LN C further explained that when there was no urine return, she would remove the catheter and stop the procedure. LN C stated that she had been a nurse for over [AGE] years and had never inflated a catheter's balloon when there was no urine return prior to this day. LN C explained that without urine return into the catheter, it would not be possible to be certain of proper placement in the bladder. On 6/19/13 at 5 pm during an interview, CNA A stated that she had been a regular caregiver for Resident 1 for six or seven months, prior to the day that Resident 1 was catheterized on 10/11/12. CNA A stated that she remembered it "very vividly" because it was a "traumatic experience" to her. CNA A explained that on 10/11/12 at approximately 10:30 pm, she had already settled Resident 1 in bed for the night when a licensed nurse asked her to be in attendance while a urinary catheter was placed. CNA A explained that when they (CNA A, CNA B, LN C, LN D, and LN K) entered the room, Resident 1 was asleep, but was awakened for the procedure. In describing Resident 1 during the catheterization procedure, CNA A stated that Resident 1 was confused, screaming, combative, kicking, and explained that she had never seen him that agitated before, adding that the experience was "very upsetting" to her. On 6/24/13 at 12 pm, DON stated that the care provided to Resident 1 by LNs C, D, and K and CNAs A and B, for the catheterization procedure, did not show dignity and respect for Resident 1. On 6/24/13 at 4 pm, during an interview, LN D stated he did not remember the details of what happened the evening of 10/11/12. LN D confirmed that LN C was a new employee and was orienting with him that night. LN D explained that he remembers that they attempted a catheterization procedure, but does not remember who was inserting the catheter, whether or not the balloon was inflated, or whether or not the catheter was left in place. LN D confirmed that Resident 1 was combative and may have been experiencing pain during the catheterization procedure. LN D stated he did not remember any follow-up, regarding this incident by administrative nursing staff. On 7/25/13 at 7 am, during an interview, LN K stated that she had been a regular caregiver for Resident 1 during the night shift. LN K explained that on 10/11/12 she had been walking down the hall past Resident 1's room, when LN D called from Resident 1's room to her, asking for her help with the catheterization procedure. LN K stated that there were five people in attendance, including her; Two CNAs on either side of Resident 1's head, two LNs on either side of his hips, and then she was there to help hold his left leg since he was combative and kicking. LN K stated that he was yelling out to "stop it," "go away," and calling them "sons of [***] es" during the procedure. LN K stated that a catheterization procedure with a cooperative resident would require the presence of only two staff. The Nurses Progress Notes, dated 10/12/12 at 2:50 am (approximately four hours after the catheter was inserted), indicated that Resident 1 had no urine in the catheter. The notes showed that LN E deflated the balloon and removed the catheter. The Nurses Progress Notes, dated 10/12/12 at 10:45 am, documented that when the CNA checked for Resident 1's incontinence status, "blood was coming out from his penis - MD (medical doctor), is in and look at the resident - MD ordered to send resident to ER (emergency room ) for treatment and evaluation since blood continue to come out from penis - LN called 911 and came in at 10:45 to pick up the resident." A review of Resident 1's emergency department (ED) record, dated 10/12/12, indicated that during a telephone consult, Urologist G concluded that since Resident 1 had been incontinent of urine while in the ED, an ultrasound of Resident 1's bladder did not show evidence of [MEDICAL CONDITION], and Resident 1 had previous bleeding from catheter trauma, urinary catheterization was not necessary. Documentation noted ecchymosis (seepage of blood into the tissue, that appears dark red to dark purple in color), to the scrotum. No documentation was found to show the extent of bleeding that had occurred in the facility. After approximately two hours in the ED, Resident 1 was transferred back to the facility with physician orders [REDACTED].

Based on interview and record review, the facility failed to ensure that care provided met professional standards of quality when Licensed Nurses (LNs) C and D failed to follow the facility's policy and accepted standards of care for a urinary catheterization procedure (a procedure during which a tube was placed into the bladder to drain urine to an outside collection bag), failing to include verification of proper placement in the bladder (verified by urine flow into the catheter), prior to the inflation of the catheter balloon, for Resident 1. The balloon is integral to the catheter, designed to keep the catheter securely in place by being inflated with 30 cubic centimeters (approximately 1 ounce) of fluid, after the catheter has been advanced through the urethra (a narrow canal through which urine is discharged from the bladder, and in males, travels the length of the penis before emptying) and proper placement into the bladder is verified. This failure resulted in avoidable psychosocial and physical harm to Resident 1 when he was awakened from sleep, confused, yelling, combative, and in pain during the procedure, and subsequently sustained severe trauma to his urethra, bled profusely from his penis, suffered severe pain, and had severe bruising and swelling of his penis, scrotum, and groin area. Resident 1 required two emergent transfers to an acute care hospital where he was treated for [REDACTED]. Refer to F309 for additional