Every finding on record at Bay Marina Post Acute

Based on interview and record reviews the facility failed to ensure to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences for two of seven sample selected residents (Resident 2 and 7) when licensed staff placed resident 2 and 7 on pureed diets not ordered by the physician. This resulted in unnecessary speech therapy evaluations and distress for residents.Findings:During a record review of Resident 1's Face Sheet (FS), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (loss of motor and sensory function in arms and legs).A review of Resident 1's After Visit Summary (AVS-admission orders) dated 6/13/2026 - 6/18/2026, indicated Resident 1 was not on a special diet.A review of Resident 1's N Adv - Clinical admission (NACA) dated 6/20/2026, indicated Resident 1 was Alert & Oriented x 3, communicated verbally, speech is clear, is able to understand and be understood when speaking and was Taking nutrition and hydration orally. No complaints of thirst. No signs/symptoms of a swallowing disorder.A review of Resident 1's Dietary Profile (DP) dated 6/22/26, indicated Resident 1 had his own teeth, no dentures, and had no problem chewing or swallowing. Resident 1 reported to dietary staff he was Displeased about being placed on easy to chew diet and did not want to eat.A review of Resident 1's Speech Therapy SLP Evaluation and Plan of Treatment (STEPT) dated 6/22/26, indicated Resident 1 Demonstrates good rehab potential as evidenced by ability to follow 1-step directions, ability to learn new information, ability to participate in tasks of increased complexity, ability to self-correct and able to make needs known .Speech therapy was to evaluate Resident 1's ability to chew and swallow. Resident 1 had been referred to speech therapy due to being admitted on altered diet of easy to chew/thin liquids.During an interview on 6/25/26 at 12:20 p.m., Resident 1 stated he had been put on a soft diet when admitted and had asked What is up with this food? Resident 1 stated he had been on a regular diet prior to admission. Resident 1 stated he had been given a soft diet which went on for a few days and the only thing he had eaten during that time were crackers. Resident 1 stated This is a crazy place.A review of Resident 2's FS indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (stroke).A review of Resident 2's AVS dated 6/10/26-6/11/26, indicated Resident 2 was admitted to the facility on a regular diet.A review of Resident 2's DP dated 6/11/26, indicated Resident 2 reported to the dietary staff he was .Very displeased with the easy to chew diet order. Staff documented Recommending speech eval and revisiting food allergies to confirm those are accurate.A review of Resident 2's STEPT dated 6/16/26, indicated, Resident 2 was evaluated by speech therapy for his ability to chew and swallow food and a cognitive-Communicative evaluation indicated Resident 2 was able to understand others, could follow 1-step directions independently and was able to express ideas and wants.During a review of the document Nutritional Risk Assessment (NRA) dated 6/17/26, indicated Resident 2 had no difficulties chewing or swallowing.During an interview on 6/25/26 at 12:25 p.m., with Resident 2, Resident 2 stated staff had placed him on a soft diet and did not tell him why. Resident 2 stated it had made him feel Terrible like he was on Baby food. Resident 2 stated he could not eat the food, and the soft diet was discontinued A week or so ago. Furthermore Resident 2 stated prior to admission he had been on a regular diet. During an interview on 6/25/26 at 11:52 a.m., with Speech Therapist (ST), ST stated residents were coming from the hospital on regular diets and the facility then put them on soft food upon admission. The ST stated she was given a list of everyone on a soft diet and was instructed by the director to perform speech evaluations to see if the residents can be advanced to a regular diet. The ST stated the Rehab Director (RD) had reported to her it was a company-wide policy to admit on lower diets because the speech case load was Too low. During an interview on 6/29/26 at 4:10 p.m., with the Regional Rehab Lead (RRL), RRL stated staff Go off of the orders as to what the diet should be and if there are no special diets on admission, the resident is placed on a regular diet.During an interview on 7/22/26 at 10:50 a.m., with the RD, RD stated Rehab has nothing to do with down grading a diet to soft. The RD stated it had recently been brought to his attention by staff that diets had been downgraded to puree (soft). The RD stated that RD raised this concern in a meeting and was told by the MDS (The Minimum Data Set- is a standardized, federally mandated clinical assessment) Coordinator this had been done for Safety reasons.During an interview on 7/22/26 at 11:10 a.m., with the Regional Dietary Manager (RDM), RDM stated, staff had 72 hours to meet with new admissions to obtain food preferences and review questions on the nutritional assessment. The RDM stated some residents will be downgraded if a difficulty is identified but We do not automatically put residents on soft diets. During an interview on 7/27/26 at 10:41 a.m., with the MDS coordinator, MDS coordinator stated she did not recall the RD asking why a resident's diet was changed from the admission order without reason. The MDS coordinator stated, staff admit residents on the same diet they had prior to admission and as ordered by the doctor. The MDS stated if during the initial assessment of the resident nursing staff identify an issue such as broken teeth, staff will call the doctor to discuss changing the diet as this would be done for safety reasons.

Based on interview and record review, the facility's skilled licensed nursing staff did not provide timely dental assistance for one of three residents (Resident 1). Resident 1 complained of oral pain and had red gums and missing teeth; however, staff did not notify the dentist and scheduled a dental consult seven days after the resident's initial complaint of pain.This resulted in worsening dental status and unnecessary discomfort for Resident 1. During a review of Resident 1's document Face Sheet (FS), the FS indicated the facility admitted Resident 1 on 9/13/2025 with multiple medical diagnoses including hemiplegia (paralysis) on his left side due to a stroke.During a review of Resident 1's document Dietary Profile (DP) dated 3/11/2026, the DP indicated Resident 1 had missing or broken teeth.During a review of Resident 1's document MDS 3.0 Nursing Home PPS (NP) Version 1.20.1 (MDS) dated [DATE], the MDS indicated Resident 1 was alert, able to focus, repeat words presented to him and could identify the correct day and month. Resident 1's Oral/Dental Status showed he had Broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose).During an interview on 3/16/2026 at 12:28 p.m. with Resident 1, Resident 1 stated his teeth were Falling out, had problems chewing, and was in pain.During an interview on 3/19/2026 at 11:05 a.m. with the Facility's Registered Dietician (RD), RD stated she was unaware of any problems with Resident 1's teeth or chewing.During an interview on 3/20/2026 at 9:41 a.m. with Registered Nurse 1 (RN 1) who was caring for Resident 1, RN 1 stated she was unaware of any issues regarding Resident 1's teeth.During a review of the document eInteract Change in Condition Evaluation - V5.1 (ECCE) dated 3/9/2026, the ECCE indicated, Registered Nurse 2 (RN 2) documented Resident 1 Reported toothache with a burning sensation on the upper and lower gums. Oral examination completed. Multiple missing and dark discolored teeth, cracked teeth, and loss of lower teeth were noted. Gums appeared irritated. The doctor was notified and a referral was made for a dental consultation. RN 2 was out of the country and could not be interviewed.During a review of the document Progress Notes *NEW* (PN) dated 3/10/2026, the PN indicated staff were monitoring Resident 1 for Toothache and burning sensation to upper and lower gums. His gums were described as Slightly irritated and he continued to report discomfort.During an interview and concurrent record review at 10:21 a.m. on 3/20/2026, with the facility's Director of Nursing (DON), the DON confirmed Resident 1's oral discomfort and stated staff continued to administer pain medication for the discomfort.During an interview at 10:27 a.m. on 3/20/2026 with the DON, stated nursing staff should have been more proactive and asked questions such as Should we increase the pain meds? Should staff consider Preventative antibiotics or an icepack? The DON stated pain, burning sensation and irritated gums could indicate an infection.During a review of the document Re: March Dentist Visit (RMDV) dated 3/16/2026, the RMDV indicated a referral was made for a dental consult for Resident 1 on 3/16/2026, 7 days after he had reported the oral pain.During a review of the document eInteract change in Condition Evaluation - V 5.1 (ECCE) dated 3/20/2026 indicated, Resident 1 was sent to the hospital for increased drowsiness, confusion, inability to recognize staff and slurred speech.During a review of the document Emergency Department Note (EDN) dated 3/20/2026, the EDN indicated Resident 1 was admitted to the hospital for an irregular heart rhythm.During review of the document CT head and neck angio with IV contrast (CTHNA) (detailed x-ray imaging test performed while Resident 1 was in the hospital) dated 3/20/2026, the CTHNA indicated Numerous bilateral dental caries. (cavities)During an interview on 3/26/2026 at 3:39 p.m. the Dental Consultant (DDS 1) stated he would have expected staff to contact his office right away regarding Resident 1's complaint of oral pain. DDS 1 stated an assessment could have been made regarding whether there was a need for more pain medications, prescribe antibiotics if it looked like an infection was developing and ordered a bedside x-ray to identify the cause of the pain and irritation. DDS 1 stated there needed to be a clear line of communication From the facility to the office.During an interview on 3/30/2026 at 1:50 p.m. Resident 1 stated he was Still having pain. During a review of the document Oral Healthcare & Dental Services (OHDS) dated 2017, the OHDS indicated The Facility will retain a consultant dentist available to care for residents. One of the dentist's responsibilities included Providing emergency dental care as needed. Cavity Facts: Cavities, also called tooth decay, often go untreated. Untreated cavities can cause pain and infections that may lead to problems with eating, speaking, playing and learning. Untreated cavities can lead to abscess, a severe infection. This can spread to other parts of the body and have serious, and in rare cases fatal, results. [CDC Oral Health dated May 15, 2024: cdc.gov/oral-health/data-research/facts-stats/fast-facts-cavities.html]

Based on interview and record review, for one of two sampled residents (Resident 1) who were discharged , the facility failed to develop and implement an effective discharge planning process for transition to post-discharge care. This failure resulted in Resident 1 suffering homelessness and had the potential to result in unnecessary re-admission to the hospitalDuring a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with diagnoses that included cognitive communication deficit (impaired memory and attention affecting communication), personal history of traumatic brain injury (temporary issues with thinking, understanding, movement, and behavior due to an external force), ataxia (poor muscle control affecting movement and balance), and repeated falls. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/23/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 (a BIMS score of 8-12 is indication of moderate impairment in cognitive status). During a review of Resident 1's Discharge Summary (DS) dated 12/23/25, the DS indicated Resident 1 was discharged that evening with medications and a medication list. The facility sent Resident 1 to an Assisted Living Facility via Uber. During a review of Resident 1's Discharge Planning Review Form (DPRF) dated and signed 12/24/25, one day after discharge, the DPRF indicated, under section Medication Reconciliation (MR), the MR indicated medication list was provided to the subsequent provider, but not to Resident 1.The DPRF did not have any signature by Resident 1 or Resident 1's family member. During a telephone interview on 1/23/26 at 12:18 p.m. the Home Health Registered Nurse (HHRN) stated she assessed Resident 1 for admission to Home Health Services on 12/25/25. Resident 1 lacked a medication list and discharge medications. HHRN had to request the home health office to call the facility for the medication list. Additionally, Resident 1 did not have a primary care physician or information about a local pharmacy for refills. During a telephone interview on 1/23/26 at 12:26 p.m. with Assisted Living Staff (ALS), ALS stated Resident 1 said he could take his own medications but did not show which ones. Resident 1 walked without a walker in an unusual way, with his trunk leaning backward. ALS also stated Resident 1 often wandered off to an unknown shelter. During a telephone interview on 1/27/26 at 4:45 p.m. with Assisted Living Owner (ALO), ALO stated Resident 1 occasionally left the home, requiring ALO had to send an Uber for pickup. ALO stated there was an instance where the Uber refused to pick up Resident 1 because he was dirty after being homeless for a few days. ALO stated Resident 1 received financial benefits, but they did not know who the payee was or who was receiving the money. During a review of Resident 1's clinical record, the IDT note dated 11/26/25 indicated Resident 1's Family Member (FM) had called about discharge plans. The IDT notes indicated FM tried to apply for financial benefits on behalf of Resident 1 and would call the facility to coordinate discharge plan once the application was finished. However, the clinical record did not indicate any further coordination or follow-up with FM by the facility staff regarding these plans. During a concurrent interview and record review on 1/23/25 at 12:44 p.m. with Director of Nursing (DON), DON stated Resident 1's clinical record did not indicate any discharge planning before the actual discharge date , and there was no discharge care plan developed. During a review of the facility's policy and procedure (P&P) titled Transfer and Discharge last revised 7/2/2020, the P&P indicated discharge planning begins upon a resident's admission. A Social Services Staff or designee will complete an initial discharge assessment within seven days. Referrals to local contact agencies and assistance with discharge planning will be recorded in the medical record. Social Services will document discharge planning, preparation, and post-discharge needs. The Social Services Staff will also develop a Discharge Care Plan with the IDT.

Based on interview and records review, the facility failed to ensure the change of resident's condition was reported and investigated properly for one of three sample selected residents (Resident 1), when Resident 1 was found with new skin discoloration on his face and the cause was not investigated by the facility.The failure to report and investigate a change in a Resident 1's condition could lead to Resident 1 experiencing delayed treatment, pain, and worsening health conditions. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including end stage renal disease (the kidneys have lost nearly all their ability to function effectively, typically defined as having less than 10-15% of normal kidney function).A review of Resident 1's Progress Note, dated 3/20/25, indicated . Skin discoloration on his face and hand.A review of Resident 1's Progress Note, dated 3/21/25, indicated .left eye and nose skin discoloration.A review of Resident 1's Progress Note, dated 3/22/25, indicated . left eye and nose skin discoloration.During an interview on 9/29/25 at 12:10 p.m. with the Minimum Data Set Coordinator (MDSC), MDSC stated nurses should report any resident's change of condition to the charge nurses and charge nurses should investigate the new change of condition's cause. MDSC confirmed that nurses did not report Resident 1's new skin discoloration on face to charge nurse and the facility did not do any investigation about that.During an interview on 9/29/25 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that he did not report Resident 1's face discoloration to the charge nurse to investigate, furthermore stated the nurses should report any unusual accordance to the Director of Nursing for further investigation.A review of the facility's policy and procedure P- AP12 Unusual Occurrence Reporting, revised 5/30/24, indicated .The Facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.

Based on observation, interview and record review, for two of two sampled residents who received dialysis (Resident 1 and Resident 2), the facility failed to ensure routine medications were available for administration. This failure had the potential to result in medical complications not limited to elevated phosphorus, cholesterol, and worsening of symptoms. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included end stage renal disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs), hyperlipidemia (high cholesterol levels in the blood), and gastro-esophageal reflux disease without esophagitis (a digestive disorder where the stomach acid flows back into the esophagus, causing irritation and discomfort). During a review of Resident 1's Order Summary Report (OSR) as of 7/31/25, the OSR indicated the following physician's orders:a. Atorvastatin Calcium 40 milligrams (mg) oral tablet: one tablet by mouth at bedtime for hyperlipidemia.b. Famotidine 10 mg one tablet by mouth as needed (Used to treat heartburn caused by acid indigestion).c. Nephro-Vite Rx oral tablet 1 mg (B complex with C and Folic Acid): one tablet by mouth at bedtime.d. Sevelamer Hydrochloride (HCL) oral tablet 800 mg (used to treat too much phosphate in the blood for patients with chronic kidney disease who are on dialysis): one tablet by mouth three times daily.e. Metoclopramide HCL 10 mg oral tablet (used to treat nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite), one tablet by mouth as needed.During a concurrent observation and interview on 7/16/25 at 2:25 p.m. with Licensed Vocational Nurse (LVN) 1, medication cart did not have the following medications for Resident 1:a. Atorvastatin Calcium 40 milligrams (mg) oral tabletb. Famotidine 10 mg one tabletc. Nephro-Vite Rx oral tablet 1 mg (B complex with C and Folic Acid)d. Sevelamer Hydrochloride (HCL) oral tablet 800 mge. Metoclopramide HCL 10 mg oral tabletLVN 1 stated that for Famotidine 10 mg, LVN 1 administered a Famotidine 40 mg labeled for Resident 3, stored with Resident 1's medications. LVN 1 stated Famotidine 40 mg was used as an alternative for famotidine 10 mg that was ordered. LVN 1 also stated regular multivitamins were used instead of Nephro-Vite Rx as both are over the counter. LVN 1 also stated, LVN1 used Sevelamer HCL 800 mg meant for Resident 4 (already discharged ) and administered metoclopramide 5 mg in place of the prescribed 10 mg for Resident 1. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in October 2021 with diagnoses that included end stage renal disease and chronic pain syndrome. During a concurrent observation and joint interview on 7/16/25 at 2:50 p.m. with Assistant Director of Nursing (ADON) and LVN 1, ADON stated that calcium carbonate oyster shell1250 mg and nortriptyline oral capsule 75 mg were not available in the medication cart. LVN 1 stated, LVN1 administered calcium carbonate 500 mg for the 9 a.m. dose instead of the ordered 1250mg. ADON stated that in-service education would be provided to licensed staff to ensure medications are ordered before the last few tablets are given. During a review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving from Pharmacy effective April 2008, the P&P indicated, refills requested by placing the bottom part of the pharmacy label on the order form. Medications should be reordered five days before they are needed to ensure an adequate supply.