information. Findings: A record review revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set, a resident assessment tool), dated [DATE], showed that Resident 1 had severe memory impairment, was alert and oriented to person, but was disoriented to time and place, and was frequently incontinent of bowel and bladder (the inability to control the passage of urine and stool). Resident 1 desired a full code status (cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest, and transfer to hospital for further treatment at a higher level of care, as needed). Review of Resident 1's physician's orders [REDACTED]. The order indicated that the catheter was to be 16 french in size with a 30 cubic centimeter balloon. The order showed that the reason for the catheter was for Resident 1's comfort and pain management (due to scrotal discomfort). There was no documented medical [DIAGNOSES REDACTED]. The Nurses Progress Notes, dated [DATE] at 5 pm, showed that Resident 1 had pain related to scrotal excoriation. The Nurses Progress Notes, dated [DATE], showed a late entry for [DATE] that documented a urinary catheter had been placed at approximately 11 pm on [DATE]. The notes indicated that LNs C and D, who were both present during the procedure, had confirmed that the catheter was properly placed in the bladder even though no urine was observed in the catheter. The notes indicated that LNs C and D reasoned that Resident 1's bladder was empty because he had just been incontinent of urine. The facility document titled, "Urinary Catheterization Procedure," dated ,[DATE], showed that the balloon should be inflated after proper placement in the bladder had been established, evidenced by urine flow into the catheter. The policy and procedure did not indicate any alternative methods to verify bladder placement, nor identify what to do if no urine flow occurred. On [DATE] at 11 am, during an interview, LN F stated that he had been a regular caregiver for Resident 1 since his admission to the facility. LN F explained that he was working on [DATE] when Resident 1 came back from the ED. LN F stated that he was "shocked" by what he saw. Resident 1 had severe bruising to his scrotum and groin area that was dark purple in color. LN F stated that Resident 1 seemed to be in a lot of pain. His scrotum was swollen to almost double its normal size. LN F explained that he called Resident 1's physician (MD H) and described Resident 1's status. MD H ordered [MEDICATION NAME] ,[DATE] milligrams (a narcotic pain medication) to be given every four hours, as needed for moderate pain. Additionally, the record showed an order for [REDACTED]. On [DATE] at 4:30 pm, during an interview, LN C explained that on [DATE], LN D told her that they needed to place a urinary catheter for Resident 1, prior to the end of their shift, since it had been ordered earlier in the day, and it "would not be fair to leave it for the limited night shift staff." LN C explained that Resident 1 was combative, confused, and yelling during the procedure. LN C stated that she tried to calm Resident 1 down by talking him through the procedure and felt bad for Resident 1, when this did not seem to be effective. LN C stated she did meet some resistance while attempting to insert the catheter, but denied using any excessive force. LN C did not feel completely confident about the catheters proper placement in the bladder and remembered telling the night shift nurse there had not been any urine in the catheter, and requested it be checked in a short while and removed, if needed. LN C explained that after she heard that Resident 1 had been hospitalized the next day, she "felt terrible" and remembers initiating a discussion where she described this experience to DON J. LN C stated she did not remember any follow-up by administrative nursing staff to ensure that this problem would not recur. There was no in-servicing on proper catheterization procedure or what to do if no urine return, no counseling of the licensed nurses involved, and no auditing of current residents and staff to evaluate catheterization competency. When asked why she did not stop the catheterization procedure, LN C explained that she was a new employee, still on orientation, and did not know Resident 1. LN C stated that everyone else in the room did know Resident 1, so she thought this was his normal level of agitation that could not be relieved. LN C stated that LN D encouraged her to continue with the procedure and when they concluded that the catheter must be in the bladder; LN D reached over and inflated the balloon. LN C stated that in hind sight, she would do things much differently. LN C explained that if she were to do it over, she would not give in to "being intimidated" by the presence of other experienced staff, but instead would ask for Resident 1 to be medicated for pain and/or anxiety, prior to the procedure. LN C further explained that when there was no urine return, she would remove the catheter and stop the procedure. LN C stated that she had been a nurse for over [AGE] years and had never inflated a catheter's balloon when there was no urine return prior to this day. LN C explained that without urine return into the catheter, it would not be possible to be certain of proper placement in the bladder. On [DATE] at 5 pm, during an interview, Certified Nurse's Assistant (CNA) A stated that she had been a regular care giver for Resident 1 for six or seven months. In remembering the evening of [DATE], CNA A explained that the experience was still very vivid in her mind because it was so "traumatic" to her. CNA A stated that she had already settled Resident 1 in bed for the night at approximately 10:30 pm when she was asked to be in attendance while a urinary catheter was placed. CNA A explained that when they (CNA A, CNA B, LN C and LN D) entered the room, Resident 1 was asleep, but was awakened for the procedure. In describing Resident 1 during the catheterization procedure, CNA A stated that Resident 1 was confused, screaming, combative, and kicking. She stated that she had never seen Resident 1 that agitated before, adding that the experience was "very upsetting" to her. When asked specifically what she was doing during the procedure, CNA A stated that she was rubbing Resident 1's hand and arm while telling him that "it (the catheterization procedures) was almost over." CNA A stated that she had been in attendance during many catheterizations, and this was the first time she had ever seen the balloon inflated when no urine had been visualized in the catheter. On [DATE] at 2:30 pm, during an interview, the Director of Nurses (DON) J explained that she had been working the morning of [DATE] when the nurses called her into Resident 1's room. DON J stated that Resident 1 was "bleeding profusely" from his penis. DON J stated that the blood was soaking onto the sheets, towels, and blankets on his bed. DON J explained that they were having difficulty getting the bleeding to stop. Resident 1's physician (MD H) was already in the facility, examined Resident 1, and placed an order to transfer Resident 1 to the emergency room (ED) for evaluation. On [DATE] at 4 pm, during an interview, LN D stated he did not remember the details of what happened the evening of [DATE]. LN D confirmed that LN C was a new employee and was orienting with him that night. LN D explained that he remembers that they attempted a catheterization procedure, but does not remember who was inserting the catheter, whether or not the balloon was inflated, or whether or not the catheter was left in place. LN D confirmed that Resident 1 was combative and may have been experiencing pain during the catheterization procedure. LN D explained that without urine return into the catheter, it would not be possible to be certain of proper placement in the bladder. LN D stated he did not remember any follow-up, regarding this incident by administrative nursing staff to address the incident. On [DATE] at 8:45 am, during an interview, Family Member (/FM) O explained that after hospitalization , Resident 1 had been transferred to a different skilled nursing facility on [DATE] where Resident 1 was in a semi-vegetative state. FM O explained that Resident 1 was not able to eat effectively, requiring that his nutrition be delivered via a feeding tube inserted into his stomach. FM O stated that Resident 1 had lost his personality and ability to make his needs known. FM O stated that the new facility was able to heal Resident 1's scrotal wound with topical treatments, adding that Resident 1 had not been catheterized at all after the experience on [DATE]. FM O explained that prior to the incident with the "botched" catheterization procedure, Resident 1 interacted with persons in his environment, but now Resident 1 was completely dependent and unable to participate in activities of daily living. FM O stated the "whole family was so sad about what had happened to their father." On [DATE] at 7:15 am, during an interview, the facility's nurse consultant who was acting as the current Director of Nurses (DON P), stated that the facility followed accepted standards of practice for their catheterization procedures and that their policy was based on Lippincott's Fundamentals in Nursing manual. The manual included Procedure Guideline ,[DATE] for the "management of the patient with an indwelling catheter." The guideline showed that it was important to be sure the "catheter is draining properly before inflating the balloon." The rationale for this guidelines indicated that "inadvertent inflation of the balloon within the urethra is painful and causes urethral trauma." The procedure further indicated that "excessive manipulation of the catheter may promote migration of bacteria," and that "Backward and forward displacement of the catheter introduces contaminants into the urinary tract." On [DATE] at 7 am, during an interview, LN K stated that she had been a regular caregiver for Resident 1 during the night shift. LN K explained that on [DATE] she had been walking down the hall past Resident 1's room, when LN D called to her asking for her help with the catheterization procedure. LN K stated that there were five people in attendance, including her. Two CNAs on either side of his head, two LNs on either side of his hips, and then she was there to help hold his left leg since he was combative and kicking. LN K stated that he was yelling out to "stop it," "go away," and calling them "sons of [***] es" during the procedure. LN K stated that a catheterization procedure with a cooperative resident would require the presence of only two staff. Review of the Medication Record, dated ,[DATE], showed that Resident 1 was not medicated for pain, prior to the catheterization procedure. The most recent dose of [MEDICATION NAME] 0.25mg (ordered to be given every 6 hours as needed for anxiety) had been given at 5 am on [DATE]. The most recent dose of Tylenol 650 mg (ordered to be given every 4 hours as needed for mild pain) had been given at 12:30 am the night before. (Refer to F309). The Nurses Progress Notes, dated [DATE] at 2:50 am (approximately four hours after the catheter was inserted), indicated that Resident 1 had no urine in the catheter. The notes showed that LN E deflated the balloon and removed the catheter. On [DATE] at 10:45 am, a nurse documented that when the CNA checked for Resident 1's incontinence status, "blood was coming out from his penis - MD (medical doctor), is in and look at the resident - MD ordered to send resident to ER (emergency