Based on interview and record review, the facility failed to ensure a safe discharge to one sampled resident (Resident 1) when Resident 1 who had a physician order to be discharged to an assisted living (a type of housing designed that offers caregiver support and assistance with activities of daily living/ADL, including dressing, grooming, showering, moving around, and managing medication) was placed to an independent living housing (designed for people who are still active and require little to no support with the activities of daily living) instead.This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization.During a record review of Resident 1's admission Record (AR) printed on 7/10/25, the AR indicated Resident 1 was admitted in the facility in January 2025 with diagnoses of cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain) affecting left-dominant side, muscle weakness, need for assistance with personal care, and history of falling. The AR also showed Resident 1 was discharged in June 2025 to a Board and care (a small, licensed residential setting that provides housing and personal care services to a limited number of residents, typically six or fewer, who need assistance with ADLs)/assisted living/group home: Assisted Living. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/8/25, the MDS assessment Section G (Functional Abilities and Goal) indicated Resident 1 needed substantial assistance (helper lifts, holds, or support trunk or limbs and provide more than half the effort) transferring to and from a bed to a chair and dependent (helper does all the effort) during toilet transferring (ability to get on and off a toilet or commode). The MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 15 out of 15 which indicated no cognitive impairment status. During a record review of Resident 1's Order Summary dated 6/19/25, the Order Summary indicated Resident1 had a physician order that showed Discharge resident to Assisted living with home health (medical care delivered in the patient's home) Registered Nurse/Physical Therapist/Occupational Therapist. During a phone interview on 7/10/25 at 11:04 a.m. with Resident 1, Resident 1 stated she was discharged to an independent living housing. Resident 1 stated she agreed with the facility-initiated discharge because the facility told her she was going to a board and care home or assisted living. Resident 1 stated she was not fully independent and needed a lot of help with her personal care. Resident 1 stated the place where the facility discharged her did not have the support she needed. Resident 1 further stated the lady that owned the house did not help her with her daily needs. During an interview on 7/10/25 at 12:20 p.m. with the Social Services Director (SSD), SSD stated Resident 1 was discharged back to her previous board and care home. SSD stated the board and care home provided Resident 1 the basic ADL care that also included transportation to and from Resident 1's appointments. During a follow-up phone interview on 7/11/25 at 11:10 a.m. with Resident 1, Resident 1 stated she never lived at the address where the facility discharged her. Resident 1 further stated the facility discharged her to a different address than the one that she signed and listed in her file. Resident 1 stated she expected to live in an environment that had caregiver support at all times because one side of her body had weakness from a stroke, and it was hard for her to do a lot of things on her own. Resident 1 stated she felt upset and helpless when the facility did not discharge her to an assisted living. Resident 1 further stated she did not want to experience this ever again.During a phone interview on 7/11/25 at 11:45 a.m. with the independent living owner (ILO), ILO confirmed her place offered room and board for independent living. ILO stated when she accepted residents from the facility, she expected them to be able to provide care for themselves. ILO stated it turned out that Resident 1 was unable to care for herself and needed a lot of assistance. ILO stated they also did not have in-house caregivers to provide support and assistance for residents.During a follow-up phone interview and record review on 7/11/25 at 12:08 p.m. with SSD, Resident 1's Progress Notes dated 6/18/25 was reviewed. SSD stated on 6/18/25, she documented that Resident 1 agreed to be discharged to a board and care home. SSD stated the address she documented as Resident 1's discharged place was wrong. SSD stated ILO owned two different locations and SSD did not know why ILO brought Resident 1 to another location different from what she documented. SSD stated she was very confused because ILO told her that she was able to provide care for Resident 1. SSD stated Resident 1 was self-responsible when asked how the facility made sure that Resident 1's discharge was safe.During a phone interview on 7/11/25 at 12:46 p.m. with the Administrator (ADM), ADM stated prior to discharging a resident, the facility should have planned a resident's discharge including the right place where they will be discharged to. The ADM stated it was important to document the correct address of the place of discharge because it was part of the residents' information. The ADM stated if Resident 1 had a physician order to discharge her to an assisted living, then it should have been followed.During a record review of the facility's policy and procedure (P&P), titled, Transfer and Discharge, revised in October 2017, the P&P indicated, To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility.Social Services Staff will participate in assisting the resident with transfers and discharges.post discharge plan of care/discharge instructions.

Based on interviews and record reviews the Facility did not take the necessary steps to prevent abuse for one of three sampled Residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) verbally abused Resident 1 and was not immediately removed from providing direct patient care. This resulted in the potential for further abuse. Findings: Record review of Resident 1's document admission Record showed the Facility admitted Resident 1 on June 2018. Diagnoses included stroke(a medical condition in which poor blood flow to a part of the brain causes cell death.) Review of Resident 1's document MDS 3.0 Nursing Home Quarterly (NQ) dated 3/13/2025, showed Resident 1 had no hallucinations or delusions and no physical or verbal behavioral symptoms directed towards self or others. Record review of Resident 1's document eINTERACT Change in Condition Evaluation - V 5.1 dated 5/17/2025, showed Resident 1 had reported to staff CNA 1 had entered his room the previous night and started Yelling and cussing. During an interview at 9:52 a.m. on 6/3/2025, the facility's administrator (ADM) stated Certified Nursing Assistant 1 (CNA 1) had reported Resident 1 told her she was Ugly. CNA 1 stated she then told Resident 1 You are ugly too. During an interview at 9:55 a.m. on 6/3/2025 Resident 1 stated CNA 1, Used to curse me out but that he hadn't Seen her in a while. Resident 1 stated the situation had Upset him. During an interview at 10:16 a.m. on 6/3/2025, the Facility's Payroll Manager (PM) stated CNA's official separation date from the facility was 6/2/2025. During an interview at 10:55 a.m. on 6/3/2025, the PM stated CNA 1 continued to provide Resident care following the incident . In a concurrent record review of the document Time Card Report dated 5/16/2025 to 5/31/2025, showed CNA 1 had Clocked in on 5/18/2025 and clocked out 5/19/2025, the day following the abuse incident. CNA 1 then Clocked in on 5/23/2025 and out on 5/24/2025. Record review of the document Reporting Abuse dated 1/8/2014, showed Upon an allegation of abuse by a Facility Staff member, the Facility Staff member will be suspended and removed from the premises during the investigations.