room ) for treatment and evaluation since blood continue to come out from penis - LN called 911 and came in at 10:45 to pick up the resident." Documentation on the facility's transfer form (form to communicate important information about a resident to the hospital emergency department), dated [DATE], showed that the reason for Resident 1's transfer to the emergency department was "bleeding." No explanation of the source or extent of bleeding was found. The paramedic documentation titled, "Patient Care Report" (form to communicate important information about Resident 1's status to the ED staff), dated [DATE], indicated that Resident 1 had less than five cubic centimeters (cc) of blood at the meatus (tip) of his penis. No explanation of the extent of bleeding was found. A review of Resident 1's ED record, dated [DATE], indicated that during a telephone consult, Urologist G concluded that since Resident 1 had been incontinent of urine while in the ED, an ultrasound of Resident 1's bladder did not show evidence of [MEDICAL CONDITION], and Resident 1 had previous bleeding from catheter trauma, urinary catheterization was not necessary. Documentation noted ecchymosis (seepage of blood into the tissue, that appears dark red to dark purple in color), to the scrotum. No documentation was found to show the extent of bleeding that had occurred in the facility. After approximately two hours in the ED, Resident 1 was transferred back to the facility with physician orders [REDACTED]. The Nurses Notes, dated [DATE], during the night shift, showed that at 02:00 am, Resident 1's condition worsened; "Eyes open when moved but no response to name." At 0430 Resident 1 developed a fever of 103 degrees, had a congested cough. The notes indicated that MD H was notified and nursing was awaiting a call back. At 0525 am, Resident 1's oxygen saturation (the level of oxygen in the blood) that was below normal at 86% (indicates insufficient oxygen level). The notes indicated that MD H was again called and nursing staff were awaiting a response from MD H. At 05:55 am and again at 6:20 am, the notes indicated that MD H was called and nursing staff were awaiting a response, and Resident 1 was exhibiting a decreased level of consciousness. At 06:30 am, MD H returned the calls previously made by the facility and ordered that Resident 1 be transferred to the local hospital for evaluation and treatment. The paramedic documentation on the Patient Care Report indicated that when they arrived in Resident 1's room on [DATE] at 7:05 am, he was lying on his back in bed, was unresponsive, and had a respiratory rate of 8 breaths per minute (the minimum normal respiratory rate for adults is 12 breaths per minute) with periods of apnea (no breathing). The documentation further showed that Resident 1 was only responsive to painful stimuli. Resident 1 had bruising and swelling to his entire genital area. The report indicated that Resident 1 was medicated, with [MEDICATION NAME] ,[DATE] milligrams (mg) at 5:25 pm the prior evening, for pain, and had received a Tylenol suppository at 4 am to address his fever. A review of the ED documentation, dated [DATE], showed that Urologist G performed a cystoscopy (a procedure that allows the physician to look at the interior lining of the bladder and the urethra) for Resident 1 while he was in the ED. The Cystoscopy report, dated [DATE], showed that the part of Resident 1's urethra that passed through his penis was normal, but the bulbar and membranous area (a segment of the urethra between the penis and the bladder) was filled with blood clots and had no recognizable normal urothelium (layer that lines the urethra). There were multiple false passages and evidence of severe trauma. The report indicated that, after 25 minutes, the cystoscopy was terminated, when multiple attempts to find a passage to the bladder were unsuccessful. The report further indicated that Resident 1 had significant scrotal swelling and bruising. There was bruising to the entire scrotum that was "probably secondary to urethral trauma." Urologist G documented that he "did not attempt any catheterization, prior to flexibly cystoscoping the patient, so obviously this trauma was present from previous urethral manipulation" with the Foley catheter. Additionally, the report indicated that as long as Resident 1 was able to decompress his bladder with incontinence and was comfortable, catheterization would not be necessary. The Hospitalist's (Hospital physician) Assessment/Plan, dated [DATE], indicated that Resident 1 had urethral trauma, severe bacteremia (bacterial infection in the blood) secondary to a urinary tract infection. A record review indicated that Resident 1's admission to the hospital from [DATE] through [DATE] required the following treatment and/or interventions: -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. - physician's orders [REDACTED]. -Resident 1's scrotum was treated with cooling measures, special positioning requirements, preventative skin care, and a dressing to the wound. -Insertion of a PICC line (a long, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart) to maintain IV access for the delivery of medications. -A Computed Tomography (CT) scan (an imaging method that uses x-rays to create detailed pictures of cross-sections of the body) of Resident 1's brain on [DATE], showed that Resident 1 had suffered a new stroke. - A naso-[MEDICAL CONDITION] tube (a tube that is passed through the nose and into the stomach) was placed for maintenance of nutritional needs and administration of medications. -A permanent [MEDICAL CONDITION] tube (a tube requiring surgical insertion through the abdomen that delivers nutrition directly to the stomach) was placed on [DATE] due to his prolonged inability to swallow.