Based on interviews and record reviews the skilled nursing facility did not ensure Residents were free from abuse for one of three sampled residents (Resident 1) when Resident 1 ' s Certified Nursing Assistant stated Resident 1 was Ugly. This resulted in unnecessary emotional distress for Resident 1. Findings: Record review of Resident 1's document admission Record showed the facility admitted Resident 1 on June 2018. Diagnoses included a stroke (a medical condition in which poor blood flow to a part of the brain causes cell death.) Record Review of Resident 1's document MDS 3.0 Nursing Home Quarterly (NQ) dated 3/13/2025, showed Resident 1 had no hallucinations or delusions and no physical or verbal behavioral symptoms directed towards self or others. Record review of Resident 1's document eINTERACT Change in Condition Evaluation – V 5.1 dated 5/17/2025, showed Resident 1 had reported to staff CNA 1 had entered his room the previous night and started Yelling and cussing. During an interview at 9:52 a.m. on 6/3/2025, the facility ' s administrator (ADM) stated Certified Nursing Assistant 1 (CNA 1) had reported Resident 1 told her she was Ugly. CNA 1 stated she told Resident 1 You are ugly too. During an interview at 9:55 a.m. on 6/3/2025 Resident 1 stated CNA 1 Used to curse me out but that he hadn ' t Seen her in a while. Resident 1 stated the situation had Upset him. CNA 1 was not available to be interviewed as she no longer works for at the facility. Record review of the document Abuse Prevention and Management dated 2022 showed The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The Facility develops policies, procedures, training programs, and screening and prevention systems.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to have evidence that an alleged physical abuse was thoroughly investigated and failed to report the result of the investigation to the State Survey Agency within 5 working days of the incident. This failure had the potential to result in the inability to protect residents from further abuse. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included hypertension (high blood pressure) and epilepsy (neurological condition characterized by recurrent, unprovoked seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 5/13/25 at 10:45 a.m. with Resident 1, Resident 1 stated, FM, Resident 2's sister, entered the room and loudly accused facility staff of mistreating Resident 2. Resident 1 and Resident 2 were roommates. Resident 1 stated FM said she was going to teach them a lesson, and started yelling and throwing things around the room. Resident 1 also stated, FM was visibly upset, came near Resident 1 and slapped Resident 1 in the face. Registered Nurse (RN) 1 entered the room and tried to stop FM from hitting Resident 1 more, but FM refused to stop, continued to yell, until FM went to sit by Resident 2's bed. Resident 1 stated wondering why FM would hit him if FM was upset with the facility staff. During a telephone interview on 5/13/25 at 12:06 p.m. with RN 1, RN 1 stated, on 4/27/25, FM, who appeared visibly upset, walked past RN 1 in the hallway to Resident 1's room. RN 1 stated following FM to the room after FM did not acknowledge RN 1. As RN 1 walked towards the room, RN 1 heard Certified Nursing Assistant (CNA) 1's voice that said, Come! come!. RN 1 stated, upon entering the room, saw FM standing between the two residents, who were in their respective beds, facing Resident 1. FM held Resident 1's arms while Resident 1 defended himself by holding FM's hair. RN 1 stated he went closer to Resident 1's bed and told FM to get out of the room but FM refused to stop and continued to yell loudly at Resident 1 and RN 1. RN 1 stated FM kept going at Resident 1, trying to agitate Resident 1 even more, calling Resident 1 derogatory names. RN 1 stated Resident 1 had a scratch on the left eyelid. During a concurrent interview and record review on 5/13/25 at 12:26 p.m. with Administrator (ADM), ADM provided a handwritten note about the interview with FM but could not provide evidence that staff who witnessed the alleged abuse were interviewed. ADM stated the investigation summary (result of the investigation) was not completed as of 5/13/25. During a follow-up telephone interview on 5/22/25 at 11:34 a.m. with RN 1, RN 1 stated, FM called Resident 1 Fucker who stole my brother's TV remote!. RN 1 also stated there was so much tension in the room from FM yelling loudly, attacking [Resident 1] further with derogatory words. RN 1 also stated Resident 1 appeared afraid of FM and told FM to go away. During a review of Resident 1's eINTERACT Change in Condition Evaluation (eCiC) dated 4/27/25 and signed by RN 1, the eCiC indicated, Licensed nurse observed that a visitor to [Resident 2] had physically attacked [Resident 1] while he was in bed .[Resident 1] says he was hit in the eye. started risk management, change of condition, 72 hour charting . The eCiC indicated Resident 1 sustained a left eye discoloration with small abrasion on eye lid that measured 0.5 c.m. x 0.5 c.m. During a follow-up telephone interview and record review on 5/22/25 at 12:18 p.m. with ADM, investigation summary dated 5/6/25, sent by ADM on 5/14/25, was reviewed. ADM stated he interviewed FM who denied the allegation. When asked if ADM reviewed RN 1's notes, ADM stated, FM denied hitting Resident 1 but could not make RN 1 change the already written notes about the incident. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention and Management last revised 5/30/24, the P&P indicated The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification .within five (5) working days of the reported allegation. Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to have evidence that an alleged physical abuse was thoroughly investigated and failed to report the result of the investigation to the State Survey Agency within 5 working days of the incident. This failure had the potential to result in the inability to protect residents from further abuse. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included hypertension (high blood pressure) and epilepsy (neurological condition characterized by recurrent, unprovoked seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 5/13/25 at 10:45 a.m. with Resident 1, Resident 1 stated, FM, Resident 2's sister, entered the room and loudly accused facility staff of mistreating Resident 2. Resident 1 and Resident 2 were roommates. Resident 1 stated FM said she was going to teach them a lesson, and started yelling and throwing things around the room. Resident 1 also stated, FM was visibly upset, came near Resident 1 and slapped Resident 1 in the face. Registered Nurse (RN) 1 entered the room and tried to stop FM from hitting Resident 1 more, but FM refused to stop, continued to yell, until FM went to sit by Resident 2's bed. Resident 1 stated wondering why FM would hit him if FM was upset with the facility staff. During a telephone interview on 5/13/25 at 12:06 p.m. with RN 1, RN 1 stated, on 4/27/25, FM, who appeared visibly upset, walked past RN 1 in the hallway to Resident 1's room. RN 1 stated following FM to the room after FM did not acknowledge RN 1. As RN 1 walked towards the room, RN 1 heard Certified Nursing Assistant (CNA) 1's voice that said, Come! come!. RN 1 stated, upon entering the room, saw FM standing between the two residents, who were in their respective beds, facing Resident 1. FM held Resident 1's arms while Resident 1 defended himself by holding FM's hair. RN 1 stated he went closer to Resident 1's bed and told FM to get out of the room but FM refused to stop and continued to yell loudly at Resident 1 and RN 1. RN 1 stated FM kept going at Resident 1, trying to agitate Resident 1 even more, calling Resident 1 derogatory names. RN 1 stated Resident 1 had a scratch on the left eyelid. During a concurrent interview and record review on 5/13/25 at 12:26 p.m. with Administrator (ADM), ADM provided a handwritten note about the interview with FM but could not provide evidence that staff who witnessed the alleged abuse were interviewed. ADM stated the investigation summary (result of the investigation) was not completed as of 5/13/25. During a follow-up telephone interview on 5/22/25 at 11:34 a.m. with RN 1, RN 1 stated, FM called Resident 1 Fucker who stole my brother's TV remote!. RN 1 also stated there was so much tension in the room from FM yelling loudly, attacking [Resident 1] further with derogatory words. RN 1 also stated Resident 1 appeared afraid of FM and told FM to go away. During a review of Resident 1's eINTERACT Change in Condition Evaluation (eCiC) dated 4/27/25 and signed by RN 1, the eCiC indicated, Licensed nurse observed that a visitor to [Resident 2] had physically attacked [Resident 1] while he was in bed .[Resident 1] says he was hit in the eye. started risk management, change of condition, 72 hour charting . The eCiC indicated Resident 1 sustained a left eye discoloration with small abrasion on eye lid that measured 0.5 c.m. x 0.5 c.m. During a follow-up telephone interview and record review on 5/22/25 at 12:18 p.m. with ADM, investigation summary dated 5/6/25, sent by ADM on 5/14/25, was reviewed. ADM stated he interviewed FM who denied the allegation. When asked if ADM reviewed RN 1's notes, ADM stated, FM denied hitting Resident 1 but could not make RN 1 change the already written notes about the incident. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention and Management last revised 5/30/24, the P&P indicated The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification .within five (5) working days of the reported allegation.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from abuse when Family Member (FM) slapped Resident 1 in the face and called Resident 1 derogatory names. This failure resulted in Resident 1's abrasion on the left eyelid. Resident 1 was sent to the Emergency Department (ED) after complaining of left eye pain. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included hypertension (high blood pressure) and epilepsy (neurological condition characterized by recurrent, unprovoked seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 5/13/25 at 10:45 a.m. with Resident 1, Resident 1 stated, FM, Resident 2's sister, entered the room and loudly accused facility staff of mistreating Resident 2. Resident 1 and Resident 2 were roommates. Resident 1 stated FM said she was going to teach them a lesson, and started yelling and throwing things around the room. Resident 1 also stated, FM was visibly upset, came near Resident 1 and slapped Resident 1 in the face. Registered Nurse (RN) 1 entered the room and tried to stop FM from hitting Resident 1 more, but FM refused to stop, continued to yell, until FM went to sit by Resident 2's bed. Resident 1 stated wondering why FM would hit him if FM was upset with the facility staff. During an interview on 5/13/25 at 10:50 a.m. with Infection Preventionist (IP), IP stated seeing FM coming down the hallway, upset and fussing about something. IP stated FM said You all don't know me, you will hear from my lawyer, you don't know what I am capable of! . IP stated she entered Resident 1's room to find out what was going on. IP stated Resident 1 told her that FM had accused Resident 1 of stealing Resident 2's TV remote. IP stated Resident 1 alleged FM was very upset, came up to Resident 1 and slapped him across the face couple times. During a telephone interview on 5/13/25 at 12:06 p.m. with RN 1, RN 1 stated, on 4/27/25, FM, who appeared visibly upset, walked past RN 1 in the hallway to Resident 1's room. RN 1 stated following FM to the room after FM did not acknowledge RN 1. As RN 1 walked towards the room, RN 1 heard Certified Nursing Assistant (CNA) 1's voice that said, Come! come!. RN 1 stated, upon entering the room, saw FM standing between the two residents, who were in their respective beds, facing Resident 1. FM held Resident 1's arms while Resident 1 defended himself by holding FM's hair. RN 1 stated he went closer by Resident 1's bed and told FM to get out of the room but FM refused to stop, went in and out of the room, and continued to yell loudly at Resident 1 and RN 1. RN 1 stated FM kept going at Resident 1, trying to agitate Resident 1 even more, calling Resident 1 derogatory names. RN 1 stated, when IP entered the room, FM calmed down and stayed at Resident 2's bedside. RN 1 stated moving Resident 1 to another room, where further skin assessment was done. RN 1 stated Resident 1 had a scratch on the left eyelid. During an interview on 5/13/25 at 12:27 p.m. with CNA 1, CNA 1 stated, as she entered Resident 1's room, FM stood between the two beds, closer to Resident 1, upset and yelled at Resident 1, Why are you grabbing my hair?. CNA 1 stated calling RN 1 for help. CNA 1 stated FM accused Resident 1 of stealing Resident 2's TV remote but Resident 1 denied taking it. CNA 1 stated looking through the entire room but did not find the TV remote. During a follow-up telephone interview on 5/22/25 at 11:34 a.m. with RN 1, RN 1 stated, FM called Resident 1 Fucker who stole my brother's TV remote!. RN 1 also stated there was so much tension in the room from FM yelling loudly, attacking [Resident 1] further with derogatory words. RN 1 also stated Resident 1 appeared afraid of FM and told FM to go away. During a review of Resident 1's eINTERACT Change in Condition Evaluation (eCiC) dated 4/27/25 and signed by RN 1, the eCiC indicated, Licensed nurse observed that a visitor to [Resident 2] had physically attacked [Resident 1] while he was in bed .[Resident 1] says he was hit in the eye. started risk management, change of condition, 72 hour charting . The eCiC indicated Resident 1 sustained a left eye discoloration with small abrasion on eye lid that measured 0.5 c.m. x 0.5 c.m. During a review of System Note signed by RN 1 and dated 4/27/25, the System Note indicated Resident 1 complained of pain on the left eye. During a review of the Interdisciplinary Note (IDT, a team composed of individuals from different departments of the facility) dated 4/28/25 and signed by Director of Nursing (DON), the the IDT Note indicated, on 4/27/25, FM allegedly slapped Resident 1 on the left side of the face, leaving a scratch over the left eyelid. The IDT Note indicated Resident 1 was sent to the Emergency Department (ED) for further evaluation. Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from abuse when Family Member (FM) slapped Resident 1 in the face and called Resident 1 derogatory names. This failure resulted in Resident 1's abrasion on the left eyelid. Resident 1 was sent to the Emergency Department (ED) after complaining of left eye pain. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included hypertension (high blood pressure) and epilepsy (neurological condition characterized by recurrent, unprovoked seizures). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 5/13/25 at 10:45 a.m. with Resident 1, Resident 1 stated, FM, Resident 2's sister, entered the room and loudly accused facility staff of mistreating Resident 2. Resident 1 and Resident 2 were roommates. Resident 1 stated FM said she was going to teach them a lesson, and started yelling and throwing things around the room. Resident 1 also stated, FM was visibly upset, came near Resident 1 and slapped Resident 1 in the face. Registered Nurse (RN) 1 entered the room and tried to stop FM from hitting Resident 1 more, but FM refused to stop, continued to yell, until FM went to sit by Resident 2's bed. Resident 1 stated wondering why FM would hit him if FM was upset with the facility staff. During an interview on 5/13/25 at 10:50 a.m. with Infection Preventionist (IP), IP stated seeing FM coming down the hallway, upset and fussing about something. IP stated FM said You all don't know me, you will hear from my lawyer, you don't know what I am capable of! . IP stated she entered Resident 1's room to find out what was going on. IP stated Resident 1 told her that FM had accused Resident 1 of stealing Resident 2's TV remote. IP stated Resident 1 alleged FM was very upset, came up to Resident 1 and slapped him across the face couple times. During a telephone interview on 5/13/25 at 12:06 p.m. with RN 1, RN 1 stated, on 4/27/25, FM, who appeared visibly upset, walked past RN 1 in the hallway to Resident 1's room. RN 1 stated following FM to the room after FM did not acknowledge RN 1. As RN 1 walked towards the room, RN 1 heard Certified Nursing Assistant (CNA) 1's voice that said, Come! come!. RN 1 stated, upon entering the room, saw FM standing between the two residents, who were in their respective beds, facing Resident 1. FM held Resident 1's arms while Resident 1 defended himself by holding FM's hair. RN 1 stated he went closer by Resident 1's bed and told FM to get out of the room but FM refused to stop, went in and out of the room, and continued to yell loudly at Resident 1 and RN 1. RN 1 stated FM kept going at Resident 1, trying to agitate Resident 1 even more, calling Resident 1 derogatory names. RN 1 stated, when IP entered the room, FM calmed down and stayed at Resident 2's bedside. RN 1 stated moving Resident 1 to another room, where further skin assessment was done. RN 1 stated Resident 1 had a scratch on the left eyelid. During an interview on 5/13/25 at 12:27 p.m. with CNA 1, CNA 1 stated, as she entered Resident 1's room, FM stood between the two beds, closer to Resident 1, upset and yelled at Resident 1, Why are you grabbing my hair?. CNA 1 stated calling RN 1 for help. CNA 1 stated FM accused Resident 1 of stealing Resident 2's TV remote but Resident 1 denied taking it. CNA 1 stated looking through the entire room but did not find the TV remote. During a follow-up telephone interview on 5/22/25 at 11:34 a.m. with RN 1, RN 1 stated, FM called Resident 1 Fucker who stole my brother's TV remote!. RN 1 also stated there was so much tension in the room from FM yelling loudly, attacking [Resident 1] further with derogatory words. RN 1 also stated Resident 1 appeared afraid of FM and told FM to go away. During a review of Resident 1's eINTERACT Change in Condition Evaluation (eCiC) dated 4/27/25 and signed by RN 1, the eCiC indicated, Licensed nurse observed that a visitor to [Resident 2] had physically attacked [Resident 1] while he was in bed .[Resident 1] says he was hit in the eye. started risk management, change of condition, 72 hour charting . The eCiC indicated Resident 1 sustained a left eye discoloration with small abrasion on eye lid that measured 0.5 c.m. x 0.5 c.m. During a review of System Note signed by RN 1 and dated 4/27/25, the System Note indicated Resident 1 complained of pain on the left eye. During a review of the Interdisciplinary Note (IDT, a team composed of individuals from different departments of the facility) dated 4/28/25 and signed by Director of Nursing (DON), the the IDT Note indicated, on 4/27/25, FM allegedly slapped Resident 1 on the left side of the face, leaving a scratch over the left eyelid. The IDT Note indicated Resident 1 was sent to the Emergency Department (ED) for further evaluation.

Based on observation, interview and record review, for one of four sampled residents (Resident 87) reviewed for anticoagulant use, the facility failed to provide treatment and care in accordance with professional standards of care when licensed nurses did not administer medications, enoxaparin sodium (Lovenox, an anticoagulant for DVT [a condition that occurs when a blood clot forms in a vein deep inside a part of the body that could potentially travel to the lungs and cause pulmonary embolism] prophylaxis) and omeprazole oral capsule (Prilosec, an antacid, treats gastro-esophageal reflux disease) as ordered by the physician. This failure had resulted in Resident 87 experiencing heartburn (a burning sensation in the chest or upper abdomen caused by stomach acid backing up into the esophagus) and discomfort and had the potential to result in DVT from not receiving anticoagulant. Findings: During a review of Resident 87's admission Record and the Minimum Data Assessment (MDS, an assessment tool used to direct resident care) dated 2/20/25, the admission Record indicated Resident 87 was admitted to the facility on [DATE]. The MDS indicated Resident 87 had diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified atrial fibrillation (Afib, an irregular heart rhythm that begins in your heart's upper chambers (atria). During a review of Resident 87's MDS dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/24/25 at 10:07 a.m. with Resident 87, Resident 87 stated not being given injectable blood thinner for the past three days. Resident 87 stated staff said they ran out of supply. There was a round pill in a medication cup on Resident 87's nightstand. Resident 87 stated it was one of the two Tums (calcium carbonate, an over-the-counter antacid to treat GERD) that staff had given for heartburn. Resident 87 stated he told staff Tums did not work and asked for Prilosec instead, but staff said Prilosec was not available. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated, a physician's order dated 2/13/25 for enoxaparin sodium injection solution prefilled syringe 40 milligram (mg) per 0.4 milliliter (ml) inject 0.4 ml subcutaneously one time a day for DVT prophylaxis (DVT prophylaxis, measures taken to prevent the formation of blood clots (thrombi) in the deep veins, typically in the legs) and omeprazole oral capsule delayed release give 1 tablet by mouth one time a day for GERD. The Order Summary Report did not indicate a physician's order for Tums. During a review of Resident 87's Medication Administration Record (MAR) for March 2025 on 3/25/25 at 10:54 a.m. the MAR indicated, Lovenox was not administered on 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During an interview on 3/25/25 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had ordered Lovenox on 3/21/25, when she administered the last dose, only for her to return today, 3/25/25 to find Lovenox was still not available. LVN 2 stated, she had found out, pharmacy delivered the medication on 3/23/25 but was not brought to the correct station (Station 2), the medication was found in Station 1. LVN 2 stated Resident 87's clinical record did not indicate Resident 87's attending physician was not notified of the missed medications. During a review of the Physician/PA/NP Note (Physician Assistant/Nurse Practitioner) dated 3/24/25, the Physician/PA/NP Note indicated, plan was for Resident 87 to continue to receive Lovenox for DVT prophylaxis and Prilosec for GERD. The note also indicated Resident 87 was at risk for falls, DVT and skin breakdown. During a review of the MARs for February 2025 and March 2025 on 3/25/25 at 1:52 p.m. the MAR for February 2025 indicated, an order for omeprazole oral capsule delayed release give 1 tablet by mouth one time a day dated 2/14/25. The medication was signed off by multiple staff on some days but was marked 9 on 2/18/25, 2/24/25, and 2/27/25. The MAR for March 2025 indicated the medication was marked 9 on the following dates: 3/4/25, 3/5/25, 3/6/25, 3/9/25, and 3/10/25; and was not signed off on the following dates: 3/14/25, 3/15/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During a concurrent observation and interview on 3/25/25 at 3 p.m. with LVN 2, LVN 2 stated there was no omeprazole in the medication cart. LVN 2 stated, a 9 indicated the medication was not available for administration or the resident refused the medication. During a telephone interview on 3/25/25 at 3:30 p.m. with Pharmacy Technician (PhT), PhT stated facility staff need to request refills three days before the actual re-fill date. PhT stated Resident 87's Lovenox was delivered 3/23/25 but the omeprazole needed clarification with the prescribing physician because it did not indicate the strength. PhT stated facility staff were told to clarify the order with the physician, but facility did not follow-up, the medication was never delivered to the facility since Resident 87's admission in February 2025. During an interview on 3/26/25 at 11:50 a.m. with Resident 87, Resident 87 stated not receiving Prilosec since being admitted because staff said they did not have it. Resident 87 stated having heartburn and Tums did not help at all.

Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: 1.Unlabeled, undated food items were stored in the kitchen refrigerator. 2.A staff drink was stored in the kitchen freezer. 3. Beyond use by date food was stored in the kitchen dry storage. 4.Unlabeled, undated and beyond use by date food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 90 residents who received food from the kitchen. Findings: During an observation 3/24/25, at 10:00 a.m., the kitchen refrigerator was observed with six unlabeled and undated ready to eat puddings and the kitchen freezer was observed with a staff's energy drink. During and observation on 3/24/25, at 10:07 a.m., the kitchen dry storage was observed with a bulk container of black eye peas with a use by date of 1/3/25. During an observation on 3/24/25, at 10:35 a.m., the nurses' station resident refrigerator and freezer was observed with the following food items that were not labeled with resident identification or date: one strawberry milk, four apple juices, and two turkey sandwiches. The resident refrigerator and freezer had one pack of popsicles with a use by date of 1/2/25. During an interview on 3/28/25, at 10:50 a.m., with Registered Dietician (RD), RD stated all food in the kitchen refrigerator and freezer should have been labeled with open date and use by date. RD stated it was not safe and sanitary for staff to store staff food with resident food in the facility refrigerator or freezer. RD stated food that was beyond their use by date should have been discarded for food quality and resident safety. RD stated food in the resident refrigerator and freezer should have been labeled with resident name, room number and date to make sure residents get their diet that was safe for them and to prevent cross contamination. During a review of the facility's P&P titled, Food Storage and Handling, revised 2/29/24, the P&P indicated, Food items will be stored, thawed and prepared in accordance with standard sanitary practices. All items will be correctly labeled and dated. During a review of the facility's P&P titled, Food Brought in by Visitors, revised June 2018, the P&P indicated, Perishable food requiring refrigeration . if refrigerated it will then be labeled, dated, and discarded after 48 hours.

Based on observation, interview and record review, the facility failed to ensure medication error rate was less than 5% when four medication errors out of 26 opportunities were observed during the medication administration for two out of five sampled residents (Resident 12 and 56). 1.Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats hypertension (high blood pressure)) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels) effectively or does not produce enough insulin to regulate blood sugar levels) as ordered by the physician. 2. Resident 56 did not receive Vitamin D as ordered by the physician. These failures resulted in a medication error rate of 15.38%. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in June 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), heart failure and dementia. During a concurrent medication administration observation and interview on 3/25/25 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering only three medications out of 6 scheduled medications for Resident 12. LVN 1 stated Resident 12's Digoxin, Furosemide and Jardiance medications were not available for administration. LVN 1 stated she would re-order the medications from the pharmacy. During a review of Resident 12's Order Summary Report dated 1/31/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of digoxin 125 micrograms (mcg) one time a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of furosemide 40 milligrams (mg) two times a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Jardiance 10 mg one time a day for type 2 diabetes. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR), dated 3/25/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 12's Digoxin, Furosemide and Jardiance. LVN 1 stated the number 9 meant the medication was not given and was not available. LVN 1 stated Digoxin prevented decreased or increased heart rate. LVN 1 stated Furosemide reduced fluids from the body. LVN 1 stated Jardiance decreased blood sugar level. 2. During a review of Resident 56's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 56 was admitted in the facility in [DATE] with a diagnosis of systemic lupus erythematosus (disease where the body's immune system mistakenly attacks its own healthy tissues and organs). During a concurrent medication administration observation and interview, on 3/25/25 at 8:36 a.m., with LVN 1, LVN 1 was observed preparing and administering five medications for Resident 12. These medications included one tablet of folic acid (a B vitamin that helps the body make healthy new cells) 1 mg, one tablet of Vitamin D3 25 mcg and one drop of Timolol, Brimonidine and Dorzolamide (medications to treat increased pressure in the eye) eye drop to left and right eye. During a review of Resident 56's Order Summary Report dated 7/4/23, the Order Summary Report indicated, Resident 56 had an order to receive one tablet of Vitamin D3 50 micrograms (mcg) one time a day for supplement. During a concurrent interview and record review on 3/25/25 at 2:59 p.m. with LVN 1, Resident 56's MAR dated 3/25/25, was reviewed. The MAR indicated; Resident 56 was to receive one tablet of Vitamin D3 50 micrograms (mcg) one time a day for supplement. LVN 1 stated two tablets of Vitamin D3 25 mcg should have been given to Resident 56. LVN 1 stated Resident 56 did not receive the correct dosage of Vitamin D3. LVN 1 stated Vitamin D3 supplement prevents Vitamin D3 deficiency. During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines.

4. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified atrial fibrillation (Afib, an irregular heart rhythm that begins in your heart's upper chambers (atria). During a review of Resident 87's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/8/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/24/25 at 10:07 a.m. with Resident 87, Resident 87 stated not being given injectable blood thinner for the past three days. Resident 87 stated staff said they ran out of supply. There was a round pill inside a medication cup on Resident 87's nightstand. Resident 87 stated it was one of the two Tums that a nurse had given for heartburn. Resident 87 stated he told staff Tums did not work and asked for Prilosec instead, but staff said Prilosec was not available. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated a physician's order dated 2/13/25 for enoxaparin sodium (Lovenox, an injectable anticoagulant, prevents blood from clotting) injection solution pre-filled syringe 40 milligram (mg) per 0.4 milliliter (ml) inject 0.4 ml subcutaneously one time a day for DVT (a condition where a blood clot forms in a deep vein, most commonly in the legs, but can also occur in the arms or other veins) prophylaxis (DVT prophylaxis, measures taken to prevent the formation of blood clots (thrombi) in the deep veins, typically in the legs) and omeprazole oral capsule delayed release give 1 tablet by mouth one time a day for GERD. There was no physician's order for Tums (calcium carbonate, an antacid to treat GERD). During a review of Resident 87's Medication Administration Record (MAR) for March 2025 on 3/25/25 at 10:54 a.m., the MAR indicated Lovenox was not administered on 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During an interview on 3/25/25 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had ordered Lovenox on 3/21/25, when she administered the last dose, only for her to return today, 3/25/25 to find Lovenox was still not available. LVN 2 stated pharmacy delivered the medication on 3/23/25 but was not brought to the correct Station. LVN 2 stated Resident 87's clinical record did not indicate Resident 87's attending physician was not notified of the missed medications. During a review of the MARs for February 2025 and March 2025 on 3/25/25 at 1:52 p.m., the MAR for February 2025 indicated omeprazole was signed off by multiple staff and was marked 9 on 2/18/25, 2/24/25, and 2/27/25. The MAR for March 2025 indicated the medication was marked 9 on the following dates: 3/4/25, 3/5/25, 3/6/25, 3/9/25, and 3/10/25; and was not signed off on the following dates: 3/14/25, 3/15/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During a concurrent observation and interview on 3/25/25 at 3 p.m. with LVN 2, LVN 2 stated there was no omeprazole in the medication cart. LVN 2 stated, 9 indicated the medication was not available for administration or the resident refused the medication. During a telephone interview on 3/25/25 at 3:30 p.m. with Pharmacy Technician (PhT), PhT stated facility staff need to request refills three days before the actual re-fill date. PhT stated Resident 87's Lovenox was delivered 3/23/25 but the omeprazole needed clarification with the prescribing physician because it did not indicate the strength. PhT stated facility staff were told to clarify the order with the physician, but facility did not follow-up, the medication was never delivered since Resident 87's admission to the facility in February 2025. During a review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving From Pharmacy effective April 2008, the P&P indicated: when ordering medications from the pharmacy, medication orders are written on a medication order form written by the physician or authorized personnel and transmitted to the pharmacy that includes; date ordered, resident's name and other identifying information, medication name and strength when indicated, and directions for use. Repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it on the order form and ordered as follows: reorder medication five days in advance of need to assure as adequate supply is on hand. Based on observation, interview and record review, the facility failed to provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of routine and emergency medications to meet the needs of three out of six sampled residents (Resident 12, 16 and 87) and to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for two out of three sampled residents (Resident 58 and 72) when: 1. Resident 12's Digoxin (medication to treat congestive heart failure [CHF, a condition where the heart muscle is weakened and cannot pump blood effectively]and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats high blood pressure) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin [a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels] effectively or does not produce enough insulin to regulate blood sugar levels) and Resident 16's Gabapentin (medication to treat nerve pain) were not available for administration. 2. Controlled medications for Residents 58 and 72 were not documented accurately in the MAR and accountability record. These failures resulted in inaccurate accountability of controlled medications and potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications. 3. One out of one oral emergency medication kit was open and not re-ordered timely. 4. Resident 87's antacid and anticoagulant medications were not available. These failures resulted in Resident 87 to not receive medications as ordered by the physician These failures resulted in multiple residents not receiving medications as ordered by the physician and also had the potential for facility residents with a census of 91 to not receive emergency medications when needed. Findings: 1 a. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in January 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), heart failure and dementia. During a concurrent medication administration observation and interview on 3/25/25 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering only three medications out of 6 scheduled medications for Resident 12. LVN 1 stated Resident 12's Digoxin, Furosemide and Jardiance medications were not available for administration. LVN 1 stated she would re-order the medications from the pharmacy. During a review of Resident 12's Order Summary Report dated 1/31/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Digoxin 125 micrograms (mcg) one time a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Furosemide 40 milligrams (mg) two times a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Jardiance 10 mg one time a day for type 2 diabetes. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR), dated 3/25/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 12's Digoxin, Furosemide and Jardiance. LVN 1 stated the number 9 meant the medication was not given and was not available. LVN 1 stated Digoxin prevented decreased or increased heart rate. LVN 1 stated Furosemide reduced fluids from the body. LVN 1 stated Jardiance lowered blood sugar level. 1 b. During a review of Resident 16's undated admission Record, the admission Record printed on 3/27/25 indicated, Resident 16 was admitted in the facility in June 2013 with a diagnosis of polyneuropathy (damage or disease affecting peripheral nerves (nerves that extend from the brain and spinal cord to the rest of the body, such as the arms, legs, and organs) in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/25/25, the MDS indicated, Resident 16 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15 out of 15, indicating intact cognitive status. During an interview on 3/24/25 at 11:53 a.m. with Resident 16, in Resident 16's room, Resident 16 stated he doesn't get his pain medication on time. Resident 16 stated the nurses would tell him the medication was coming but did not get it. During an interview on 3/24/25 at 12:18 p.m. with LVN 1, LVN 1 stated Resident 16's Gabapentin medication was not available for administration at 2:00 p.m. LVN 1 stated she would re-order the medication from the pharmacy. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 16's MAR, dated 3/24/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 16's gabapentin scheduled at 2:00 p.m. LVN 1 stated the number 9 meant the medication was not given and was not available. During a review of Resident 16's Order Summary Report dated 2/10/22, the Order Summary Report indicated, Resident 12 had an order to receive one capsule of Gabapentin 400 mg three times a day at 6:00 a.m., 2:00 p.m. and 08:00 p.m. for neuropathy. During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines. 2 a. During a review of Resident 58's undated admission Record, the admission Record printed on 3/28/25 indicated, Resident 58 was admitted in the facility on 1/29/25 with a diagnosis of anxiolytic (medications used to treat anxiety disorders and reduce anxiety symptoms) dependence. During a concurrent interview and record review, on 3/28/25 at 11:29 a.m. with the MDSC, Resident 58's March 2025 MAR and Individual Narcotic (Controlled Medication) Record (an inventory sheet that keeps record of the usage of controlled medications) dated 2/7/25 and 2/23/25 was reviewed. The MAR and Individual Narcotic Record indicated, one tablet of Lorazepam (medication used to treat anxiety disorders) 0.5 mg was given to Resident 58 when the order was to give two tablets. The MDSC stated the documentation in the MAR and the narcotic record should match. During a review of Resident 58's Order Summary Report dated 2/15/25, the Order Summary Report indicated, Resident 58 had an order to receive two tablets of Lorazepam 0.5 mg every 12 hours as needed for anxiety. 2 b. During a review of Resident 72's undated admission Record, the admission Record printed on 3/28/25 indicated, Resident 72 was admitted in the facility on 1/19/24 with a diagnosis of osteoarthritis (occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down, resulting in pain) of hip. During a concurrent interview and record review, on 3/28/25 at 11:19 a.m. with the MDSC, Resident 72's March 2025 MAR and Individual Narcotic Record dated 3/2/25 was reviewed. The Individual Narcotic Record indicated, one table to hydrocodone-acetaminophen (controlled medication to treat pain) 10 mg-325 mg was given to Resident 72 at 07:15 a.m. The MAR was blank and was not documented. The MDSC stated the nurses should document the administration of the medication in both the MAR and narcotic record to show the medication was given to the resident. During a review of Resident 72's Order Summary Report dated 1/2/25, the Order Summary Report indicated, Resident 72 had an order to receive one tablet of hydrocodone-acetaminophen every six hours as needed for moderate to severe pain. During a review of facility's P&P titled, Preparation and General Guidelines-Controlled Medications, dated 8/14, indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special . recordkeeping in the facility, in accordance with federal and state laws and regulations . C. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR). 3. During a concurrent observation and interview, on 3/26/25 at 12:23 p.m. with the MDSC, in the medication room, a gray container with label oral emergency kit had a yellow plastic security seal zip tie. The MDSC stated the yellow plastic security zip tie meant the emergency kit was opened, and a medication was taken out. The MDSC was unable to identify when the emergency kit was opened or what medication was taken out. During a follow up concurrent observation and interview on 3/26/25 at 12:25 p.m., with the MDSC, in the medication room, the MDSC cut the yellow plastic security seal zip tie of the emergency kit. The MDSC removed a paper from the emergency kit with label Emergency Kit Pharmacy Log. The MDSC stated the white paper copy of the log should be kept by the facility and the yellow paper copy should be inside the emergency kit. During a concurrent interview and record review on 3/26/25 at 12:27 p.m. with the MDSC, the Emergency Kit Pharmacy Log, dated 3/23/25 was reviewed. The log indicated, one tablet of sulfamethoxazole/trimethoprim (a combination antibiotic used to treat various bacterial infections) was removed from the emergency kit at 04:00 p.m. The MDSC was unable to identify when the emergency kit was re-ordered. The MDSC stated the emergency kit should be re-ordered as soon as it was opened. The MDSC stated timely re-ordering of emergency kit ensured medications was available when needed. During a review of facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated 8/14, indicated, I. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply.

Based on observations, interviews, and record reviews, the facility failed to follow proper infection control techniques and did not follow their infection control policies and procedures for two of two sampled residents, Resident 6 and Resident 35, when: 1. Nursing staff did not don gloves when handling Resident 6's soiled bed linens and personal clothing. 2. Resident 35's mattress was worn out and soiled with urine and bodily fluids. 3. Staff in the laundry room did not separate clean linens from soiled linens in the laundry room. 4. Staff in the laundry room did not change gloves after loading soiled laundry and before handling clean linens. 5. Staff in the laundry room did not clean and sanitize washing machine's exterior after loading soiled laundry. These failures resulted in Resident 35 to sleep on an unsanitary and uncomfortable worn-out mattress, not homelike, being at risk for infection, and residents being at risk for infections from cross contamination from staff causing the spread of infection among residents in the facility which could lead to hospitalization and possibly death. Findings: During a record review of Resident 35's Face Sheet, the Face Sheet indicated Resident 35 is a [AGE] year old female admitted to the facility in 2018. The Face Sheet indicated Resident 35 has diagnoses to include asthma (inflammation and narrowing of the airway in the lung), overactive bladder (sudden need to urinate), and hypertension (high blood pressure). During an observation on 3/24/25 at 10:15 a.m. with Restorative Nursing Assistant (RNA) 2, Resident 35 was in the middle bed 21 B, and had two roommates, 21 A (door bed) and 21 C (window bed). A soiled linen cart was placed at the entrance to the room. There was no bedding or sheets on Resident 35's bed, soiled bed linens were rolled up and placed on top of the foot of Resident 35's bed. Resident 35 was seated in her wheelchair, and RNA 2 had just completed grooming Resident 35. RNA 2 picked up Resident 35's rolled up soiled linens (blankets, sheet, pillowcases) without wearing gloves, linens held close against her clothing, walked a few steps to the door where the cart was placed, and placed Resident 35's soiled linens in the soiled linen cart. RNA 2 stated she was not supposed to hold the soiled linens without gloves, and she typically held linens with gloves because they are soiled, have germs, and she needs the required personal protective equipment (PPE) to prevent cross contamination to other Residents not in her room. During an observation on 3/24/25 at 10:20 a.m., with RNA 2, Resident 35 was sitting up in her wheelchair by the sliding door with a mouth full of clear bubbly sputum and spit up on the floor and on her wheelchair. During an interview on 3/26/25 at 12:57 p.m., with Infection Preventionist (IP) and Regional Infection Preventionist (RIP), IP stated soiled linens should be carried in a plastic bag, with one glove on to carry the plastic bag, the other hand without gloves to open the lid of the linen cart. IP stated, it's not the process, staff should not be handling soiled linens without gloves to prevent the spread of infection, that it was better to wear PPE (personal protective equipment). 2. During a record review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 is a [AGE] year old female admitted to the facility in 2017. The Face Sheet indicated Resident 6 has diagnoses to include chronic kidney disease Stage 3 (mild to moderate kidney damage), chronic viral hepatitis B (serious viral liver infection), atrial fibrillation (irregular rapid heart rate), and acute ischemic heart disease (sudden blockage or reduction of blood flow to the heart). During an observation on 3/24/25 at 10:25 a.m., Resident 6's bed is in 19A by the door. Resident 6 had two roommates in 19B and 19C, both lying in bed resting. Resident 6 was not in her room and her bed was stripped, no sheets, blankets, or pillows. Resident 6's bed had a deep indentation or body impression in the middle of the mattress, with brown/yellowish discoloration on the middle part of the mattress. During an interview on 3/24/25 at 10:30 a.m. with Director of Staff Development (DSD), DSD stated the mattress was worn out and it needs to be replaced or disinfected several times for infection control prevention. During an interview on 3/24/25 at 11: 29 a.m., with Environmental Service Director (ESD), ESD stated the mattress is worn out and needs to be replaced. ESD stated Resident 6's mattress was on his to do list. 3. During an observation and an interview on 3/27/25 at 09:48 a.m. with IP and Laundry Staff (LS), the laundry room hard a door to the clean side and a door to the soiled side. The washer was placed on the clean side of the laundry room. LS was standing in the clean side of the laundry room with gown and gloves on, sorting out Residents soiled linens (gown, beddings, blankets, wash cloths, towels) into the washing machine. The clean linen cart with clean linens in it and soiled linen cart with soiled linens in it were placed on the same side (dirty side) in the laundry room. IP stated clean linens must be separated from soiled linens, and they should not be on the same side of the laundry room. 4. During an observation on 3/27/25 at 09:48 a.m. with LS and IP, LS did not doff gloves and gown after sorting out soiled linens. LS repeatedly touched the clean linens in the cart with her soiled gloves. LS stated the blankets placed in the soiled area are clean linens. IP stated LS should have removed the soiled gown and gloves before handling the clean linens in the clean laundry cart for infection control purposes. 5. During an observation and an interview on 3/27/25 at 10:01 a.m. with IP and LS, LS removed her gloves and gown, left the laundry room for a break, without sanitizing the exterior of the washing machine. The outside of the two washing machines had white dust particles on them. During an interview on 3/27/25 at 10:04 a.m. with ESD, IP, and Regional Infection Preventionist (RIP), ESD stated the exterior part of the washing machine should be clean and sanitized after every laundry load in the washing machine. so that once the clothes came out of the washer, the clean laundry does not touch the dirty part of the washer and the clean laundry are all clean and sanitized. IP stated it was the policy for staff to sanitize the exterior of the washing machine after loading the soiled linens to help with cross contamination. RIP stated staff should sanitize the exterior of the washing machine after loading soiled linens in the washer as it is the facility's process for infection control. During a review of facility's policy and procedure (P&P), titled Infection Control- Policies & Procedures. The P&P indicated, purpose . to provide infection control policies and procedure required for safe and sanitary environment. Policy . The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. Procedure . 1. The facility's infection control policies and procedures apply equally to all Facility Staff, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed .or payor source. During a record review of facility's policy and procedures (P&P), titled Infection Control Committee, Composition and Duties. The P&P indicated, II. Risk Exposure categories . i . b. identify all facility staff who perform tasks that may involve blood and/or body fluids as part of their regular employment .ii. Develop and/or supervise processes for tasks involving exposure to blood and body fluids . a. the processes include mandatory work practices and required PPE. During a record review of facility's (P&P), titled Laundry Services. The P&P indicated, purpose . to ensure that the facility provides laundry services that meets the needs of the residents .Policy . 1. The facility works to maintain its own or contract laundry for the residents. To do so, the facility adheres to the following: . Procedure . I. On site laundry services: . A. When the facility operates its own laundry, the laundry: . iii. Has equipment that is of a suitable capacity, kept in good repair and maintained in a sanitary condition . iv. Is maintained in a clean and sanitary condition . v. has written procedures for handling, storage, transportation and processing of linens in the laundry room.

Based on observation, interviews, and record reviews, facility failed to provide assistant for one out of two sampled residents(Resident 193), when Resident 193 who is dependent on staff was not assisted with setting up his meal tray and given required assistant with eating during lunch period. This failure resulted in Resident 193 not being able to eat and enjoy his meals at his own desire time, had his meal cold, challenges eating with his left non-dominant hand, and potential to not maintain good nutritional status and poor quality of care. Findings: During an observation and interview on 3/24/25 at 1:12 p.m.with Resident 193, Resident 193 was sitting up dangling at the bedside awaiting his lunch tray. Resident 193 had a white hard rubber cast to his right arm from his right shoulder down to his mid forearm, and a splint to the right arm down to his fingers. Resident 193 stated he had a gun shot wound to his right shoulder and abdomen which made it very difficult for him to feed himself with his left hand. Resident 193 demonstrated how challenging it was for him when he attempts to lift the spoon up to his mouth to feed himself. Resident 193 stated his hand trembles when he attempts to feed himself and would spill most of the food on himself and on the table or floor. Resident 193 stated he is left-handed only and is not able to open his fruit cup, milk and to chop up his meals. During an observation on 3/24/25 at 1:17 p.m., the Rehabilitation Nursing Assistant (RNA) 1 took Resident 193's lunch tray to his bedside table and left the room. During an observation on 3/24/25 at 1:39 p.m., Resident 193's was still sitting up at his bedside with his lunch tray on his bedside table and the lunch plate still covered. The milk and water were still covered with a ceramic plastic wrap. Resident 193's food not chopped to bite size. Resident 193 stated he cannot remove the plastic wrap use to cover his milk and water from both cups. Resident 193 stated no staff had come into his room to help him with his meals since his tray was served by the RNA. During an interview and observation on 3/24/25 at 1:44 p.m. with Minimum Data Set Coordinator (MDSC), Resident 193's milk and water was still covered with the ceramic plastic wrap, his food not chopped and still covered with the lid. MDSC stated Resident 193 should have been assisted with eating during lunch mealtime as he is one handed, he could only use one hand for now with his present medical condition and getting assistance from staff will make Resident 193 able to eat his food served at lunch. During a review on 3/24/25 of Resident 193's Facesheet (FC), FC indicated Resident 193 is [AGE] years old male newly admitted to the facility, less than 30 days. The FC further indicated Resident 193 has diagnosis of Displaced Comminuted Fracture (bone breaks into three or more fragments) of Shaft of Humerus (long bone of the upper arm from shoulder to the elbow), right arm, need for assistance with his personal care, muscle weakness (generalized), Protein-Calorie Malnutrition (poor nutrition), open wound of right upper arm, open wound of left forearm. During a review on 3/24/25 of Resident 193's Physician Order Summary (POS), the POS indicated, keep brace on full time. Should remove brace for wound care and clean skin with an ordered date of 3/14/25. During a review on 3/26/25 of Resident 193's Occupational Therapy Treatment Encounter Notes ([NAME]), the [NAME] indicated, date of service 3/25/25, electronically signed at 8:39 p.m., by Occupational Therapist (OT). Functional skills Assessment- Activities of Daily Living (ADLs) & instrumental ADLs . Eating . =Substantial/maximal assistance . 97535 . Pt noted with tremor with LUE when bringing hand to mouth. Pt provided education on bringing head to stationary utensil held by LUE, able to complete without tremor. Nursing informed and collaborated with nursing regarding pt need for supervision and occasional CGA for self-feeding tasks. Pt need assistance for cutting-up food at this time. During an interview on 3/25/25 at 11:38 a.m. with OT, OT stated Resident 193 has been getting OT for the past one week. OT further stated Resident 193 needs contact guard (assistant to help support his hand),' with his meals. OT stated it is important Resident 193 gets the assistant he requires from staff as it is very challenging for Resident 193 when he tries to self-feed, without any staff supervision or assistant.

Based on observation, interview, and record review, the facility failed to allow two out of 27 Residents (Residents 45 and 70) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 45 and 70 feeling upset and disrespected. Findings: During a review of Resident 45's admission Record, printed 3/27/25, the record indicated Resident 45 was admitted to the facility in October 2021 with a diagnosis of constipation. During a review of Resident 45's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 1/22/25, the record indicated Resident 45's BIMS score was 15. During a review of Resident 70's admission Record, printed 3/27/25, the record indicated Resident 2 was admitted to the facility in June 2023 with a diagnosis of constipation. During a review of Resident 70's BIMS, dated 3/12/25, the record indicated Resident 70's BIMS score was 15. During a concurrent observation and interview on 3/24/25, at 1:03 p.m., in the facility dining room, Residents 61 and 70's lunch trays were observed without salad. Residents 61 and 70 stated they were supposed to get salads with their lunch, and they were upset because they did not get them. During a concurrent observation and interview on 3/24/25, at 3:31 p.m., with Resident 45, Resident 45's lunch tray was observed with cut tomatoes in their salad. Resident 45 stated they were not supposed to get tomatoes and did not eat their salad. Resident 45 stated they felt disrespected. During an interview on 3/28/25, at 10:50 a.m., with Registered Dietician (RD), RD stated it was important follow resident food choices so they would have felt comfortable and happy with the food and satisfied. During a review of Resident 70's Lunch Meal Ticket, dated 3/24/25, the Meal Ticket indicated, Resident 70's Likes: Salad with Lunch During a review of Resident 45's Lunch Meal Ticket, dated 3/24/25, the Meal Ticket indicated, Resident 45's Dislikes: .Tomato Products . During a review of the facility's policy and procedure (P&P) titled, Dietary Profile and Resident Preference Interview, revised April 21, 2022, the P&P indicated, The Dietary Department will provide residents with meals consistent with their preferences and Physician order as indicated on the tray card.

Based on interview and record review, for one of six sampled residents (Resident 58) who were investigated for advance directives, the facility failed to ensure Resident 58 was afforded the right to formulate an advanced directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated). This failure had the potential to result in Resident 58's wishes for life-sustaining treatment not documented and respected. Findings: During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted to the facility in January 2025 with diagnoses that included chronic obstructive pulmonary disease. The AR also indicated Resident 58 was self-responsible, and two significant others, a sister and a friend, as emergency contacts. During a review of Resident 58's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 2/5/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent interview and record review on 3/25/25 at 10:10 a.m. with Registered Nurse (RN) 2, RN 2 stated there is no copy of Resident 58's Physician Order for Life Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration) in the clinical record to show if Resident 58 had an advanced directive. RN 2 stated, should Resident 58 go into cardiac arrest, Resident 58 will be treated as Full Code (indicates that a patient wants their medical team to do everything possible to save their life in the event of a medical emergency, such as cardiac or respiratory arrest.) and all necessary life-saving treatments will be provided since there is no information about Resident 58's choices in the chart. During an interview on 3/27/25 at 11:20 a.m. with Resident 58, Resident 58 stated not having an advance directive but would like to make changes to current code status, if given the opportunity. Resident 58 also stated not wanting to have artificial nutrition and artificial ventilation/respiration and wanted to live a natural life. Resident 58 stated signing the pink paper while in the hospital but has not been offered to formulate an advanced directive since being admitted to the facility. During a joint interview on 3/27/25 at 11:23 a.m. with Resident 58 and Social Services Director (SSD), SSD stated a care conference meeting was held with Resident 58 and Resident 58's son right after Resident 58 was admitted to the facility. SSD stated Resident 58 at the time wanted to be Full Code. Resident 58 stated not recalling such meeting, and added Resident 58's son is not of legal age to make healthcare decisions. Resident 58 stated she wanted to change code status while still cognitively able to make those decisions. During a concurrent interview and review of Resident 58's clinical record on 3/27/25 at 11:52 a.m. with SSD, SSD stated there was no documentation in Resident 58's clinical record of a care conference meeting to discuss advance directive and Resident 58's choices of life-sustaining treatment. SSD also added it was not necessary to complete and keep a copy of a signed POLST form in the medical record. During a review of the facility's policy and procedure (P&P) tiled Physician Orders for Life-Sustaining Treatment (POLST) last revised 6/3/2020, the P&P indicated, a resident can change his/her mind about his/her treatment preferences by executing a verbal or written advance directive.

2.During a record review on 3/25/25 of Resident 37's Facesheet (FC), the FC indicated Resident 37 is [AGE] year old female admitted to the facility in 2021. The FC also indicated Resident 37 has diagnosis of Primary Osteoarthritis (a degenerative joint condition, causing pain, , swelling, stiffness that prevents a person from moving freely) Right Hip, Neuralgia (Nerve pain) and Neuritis (inflammation of the peripheral nerves), low Back Pain, and Arthropathy (disease of the joint). During an observation and an interview on 3/25/25 at 11:20 a.m. in Resident 37's room, Lidocaine 5% patch medication was the packet, left open and unsupervised on Resident 37's bedside table. Resident 37 stated License Vocational Nurse (LVN) 2 had left the medication patch on her bedside table for her assigned Certified Nursing Aide (CNA) to apply the Lidocaine patch on her after assisting her with her morning Activity of Daily Living (ADL) care. Resident 37 stated she is legally blind and cannot see anything, neither the TV. During an interview on 3/25/25 at11:30 a.m. with LVN 2, LVN 2 stated the Lidocaine patch medication placed on Resident 37's bedside table was Resident 37's Lidocaine pain patch medication and that she had placed it on Resident 37's bedside table. LVN 2 further stated she should not have left the medication pain patch unattended on the table as there is a risk of a staff or another Resident picking up the medication and use it for non-intended uses. LVN 2 also stated she had signed for the medication in the Medication Administration Record (MAR) without administering the Lidocaine pain patch to Resident 37. During a record review on 3/25/25 at 11:57 a.m., of Resident 37's MAR, the MAR indicated Lidocaine External Patch 5% administration scheduled time at 8:00 a.m., and the MAR had been signed as given by LVN 2 at 8:00 a.m. During a record review on 3/25/25 at 12:00 p.m., of Resident 37's Physician Order Summary, the Physician Order Summary indicated Lidocaine External Patch 5 % (Lidocaine) to apply to lower back topically one time a day for pain management 12 on, 12 hours off, and remove per schedule, with a start date on 1/03/2025, and no end date. During a record review of facility's Policy and Procedure (P&P), the P&P title Medication-Administration dated 01/01/2021, indicated, Purpose .To ensure the accurate administration of medication for resident in the facility .-I. Medication will be administered directly by a licensed Nurse and upon the ordered a physician or licensed independent practitioner .-II. no medication will be used for any patient other than the patient for whom it was prescribed .1-B. The Licensed Nurse will prepare medications within one hour of administration .I. Medications may be administered one hour before or after the scheduled medication administration time . X. Documentation .A. The time and dose of the drug or treatment administration to the patient will be recorded in the patient's individual medication record y the person who administered the drug or treatment .B. Recording will include the date, the time and the dosage of the medication or type of treatment. Based on observation, interview and record review, the facility failed to provide services to meet professional standards of quality for two of two sampled residents (Resident 12 and 37) when: 1. Licensed Vocational Nurse (LVN) 1 was not knowledgeable of the correct indication, dosage, and administration procedure of Resident 12's rivastigmine (medication used to treat mild, moderate, and severe dementia (memory loss and mental changes) associated with Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills) transdermal (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) patch. These failures resulted in Resident 12 to receive inadequate dosage of rivastigmine and not according to manufacturer's specification. 2. Resident 37's lidocaine patch (medication to ease pain by numbing the nerves and making them less sensitive to pain) was not applied per physician orders and left unsupervised at the bedside table. These failures resulted in Resident 37 to not receive lidocaine as ordered by the physician and potential for other residents to have access to unsupervised medication. These failures resulted in Resident 12 not receiving adequate dosage of rivastigmine according to manufacturer's specification and Resident 37 not receiving lidocaine as ordered and other residents to have access to unsupervised medication. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in [DATE] with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause) and dementia. During medication administration observation on 3/25/25 at 9:08 a.m. with LVN 1, LVN 1 was observed preparing three medications for Resident 12. These medications included one tablet of Eliquis (a blood thinner medicine that reduces blood clotting), one tablet of Metoprolol (a medication that lowers blood pressure and heart rate) and one Rivastigmine 13.3 milligram (mg)/24 hour (hr) transdermal patch. During a concurrent observation and interview, on 3/25/25 at 9:28 a.m. with LVN 1, in Resident 12's room, LVN 1 administered Resident 12's one tablet of Eliquis and one tablet of Metoprolol. LVN 1 applied one rivastigmine 13.3 mg/24 hr transdermal patch to Resident 12's left rear shoulder without removing the old patch. LVN 1 stated Resident 12's Rivastigmine transdermal patch that was applied the day before was removed by the evening nurse last night. LVN 1 stated the patch was applied to the left shoulder for pain. During a review of Resident 12's Order Summary Report dated 2/26/23, the Order Summary Report indicated, Resident 12 had an order to receive one transdermal patch of rivastigmine 13.3 mg/24 hr one time a day and remove per schedule for dementia. During a follow up concurrent interview and record review, on 3/25/25 at 3:01 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR) dated 3/25/25 was reviewed. The MAR indicated, Resident 12's rivastigmine 13.3 mg/24 hr transdermal patch was to be removed at 08:59 a.m. and applied at 9:00 a.m. one time a day for dementia. LVN 1 stated the evening nurse removed the patch. LVN 1 stated the patch was applied to Resident 12's left rear shoulder because Resident 12 complained of left shoulder pain most of the time. During a review of Resident 12's March 2025 MAR, the MAR indicated, rivastigmine 13.3 mg/24 hr transdermal patch was applied on Resident 12's left rear shoulder on 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/15/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/22/35, 3/23/25, 3/24/25 and 3/25/25. The MAR indicated, the site was not rotated as per manufacturer's guidelines. During a review of rivastigmine manufacturer's specification dated 5/24, the manufacturer's specification indicated, rivastigmine transdermal patch is indicated for the treatment of dementia of the Alzheimer's type . Apply patch on intact skin for a 24-hour period; replace with a new patch every 24 hours . Change the site of patch application daily to minimize potential irritation. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/022083s028lbl.pdf) During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines.

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) and the Ombudsman within two hours for one of 27 sampled residents (Resident 92), when Resident 92's sister alleged a Registered Nurse (RN) called Resident 92 stupid. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents. Findings: A review of Resident 92's Admission Record printed 3/27/25, indicated Resident 92 was admitted to the facility in September 2023 with a diagnosis of chronic pain. During an interview on 3/26/25, at 1:25 p.m. with RN 1, RN 1 stated, on 2/9/25 Resident 92's sister notified RN 1 that an unknown nurse called Resident 92 stupid. RN 1 stated they did not complete and submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), to the ombudsman or CDPH. RN 1 stated they did not notify the ombudsman or CDPH of the alleged abuse. During an interview on 3/26/25, at 3:25 p.m. with Medical Records (MR), MR stated on 2/9/25 Resident 92's sister notified MR an unknown nurse called Resident 92 stupid. MR stated they did not complete and submit a SOC 341, to the ombudsman or CDPH. MR stated they did not notify the ombudsman or CDPH of the alleged abuse. During a concurrent interview and record review on 3/26/25, at 12:03 p.m., with Social Services Director (SSD), Resident 92's SOC 341, dated 2/10/25, was reviewed. SSD stated on 2/10/25, at approximately 5 p.m., Resident 92 notified SSD that RN 1 called Resident 92 stupid. SSD stated they completed the SOC 341, and notified the ombudsman and CDPH of the alleged abuse within 2 hours of the reported abuse. SSD stated their policy was to notify the ombudsman and CDPH within 2 hours of alleged abuse to protect the residents. During a review of the facility's policy and procedure (P&P) titled, Abuse - Reporting & Investigations, revised March 2018, the P&P indicated, Notifications of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury . The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the ombudsman and Law Enforcement . The Administrator or designated representative will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and maintain a functioning elopement alarm (a system that activates when an individual wearing a specific transmitter crosses the threshold of the alarm's receiver), for two (Residents 1 and 2) of two sampled residents identified as at risk for elopement. This failure resulted in Resident 1 leaving the facility's premises unsupervised and had the potential for harm. For Resident 2, this had the potential for elopement without alerting staff. Definition: Immediate jeopardy is a situation in which a provider ' s noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident. This failure was determined to constitute Immediate Jeopardy (IJ) when staff failed to ensure the elopement alarm alert system was fully operational. The Administrator (ADM) was verbally notified of the IJ on 11/30/21 at 3:58 p.m. Through observations and interviews with staff members, including record reviews of the facility's training records, the facility initiated their plan of action through training of their employees regarding elopement risk and use of the elopement monitoring device. The IJ was lifted on 12/1/21 at 1:05 p.m. Findings: 1. During a record review of Resident 1's Admission Record dated 11/30/21, which indicated Resident 1 was admitted to the facility with diagnoses of [CONDITION(S)] (liver damage), alcohol dependence with intoxication and [CONDITION(S)] (chronic progressive disease causes damage to the brain). During a record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool used to plan care) dated 8/22/21, on the Brief Interview for Mental Status (BIMS, a tool for cognitive assessment) showed Resident 1 scored 8 out of 15 indicating moderate cognitive impairment. During a record review of Resident 1's Elopement Evaluation dated 9/3/21 indicated Resident 1 was at risk for elopement due to a history of elopement at home and at the facility with wandering behavior. During an interview with the Director of Nursing (DON) on 11/30/21 at 10:30 a.m., DON stated Resident 1 eloped from the facility on 11/23/21 and was located at the local supermarket half a mile from the facility. Resident 1 was taken to the ED by ambulance and was returned to the facility on the same day without injury. DON further stated the facility purchased an alternate alarm system for Resident 1 called Alerta (alarm system that has a transmitter attached to the person's body and secured by an adhesive patch). DON stated the Alerta receiver was set to alarm when the transmitter was 100 feet away from the receiver which was kept in the Social Services Coordinator's (SSC) office. DON further stated the facility initiated Alerta because Resident 1 had previously removed the CODE ALERT Wander Management alarm (a system that tracks a person using a wrist or ankle bracelet which automatically alarms if the person moves outside a defined area). During record review of Resident 1's Health Status Note (Nurse's Notes) dated 11/23/21, Resident 1 was returned to the facility from the Emergency Department at 6:15p.m. by ambulance. During an observation and interview with the ADM on 11/30/21, at 10:35 a.m., Resident 1 was sitting in a chair at the main entrance. ADM removed Resident 1's right shoe and removed the inner sole. The Alerta alarm transmitter was under the heel of the inner sole inside the Resident 1's shoe. During an observation and interview with SSC on 11/30/21, at 11:10 a.m., SSC took the Alerta transmitter recovered from Resident 1's shoe 850 feet away from the Alerta receiver. The receiver was back at the facility with DON, and DON stated the receiver did not alarm. During a record review of the undated User's Guide for Alerta which indicated, The Patch and the Wedge communicate with each other when they are up to 65 to 90 feet apart depending on the environment. Beyond this distance the Wedge will alarm and flash.Applying the Patch to the Body: 1. Remove the covering from the adhesive lining on the perimeter of the underside of the Patch. 2. Place the Patch on the upper back . During an observation and further interviews with SSC on 11/30/21 at 11:20 a.m. and 1:15 p.m., SSC stated the battery-operated receiver had a light indicating both power and signal strength but could not remember when she last saw the signal and never changed the batteries in the device. SSC stated Alerta was implemented for Resident 1 around 9/2021 and confirmed it was not blinking on 11/30/21. Furthermore, none of the staff, including Resident 1's direct care staff or the reception staff were trained on the use of the Alerta System. SSC stated the Interdisciplinary Team (IDT) was responsible to ensure the Alerta system was working properly and there was no documentation indicating the Alerta system was functioning properly since 9/2021. During an interview with DON on 11/30/21 at 12:15p.m., DON stated Resident 1 had eloped before on 11/15/21 in addition to 11/23/21 after the facility initiated the Alerta system. During an interview on 11/30/21 at 12:32 p.m., the Certified Nursing Assistant (CNA 1) assigned to Resident 1 on 11/23/21, last saw Resident 1 when she picked up his lunch tray between 1:00 p.m. and 1:30 p.m. During an interview with the Licensed Vocational Nurse, (LVN 1) on 11/30/21, at 12:26 p.m., LVN 1 stated she was the Charge Nurse on 11/23/21 when Resident 1 eloped. LVN 1 stated she was informed that Resident 1 left the building and was found at the local supermarket by an off-duty staff member (CNA 2). During an interview on 11/30/21, at 1:50 p.m., Registered Nurse 1 (RN 1) stated she had not been trained on the use of the Alerta system. During an interview on 12/1/21 at 12:32 p.m., the front desk Receptionist stated on 11/23/21, the Alerta alarm did not sound when Resident 1 managed to leave the facility and had received a call from CNA 2 that Resident 1 was at the local supermarket. The Receptionist checked her cell phone showing the alert was issued on 11/23/21 at 2:13 p.m. notifying the ADM, SSC, Social Services Director, and DON via text message. During a telephone interview on 12/3/21 at 12:00 p.m., CNA 2 stated she was off work on 11/23/21 and at the local supermarket, about a half mile away from the facility between 1:00 p.m. and 1:30 p.m. CNA 2 stated she saw Resident 1 speaking to a vendor in the parking lot, and as she approached Resident 1, he walked away from the vendor. The vendor told CNA 2 that Resident 1 was waiting for an ambulance. CNA 2 called the facility to report Resident 1's whereabouts. 2. During an interview and record review on 11/30/21 at 11:30 a.m., DON highlighted residents at risk for elopement on the resident census dated 11/29/21 which included Resident 2. During a record review of Resident 2's MDS dated [DATE] indicated Resident 2 had a BIMS score of 8 out of 15 indicating moderate cognitive impairment and was ambulatory with a walker. During an interview on 11/30/21 at 2:46 p.m., LVN 2 stated Resident 2 was identified as an elopement risk because she tried to exit the facility unattended a few weeks ago. During an observation and interview on 11/30/21 at 2:50 p.m. with LVN 2 and DON, Resident 2 was walking with a front wheel walker in the hallway. DON stopped Resident 2 to check for the elopement alarm transmitter on Resident 2's wrists and ankles and confirmed there was no transmitter on Resident 2. During an interview and record review on 11/30/21 at 3:41 p.m. of Resident 2's Nurses Notes dated 10/7/21, LVN 3 stated on 10/7/21, Resident 2 exited the facility unattended and was returned from the rear parking lot by ADM. LVN 3 stated ADM asked her to obtain a physician's order for the elopement alarm transmitter placement for Resident 2 and obtained the order from the On-Call physician. LVN 3 stated Resident 2 needed a wander guard due to her wandering behavior. LVN 3 stated if Resident 2 managed to leave the facility unattended, she could be seriously injured because the street the facility was located on a very busy street. During a record review of Resident 2's physician orders dated 10/7/21 which indicated to, Place Wander Guard (generic term for elopement alarm system) to prevent elopement. During a record review of Resident 2's Wandering/Elopement Care plan dated 10/7/21, indicated staff were to place the elopement alarm on Resident 2 and assure the alarm was functional. During a record review of the Wander Management User Guide dated 2018 indicated, The Wander Management Solution monitors doors, elevators, hallways and stairwells to assist staff in monitoring residents in facilities. The transmitter is place on the wrist or ankle of the resident. If a transmitter is detected in an Exit Alarm Zone and the door is open, the alarm sounds at the exit. During a record review of facility's undated policy and procedure, Wandering and Elopement which indicated the facility's purpose was To enhance the safety of residents of the facility .The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and maintain a functioning elopement alarm (a system that activates when an individual wearing a specific transmitter crosses the threshold of the alarm's receiver), for two (Residents 1 and 2) of two sampled residents identified as at risk for elopement. This failure resulted in Resident 1 leaving the facility's premises unsupervised and had the potential for harm. For Resident 2, this had the potential for elopement without alerting staff. Definition: Immediate jeopardy is a situation in which a provider ' s noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident. This failure was determined to constitute Immediate Jeopardy (IJ) when staff failed to ensure the elopement alarm alert system was fully operational. The Administrator (ADM) was verbally notified of the IJ on 11/30/21 at 3:58 p.m. Through observations and interviews with staff members, including record reviews of the facility's training records, the facility initiated their plan of action through training of their employees regarding elopement risk and use of the elopement monitoring device. The IJ was lifted on 12/1/21 at 1:05 p.m. Findings: 1. During a record review of Resident 1's Admission Record dated 11/30/21, which indicated Resident 1 was admitted to the facility with diagnoses of [CONDITION(S)] (liver damage), alcohol dependence with intoxication and [CONDITION(S)] (chronic progressive disease causes damage to the brain). During a record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool used to plan care) dated 8/22/21, on the Brief Interview for Mental Status (BIMS, a tool for cognitive assessment) showed Resident 1 scored 8 out of 15 indicating moderate cognitive impairment. During a record review of Resident 1's Elopement Evaluation dated 9/3/21 indicated Resident 1 was at risk for elopement due to a history of elopement at home and at the facility with wandering behavior. During an interview with the Director of Nursing (DON) on 11/30/21 at 10:30 a.m., DON stated Resident 1 eloped from the facility on 11/23/21 and was located at the local supermarket half a mile from the facility. Resident 1 was taken to the ED by ambulance and was returned to the facility on the same day without injury. DON further stated the facility purchased an alternate alarm system for Resident 1 called Alerta (alarm system that has a transmitter attached to the person's body and secured by an adhesive patch). DON stated the Alerta receiver was set to alarm when the transmitter was 100 feet away from the receiver which was kept in the Social Services Coordinator's (SSC) office. DON further stated the facility initiated Alerta because Resident 1 had previously removed the CODE ALERT Wander Management alarm (a system that tracks a person using a wrist or ankle bracelet which automatically alarms if the person moves outside a defined area). During record review of Resident 1's Health Status Note (Nurse's Notes) dated 11/23/21, Resident 1 was returned to the facility from the Emergency Department at 6:15p.m. by ambulance. During an observation and interview with the ADM on 11/30/21, at 10:35 a.m., Resident 1 was sitting in a chair at the main entrance. ADM removed Resident 1's right shoe and removed the inner sole. The Alerta alarm transmitter was under the heel of the inner sole inside the Resident 1's shoe. During an observation and interview with SSC on 11/30/21, at 11:10 a.m., SSC took the Alerta transmitter recovered from Resident 1's shoe 850 feet away from the Alerta receiver. The receiver was back at the facility with DON, and DON stated the receiver did not alarm. During a record review of the undated User's Guide for Alerta which indicated, The Patch and the Wedge communicate with each other when they are up to 65 to 90 feet apart depending on the environment. Beyond this distance the Wedge will alarm and flash.Applying the Patch to the Body: 1. Remove the covering from the adhesive lining on the perimeter of the underside of the Patch. 2. Place the Patch on the upper back . During an observation and further interviews with SSC on 11/30/21 at 11:20 a.m. and 1:15 p.m., SSC stated the battery-operated receiver had a light indicating both power and signal strength but could not remember when she last saw the signal and never changed the batteries in the device. SSC stated Alerta was implemented for Resident 1 around 9/2021 and confirmed it was not blinking on 11/30/21. Furthermore, none of the staff, including Resident 1's direct care staff or the reception staff were trained on the use of the Alerta System. SSC stated the Interdisciplinary Team (IDT) was responsible to ensure the Alerta system was working properly and there was no documentation indicating the Alerta system was functioning properly since 9/2021. During an interview with DON on 11/30/21 at 12:15p.m., DON stated Resident 1 had eloped before on 11/15/21 in addition to 11/23/21 after the facility initiated the Alerta system. During an interview on 11/30/21 at 12:32 p.m., the Certified Nursing Assistant (CNA 1) assigned to Resident 1 on 11/23/21, last saw Resident 1 when she picked up his lunch tray between 1:00 p.m. and 1:30 p.m. During an interview with the Licensed Vocational Nurse, (LVN 1) on 11/30/21, at 12:26 p.m., LVN 1 stated she was the Charge Nurse on 11/23/21 when Resident 1 eloped. LVN 1 stated she was informed that Resident 1 left the building and was found at the local supermarket by an off-duty staff member (CNA 2). During an interview on 11/30/21, at 1:50 p.m., Registered Nurse 1 (RN 1) stated she had not been trained on the use of the Alerta system. During an interview on 12/1/21 at 12:32 p.m., the front desk Receptionist stated on 11/23/21, the Alerta alarm did not sound when Resident 1 managed to leave the facility and had received a call from CNA 2 that Resident 1 was at the local supermarket. The Receptionist checked her cell phone showing the alert was issued on 11/23/21 at 2:13 p.m. notifying the ADM, SSC, Social Services Director, and DON via text message. During a telephone interview on 12/3/21 at 12:00 p.m., CNA 2 stated she was off work on 11/23/21 and at the local supermarket, about a half mile away from the facility between 1:00 p.m. and 1:30 p.m. CNA 2 stated she saw Resident 1 speaking to a vendor in the parking lot, and as she approached Resident 1, he walked away from the vendor. The vendor told CNA 2 that Resident 1 was waiting for an ambulance. CNA 2 called the facility to report Resident 1's whereabouts. 2. During an interview and record review on 11/30/21 at 11:30 a.m., DON highlighted residents at risk for elopement on the resident census dated 11/29/21 which included Resident 2. During a record review of Resident 2's MDS dated [DATE] indicated Resident 2 had a BIMS score of 8 out of 15 indicating moderate cognitive impairment and was ambulatory with a walker. During an interview on 11/30/21 at 2:46 p.m., LVN 2 stated Resident 2 was identified as an elopement risk because she tried to exit the facility unattended a few weeks ago. During an observation and interview on 11/30/21 at 2:50 p.m. with LVN 2 and DON, Resident 2 was walking with a front wheel walker in the hallway. DON stopped Resident 2 to check for the elopement alarm transmitter on Resident 2's wrists and ankles and confirmed there was no transmitter on Resident 2. During an interview and record review on 11/30/21 at 3:41 p.m. of Resident 2's Nurses Notes dated 10/7/21, LVN 3 stated on 10/7/21, Resident 2 exited the facility unattended and was returned from the rear parking lot by ADM. LVN 3 stated ADM asked her to obtain a physician's order for the elopement alarm transmitter placement for Resident 2 and obtained the order from the On-Call physician. LVN 3 stated Resident 2 needed a wander guard due to her wandering behavior. LVN 3 stated if Resident 2 managed to leave the facility unattended, she could be seriously injured because the street the facility was located on a very busy street. During a record review of Resident 2's physician orders dated 10/7/21 which indicated to, Place Wander Guard (generic term for elopement alarm system) to prevent elopement. During a record review of Resident 2's Wandering/Elopement Care plan dated 10/7/21, indicated staff were to place the elopement alarm on Resident 2 and assure the alarm was functional. During a record review of the Wander Management User Guide dated 2018 indicated, The Wander Management Solution monitors doors, elevators, hallways and stairwells to assist staff in monitoring residents in facilities. The transmitter is place on the wrist or ankle of the resident. If a transmitter is detected in an Exit Alarm Zone and the door is open, the alarm sounds at the exit. During a record review of facility's undated policy and procedure, Wandering and Elopement which indicated the facility's purpose was To enhance the safety of residents of the facility .The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement.

Based on interviews and record reviews, the Facility 1 failed to implement dietary and physician recommendations for one of three sampled residents (1) to prevent Resident 1 from further weight loss, which resulted in Resident 1 being hospitalized for [REDACTED]. Resident 1 lost 4 pounds over two months from [DATE] when he weighed 99.8 pounds to [DATE] when he weighed 94.2 pounds. The facility failed to implement the dietary recommendations dated [DATE] to provide a fortified diet, give Med Pass (dietary supplement) with medications three times a day; and weigh the resident weekly as ordered by the physician on [DATE], resulting in Resident 1 continuing to lose weight and by [DATE], he weighed 91 pounds and required hospitalization for weight loss, dehydration and kidney failure. Findings: An unannounced visit was made to Facility 1 on [DATE] to investigate a complaint the California Department of Public Health received regarding Resident 1 being neglected at the facility. On [DATE], review of Resident 1's closed record showed Resident 1 was originally admitted to the facility on [DATE]. His admission [DIAGNOSES REDACTED]. Review of the annual comprehensive MDS (Minimum Data Set - an assessment tool), dated [DATE], and the quarterly MDS, dated [DATE], documented Resident 1 required total assistance of one to two people with his activities of daily living including eating. Review of the weight record revealed Resident 1 was five feet two inches tall and weighed 99.8 pounds on [DATE]. Resident 1's last documented weight at the facility was on [DATE] and he weighed 94.2 pounds. According to the facility's form titled, Amount Eaten dated between [DATE] and [DATE], Resident 1 ate ,[DATE] % of his breakfast, lunch and dinner on the following dates: breakfast on ,[DATE] and [DATE]; lunch on [DATE], [DATE] and [DATE]; dinner on [DATE], ,[DATE] - [DATE], [DATE], and [DATE]. On the following dates Resident 1 ate 26 % to 50 % of his meals: breakfast on [DATE], [DATE] and [DATE] through [DATE]; lunch on [DATE], [DATE], and [DATE], and [DATE] and dinner on [DATE], [DATE], [DATE], and [DATE]. A physician's telephone order dated [DATE] at 7:00 p.m. instructed the staff to weigh Resident 1 weekly times four and to have a R.D. (Registered Dietician) Consultation. The record review showed that the R.D. visited the facility on [DATE] and documented on the Nutrition Care Notes that Resident 1's nutritional needs were not met with his current intake; and his weight loss was likely related to his variable by his oral intake. The R. D. interventions and goals for Resident 1 included: 1. Change diet from regular pureed diet to fortified diet (add extra nutrients butter, gravy etc.) 2. Increasing Med Pass (dietary supplement) to 120 ml (milliliter) three times a day with medication pass. 3. Weigh Resident 1 weekly for four times as his physician had ordered. Review of the Medication Record showed the nursing staff did not implement the fortified diet or the increase of Med Pass until five days later on [DATE]. The Medication Administration Record [REDACTED]. Review of Physician/NP/PA Communication and Progress Note, dated [DATE] at 10:20 p.m. showed that Nurse 5 documented, At about 10:15 p.m. upon assessing pt. (patient), I noted pt. with sunken eyes (sign of severe dehydration), poor appetite, gave Med Pass ., called MD/NP (medical doctor/nurse practitioner), explained my observation and the change of condition of pt. NP ordered pt. to be sent out. Further review of the acute hospital ED (Emergency Department) notes, dated [DATE] 11:54 p.m., showed, Patient presents with low blood pressure, . decreased intake the last two days and decrease urinary output. The lab test showed that Resident 1 had acute [MEDICAL CONDITION]. Resident also had [MEDICAL CONDITION] (an electrolyte imbalance indicated by a high level of sodium in the blood) which was severe. At that time, the ED doctor wrote, Patient will require admission. According to the acute hospital notes, Resident 1's admission weight was 91 pounds on [DATE]. According to the acute hospital History and Physical report, Resident 1 was treated with intravenous fluid (given through the vein) for his dehydration and he was medicated with different types of vitamins to treat his protein calorie malnutrition diagnoses. While Resident 1 was still in the acute hospital, he was placed under hospice care (the last stage of life due to terminal illness) due to his poor prognosis. Review of the acute hospital discharge summary dated [DATE] showed that Resident 1 was transferred to a Facility 2 (skilled nursing facility) and according to the Facility 2's face sheet, Resident 1 expired on [DATE]. On [DATE] at 10:00 a.m., during a telephone interview, the facility nurse practitioner stated that Resident 1 had a good appetite and he was a feeder as she knew. The nurse practitioner stated, They (facility staff) did not notify me about his not eating. They usually call me for problems and if I don't answer, they will call the doctor. During a telephone interview on [DATE] at 10:45 a.m., Resident 1's physician stated the nurses did not tell him the Resident was not eating. He stated he could have order an appetite stimulant for him.

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection affecting one of 19 sampled residents (Resident 9) who had an intestinal infection due to Clostridium difficile with active diarrhea. (Clostridium difficile, also known as C.diff, is a germ that can cause watery diarrhea, fever, loss of appetite. [DIAGNOSES REDACTED] spores can live outside the human body for a very long time (as long as 5 months) and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. C.diff infection can spread from person-to-person on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors. (Centers for Disease Control and Prevention - CDC Frequently Asked Questions (FAQ)). Resident 9 was identified during the survey as having an active[DIAGNOSES REDACTED]. infection beginning on 4/8/15. The facility did not have surveillance records for infections in March or May, 2015 and Resident 9 was the only identified infection in April 2015. The facility also failed to prevent the spread of infection by not implementing their policies and procedures for handling the soiled linen, housekeeping and meal delivery for a resident (9) with active C.Diff. The facility licensed nurses failed to follow policies and procedures for dressing changes when the DSD and LVN 13 did not wear gloves while setting up the treatment supplies for two (7,11) residents in a sample of 19. These failures resulted in the potential to spread C.-Diff, a hardy bacteria which can cause a debilitating illness which could result in hospitalization or even death, among the residents with multiple medical problems. The Regional Administrator (RAdmin) was notified of an immediate jeopardy on 5/4/15 at 10:40 a.m. The facility's staff lack of awareness of infected individuals, and lack of an infection control program with an appointed coordinator to monitor, control and prevent the spread of infection was a threat to the health of the individuals living and working in the facility. The DON nor any other nursing staff had any knowledge of the numbers of infected residents in the facility at the time of the survey. One resident (9) was identified as having C.Diff. and had been moved to a single room from a three bed room two weeks ago. The facility records however, reflect Resident 9 had[DIAGNOSES REDACTED]. since February 2015. The CNAs, Laundry worker, Housekeeping, and Dietary departments were not notified and the contaminated linens were sent with the regular laundry, the meal trays sent to Resident 9 were commingled with the other dirty trays after she ate, and the housekeeper was not clear on the housekeeping procedures to prevent the spread of infection from Resident 9's room to the rest of the facility. During the extended survey 5/20/15 and 5/21/15 the immediate jeopardy was lifted and the faciity management including RAdmin were informed on 5/26/15 at 2:45 p.m. The facility obtained infection control professionals to establish a program of surveillance and provide training for the new Director of Staff Development to implement in the facility. Resident 9 was no longer infected with[DIAGNOSES REDACTED]. Findings: 1. The State Agency received complaints ( 4 and 1) regarding the lack of infection control in the facility and there were unnamed residents infected with C.-Diff who were wandering around the facility. Additionally, the staff weren't washing their hands when necessary, wearing gloves in the hallway, and not changing gloves between residents. During the initial tour of the facility on 5/4/15 at 8:20 a.m. Resident 9's room had a plastic container with gloves, paper gowns and face masks hanging over the door inside the room. There was a sign on the door to see nurses before entering room. LVN 3 stated at 8:46 a.m. that Resident 9 had C.-Diff and was moved from Station 2. She said that the staff should wear a gown, gloves and wash hands when going in and out, and everything stays in the room. On 5/4/15 at 8:20 a.m. observed one trash container in the room, but no container for soiled linen. In an interview with CNA 12 at 8:46 a.m. she stated that she would put Resident 9's soiled linen in a clear plastic bag and place it in the linen barrel in the hallway with the other resident's soiled linen. During an observation and interview in the laundry room on 5/4/15 at 9:15 with the Laundry worker, put on a mask and apron and gloves. She put linens from a barrel into the washing machine, added detergent and then turned on the machine. She then took of her gloves and apron off and washed her hands. She stated that if a resident has C.-Diff. the linen should be in a red bag and washed separately. She also stated that she was unaware of any resident having C.-Diff. in the facility. In an interview with the Janitor who was outside Resident 9's room at 9:45 a.m. he said that he did not know what the infection was in the room but remembered when another resident had a similar sign and set up and he would rear gloves and gown and disinfect everything and the walls. He didn't know if the resident had diarrhea. During a kitchen observation on 5/5/15 at 7:30 a.m. the cook stated that she had not heard of C.-Diff and never heard about it before. She was unaware of any residents that currently had an infection and unaware of the facility's policy and procedure for handling linen of[DIAGNOSES REDACTED] infected residents. A review of the facility's undated Laundry policy and procedure for C.Diff, reflected, .Be sure that all soiled linens containers on the floor are lined with red biohazard bags (to identify any linen that may have contacted c.Diff).Any surfaces that come in contact with the contaminated laundry should be wiped down with bleach.then disinfected.Be sure to wipe down the rim of the washer as well as the handle and the control panel. The DSD provided copies of the infection control Surveillance sheets on 5/4/15 which contained data from Jan, Feb and [DATE]. There were four instances of[DIAGNOSES REDACTED] identified. He stated that he had not been trained on infection control and those were to documents left over from the previous DSD. 2. Review of the clinical record, on 5/5/15 at 11:30, showed Resident 9 was admitted to the facility on [DATE] with multiple diagnoses. The document titled, Surveillance Data Collection Form, dated 4/12/15, indicated Resident 9 was hospitalized from [DATE] through 4/7/15 and readmitted to the facility on [DATE] with an onset of [DIAGNOSES REDACTED] on 4/8/15. During an observation and concurrent interview, on 5/6/15 at 8:10 a.m., CNA (certified nurse assistant) 14 carried a food tray into Resident 9's room. The tray was placed on Resident 9's over bed tray which had spills on top. The tray held food placed in disposable containers and disposable eating utensils. The plate of food was covered with a plastic food cover. When CNA 14 had finished feeding the resident, she stated, I don't know where we're supposed to throw the food. They just started this disposable stuff since you guys came. Usually we just put it on the cart with the other trays. CNA14 dumped the disposable containers and utensils and the leftover food in the trash container located in the room. CNA14 took the tray and food cover out of the room and placed them on a three tier cart sitting in the hallway. The top tier of the cart held three large carafes, two were labeled coffee and one was labeled hot water. The tray and food cover were placed on the second tier of the cart. During an interview, on 5/6/15 at 8:25 a.m., the DA (dietary aide) stated food trays were not allowed in Resident 9's room. The CNAs were to remove the food from the tray, leave the tray outside of the room and carry the food in the disposable containers into the room. When done, the disposable items were to be discarded in the trash container in the resident's room. The DA stated this information had been discussed with the charge nurses. During an interview, on 5/6/15 at 8:42 a.m., LVN (licensed vocational nurse) 2 stated the CNAs working with Resident 9, including CNA14, had been told to take disposable plates and utensils into Resident 9's room and leave the tray outside of the room. In an interview, on 5/6/15 at 8:40 a.m., the DSD stated LVN2 had been trained yesterday after a meeting in which someone mentioned it would be good to start using disposable plates and utensils in the infected rooms and leave the tray outside of the room. (re: Complaint 4 and 1) 3. Review of the clinical record, on 5/4/15 at 1:30 p.m., showed Resident 7 was admitted to the facility with multiple medical [DIAGNOSES REDACTED].) During an observation and concurrent interview, on 5/4/15 at 2:46 p.m., LVN (licensed vocational nurse) 13 prepared to do Resident 7's dressing change for a pressure ulcer of the sacrum (lower back). LVN13 placed three plastic containers onto the top of the treatment cart, which was sitting in the hall outside of the resident's room. LVN13 poured normal saline (salt water solution) into 2 of the plastic cups, put on a pair of non-sterile gloves and placed gauze into the third cup. LVN 13 took the cups, an unopened package of packing strips and an unopened drape package into Resident 7's room and placed them on the soiled over bed table. LVN removed the gloves and spread the drape on the over bed table, and moved the containers and packing strips from the table onto the drape. When asked if LVN13 was using a clean technique (free from dirt) or sterile technique (free from organisms) for the dressing change, she stated, Sterile. Clean technique I would have used a bleach towelette, wiped it down to make sure the counter top was clean. Review of the facility's policy and procedure titled, Dressings- Application with a revision date of 1/01/12 under Application of Sterile Dressings (Clean Technique) read, Set up non-sterile moisture barrier drape on over-bed tale only. Bring all dressings, solutions and items to be used and place on on-sterile drape. (re: Complaint 9) 4. During the initial observation of the facility on 5/4/15 at 11:00 a.m. the maintenance supervisor had the maintenance cart in Resident 9's bathroom. During an interview with the maintenance supervisor on 5/4/15 at 11:15 a.m. he stated , I'm changing the light bulb. I did not have an inservice. I couldn't tell you what precautions to take for C Diff. 5. On 5/5/15 at 2:30 p.m. the surveyor observed the DSD prepare to do the treatment to Resident 11's stage three (Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible) pressure sore on her right shin. The DSD removed some gauze from one package and opened up another package and removed a self adhesive dressing without wearing gloves. He then put gloves on went into Resident 11's room and after removing the old dressing washing his hands and putting new gloves on he cleansed the pressure sore to her right shin with the gauze and covered it with the adhesive dressing. Review of the facility's policy and procedure for dressings application revised on 1/ 1/12 read under purpose, To ensure cleanliness and prevent infection by protecting the skin's surface and to promote comfort and wound healing. Under procedure read, Wash hands before and after each procedure and put on gloves. During an interview with the DSD on 5/6/15 at 8:15 a.m. he stated, I didn't receive any formal training on wounds. The previous treatment nurse just gave me a run down on how she was doing the treatments. I just started doing the treatment from memory. This was my first job as a licensed nurse. I've only been a nurse for ten months. (re: Complaint 9)

Based on observation, interview and record review, the facility failed to provide services for untreated and unassesed skin ulcers, and untreated pain for four residents (1, 3, 13, 14) of 19 sampled residents and two additionally sampled (29, 30) resulting in the neglect of residents' (1, 3, 13, 29, 30) skin ulcers resulting in the residents being placed at risk for infection and neglect of residents (3, 14)who did not receive pain medications timely. Resident 1 had physician's orders [REDACTED]. skin, bones, possibility of losing his leg and at risk for infection due to the lack of nursing care as prescribed by his physician. Resident 3 was placed on Hospice (end of life) care and did not receive medications and pressure ulcer care as ordered. She went without [MEDICATION NAME] (narcotic pain relief medication) for 19 hours when it was to be given every four hours, and her open pressure ulcers went untreated. The nurses did not follow doctor's orders for Hospice care resulting in Resident 3 suffering from pain and agitation due to not receiving Hospice medication, and not receiving pressure ulcer treatment. Resident 13 was paralyzed and had extensive pressure ulcers to his buttocks and upper thighs. He was exhibiting symptoms of illness and his family insisted he be sent to the hospital. He was sent to the ER where the doctor documented they found the resident covered in feces from his mid back to his upper thighs, and was subsequently place in the intensive care unit [MEDICAL CONDITION] (potentially life threatening complication of an infection). Resident 14 was admitted to the facility with orders for a medication to treat his pain which was not provided by the facility resulting in Resident 14 stating he felt like he was going to die if if he did not get his medication. He called 911 to take him to the hospital in order to obtain his medication. During the extended survey on 5/20/15 and 5/21/15, two additional residents were found to have ulcerated skin that was not assessment or treated. Resident 29 had an open pressure ulcer on his right elbow which was identified by the Occupational Therapist (OT) and reported to the DSD. The DSD did not notify the physician, obtain treatment orders or treat the resident's open area which put him at risk for further breakdown and/or infection. Resident 30 had a pin (metal rod) in his left lower leg (through the skin bone) that had an open area around the pin site and was on antibiotic medication to treat a bone infection at the site. There was a doctor's order for pin care which was not clarified as to what pin care was needed. The wound around the pin had some depth, was crater shaped, was moist with yellow tissue, and loosely covered with a gauze wrap. (Cross-reference F226) The RAdmin was notified of the Immediate Jeopardy (IJ) on 5/4/15 at 10:40 a.m. RAdmin provided the team a written Plan of Correction for IJ of Neglect on 5/4/15. The items listed, such as discontinuing electronic records and starting paper based medication and treatment records, training of all nurses, admission audits etc. were not immediately feasible. The IJ could not be lifted by the end of the standard survey, which was then extended due to substandard care. The RAdmin was notified again by telephone on 5/13/15 at 10:54 a.m. of the IJ and to make corrections. During the extended survey on 5/20/15 and 5/21/15, items 5. and 6. were identified. The facility managers, including RAdmin were informed during the exit conference on 5/26/15 at 2:45 p.m. that the IJ could not be lifted because of the continued neglect in not caring for Resident 29 newly aquired pressure ulcer and not following up on physician's orders [REDACTED]. During an on-site visit on 6/8/15 the IJ was abated and at 11:30 a.m. the Administrator was informed in an exit conference. Findings: 1. On 4/16/15 at 2:20 p.m. the facility was entered to investigate an anonymous complaint ( 4) regarding Resident 1 feeling afraid he would lose his leg because his wound dressings were not changed and not receiving his intravenous (IV) antibiotic (administered into the vein) as ordered, because of lack of a registered nurse (RN) in the facility. (RNs are the only licensed nurses who can administer IV antibiotics.) On 4/16/15 at 2:20 p.m., Resident 1 was observed sitting up in his wheelchair by the foot of the bed in his room where he was watching television. His right heel was wrapped in a gauze bandage that was brown with red drainage. At 2:40 p.m., LVN 3 who came to the resident's room, stated that she was the charge nurse. When LVN 3 was asked if Resident 1 was to have his dressing changed, LVN 3 stated that she didn't know because he goes out for his treatments. LVN 3 did not look at Resident 1's foot and walked out of the room. LVN 3 went to the nursing station to check if Resident 1 had a doctor's order for treatment. The DON found an order in the paper chart which had not been entered into the computer for the nurses to implement. The physician's orders [REDACTED]. The order was for daily cleansing with normal saline, wound gel (ointment to treat pressure ulcers) and dressings to his sacral (back)wounds and daily cleaning with normal saline and Santyl ointment ([MEDICATION NAME] agent to remove dead tissue) and cover with dry gauze to his right heel wound. Those orders were dated 4/6/13. At 3 p.m., the DON was observed measuring and dressing Resident 1's wounds. Resident 1 was placed in his bed, and the dressing from his right heel was unwrapped and revealed a malodorous wound covering the entire area of Resident 1's heel. The wound measured 8 cm by 8.4 cm with a depth of 1 cm, and was reddened with some areas of yellow slough (necrotic tissue). His buttocks was assessed and there were no dressings covering the left inner buttock which had a 6 cm by 2 cm stage 2 pressure ulcer (Partial thickness loss of skin, presenting as a shallow open ulcer with a red-pink wound bed) and the right inner buttock had a 2.5 cm by 3 cm stage 2. His right upper thigh just below his buttocks had many scattered small areas of skin breakdown. In addition, the skin on his back was dry and dead skin was flaking off onto the bed. According to a review of the medical record on 4/17/15, Resident 1 had been a resident of the facility since 11/23/13. He had [DIAGNOSES REDACTED]. In February 2015, Resident 1 had an infection of the right foot ulcer and was prescribed three different antibiotics intravenously at the facility. According to his MDS assessment dated [DATE] he was totally dependent on two persons to transfer from his bed to the wheelchair, and needed assistant to move about his room and the facility. He needed extensive assistance for bathing and personal hygiene, was occasionally incontinent of urine and frequently incontinent of bowels. He was at risk of developing pressure ulcers and had a [MEDICAL CONDITION] as well as moisture associated skin damage (i.e. incontinence, perspiration, drainage). During an interview on 4/17/15 at 3:10 p.m., the DSD stated that on Monday (4/13/15), Resident 1 came to the DSD office and asked him to change his dressing. The DSD said he only did the right heel dressing and then told the Station 3 charge nurse that he did it, but he did not document it. He also said he did the dressing to his heel that was ordered when he was working as the treatment nurse and he did not look to see if there were any new orders for treatment. According to a nurses' note dated 4/17/15 at 4:40 p.m., the DSD wrote the following late entry note for 4/13/15: Resident (1) came by my office requesting to have his dressing changed for his RIGHT HEEL pressure wound ONLY.When I checked on patient's order's for clarification of his wound care order, the previous order was only present, but from DON's previous statement to me, resident would no longer be on wound vac (vacuum dressing using negative pressure to promote healing). Since there was no actual treatment order for resident, I could not clarify the order.I only did a simple dressing change which was clean with normal saline, pat dry, apply foam dressing and cover with gauze roll.Wound was only foul smelling with dressing, after cleaning wound and getting rid of the old dressing, there was no foul smell. On 4/27/15 at 3 p.m., Resident 1 was sitting up in his wheelchair with his right foot wrapped in a pillow case. The DON and a nurse consultant (NC 1) came in the room and unwrapped the resident's foot. His foot was swollen and the gauze bandage was wrapped around his ankle so that the under part of his heel wound was uncovered and exposed. A review of the April 2015 Treatment Administration Record (TAR) showed Resident 1 had four different treatment orders for the right heel ulcer. The physician's orders [REDACTED]. The TAR reflected a new treatment order on 4/20/15 for, Right Heel: Clean with normal saline, pat dry apply silver alginate (antimicrobial highly absorbent dressing) over wound bed, non-adherent oil [MEDICATION NAME] gauze (dressing that won't stick to the wound tissue) over wound, wrap with 2 layer compression. Change three times a week.every Mon, Wed, Fri. The order from 4/6/15 had not been verified by the physician or transcribed onto the TAR. The DON confirmed in an interview on 4/27/15 at 3:30 p.m. that no treatment had been performed between 4/16/15 and 4/20/15 when she discovered that nobody processed the order discovered on 4/16/15. The DON stated that on 4/20/15 she asked DSD to call the doctor to get a treatment order. DDS wrote a progress note on 4/20/15 1:52 (Late Entry date not specified) as follows: Resident requested to have dressing on his right heel pressure ulcer dressing to be change from me. I agreed to change his dressing.I also asked if he would like me to do the treatment for [REDACTED]. During a telephone interview with the wound care nurse (WCN 2) at the wound clinic on 4/24/15 at 10:30 a.m. she stated that Resident 1 had been coming into the wound care center and his bandage was not being changed at the facility. She notified the facility to let them know that it needed changing and they said he was refusing. She said that Resident 1 was there on 4/23/15 and his next appointment was set for 4/30/15. He only goes to the clinic once a week, and his orders for treatment of [REDACTED]. In a telephone interview with Resident 1's physician (MD 1) on 4/30/15 at 3:40 p.m. she stated that the resident was non-compliant with his wound care and that the facility staff were saying that the resident refused treatment, and Resident 1 said that the staff weren't doing the dressing changes. She said she could not figure out who was telling the truth. (Cross reference F278 #1) 2. The state agency received a complaint ( 4) regarding Resident 3 not receiving pain medication (liquid [MEDICATION NAME]), [MEDICATION NAME] (antipsychotic medication) and treatment of [REDACTED]. The staff recorded that [MEDICATION NAME] was given even though it was in a sealed box. On 5/4/15 at 11:45 a.m. Resident 3 was observed lying in bed with her daughter at her side. Resident 3's daughter said that her mother had been in the facility since last July 2014 and was placed under Hospice care recently. She said the physician ordered [MEDICATION NAME] for pain every four hours, and the Hospice nurse came in on 4/29/15 and found that the [MEDICATION NAME] had not been given for 14 hours. Resident 3's daughter said her mother had been in a lot of pain. She also said that now that the resident is getting her pain medication and the [MEDICATION NAME], she is better, quiet and resting. The Hospice nurse (HRN) stated in an interview at the facility on 5/5/15 at 9:30 a.m., that she was upset with the facility nurses because they had not implemented the hospice physician's orders [REDACTED]. They did not carry out the orders for a [MEDICATION NAME] (narcotic pain medication in a patch that delivers the medicine through the skin), [MEDICATION NAME] for her agitation, and she couldn't tell if the Resident had a bowel movement because there was none charted. Also the resident had pressure ulcers on her sacrum and the orders for treatment had not been carried through. HRN had to instruct the facility nurse to give the medications and do the treatment, she even laid the treatment bandages out on the treatment cart for the nurse to do. Review of the medical record revealed that Resident 3, a [AGE] year old female was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].) by mouth in the morning and 1 ml (2 mg) in the evening for agitation .New orders for wound care were written on 4/23/15, wound # 1 sacrum (above the tail bone) to do wound care three times a day and more if needed, cleanse with warm soap and water, apply barrier cream (cream to protect the skin from moisture). The same was written for wound # 2 on the coccyx (tail bone). According to the Hospice Clinical Note dated 4/24/15, Resident 3 was described as .in bed, stiff, non-verbal. Yells if touched.Unable to get BP D/T (blood pressure due to) stiffness and combativeness. The plan had been for the staff nurse to assess.monitor and mitigate pain with MS around the clock and as needed. The HRN wrote, Intervention performed by clinician. Coordinated with Facility RN and DON about the importance of transcribing orders and giving meds for comfort as ordered. DON will transcribe orders herself. Pt (patient) is comfortable and not in any distress. The Hospice Clinical Note dated 4/29/15 revealed that The LVN today reported that she has not been giving any [MEDICATION NAME] on her shift because she did not know where it was. I worked with her to find it in the cart with the box still sealed. The medication had not been given up to this point. The record also reflected a new area on the right heel deep tissue injury, (wound #3) and orders for facility nurse to paint with skin prep (a liquid that's applied skin to form a protective film) three times a day until healed, and float the heels at all times while in bed. The Hospice Clinical Note dated 4/30/15 revealed that, Patient was in pain when I arrived. When I went to look at the MAR (medication administration record) to see when or if Pt had a MS dose, I found in the Narcotic Count Book, that the patient had not had [MEDICATION NAME] since 9 p.m. last night. The nurses had been documenting that they had been giving the medication in the electronic MAR but not administering the medication to the patient. Then the Nurse (RN 4) reported the patient had been refusing the doses. Requested a dose be given immediately and then put back to bed. HRN's note continued to reveal, Wound care orders written on 4/28 and 4/29 were not carried out and the treatment nurse knew nothing about them. Waited to ensure the orders were carried out and the initial treatment were done. On 4/30/15 at 3:30 p.m. the physician ordered a [MEDICATION NAME] 12 micrograms (mcg) to be applied to the back of her arm every 72 hours for pain. An order dated 5/2/15 changed the order to discontinue current 12 mcg [MEDICATION NAME] by removing it. Add [MEDICATION NAME] 12 mcg apply 2 patches (24 mcg) to back of her arm every 72 hours for pain. Once 24 mcg [MEDICATION NAME] placed, discontinue routine [MEDICATION NAME] and continue the [MEDICATION NAME] on an as needed basis. HRN's Clinical Note dated 5/3/15 revealed that, Routine visit today to do skin assessment, wound care, check MD orders, and pain assessment. When I arrived the order from 5/1 and 5/2 had not been transcribed. Patient was still on the old order of [MEDICATION NAME] 12 mcg every 72 hours and that patch was due to be changed today. The physician's orders [REDACTED]. The HRN note dated 5/3/15 revealed the actions of the HRN, I changed the [MEDICATION NAME]es per MD order.Ensured the [MEDICATION NAME] routine was stopped at 8 p.m. tonight in the electronic MAR. (re: Complaint 9) 3. The Department of Public Health received a complaint ( 4) on 4/13/15 alleging Resident 13 was sent to the acute hospital on [DATE] without the staff assessing or checking on him from 8:00 p.m. until the time the ambulance arrived. He was sent to the acute hospital soaked with fecal material extending from his lower back to his knees. On 4/27/15, review of Resident 13's closed record showed Resident 13 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a stay in the acute hospital from 2/11/15 thru 4/7/15. His readmission [DIAGNOSES REDACTED]. LVN 1 documented in the progress notes on 4/10/15 at 10:58 p.m., that while Resident 13's father and sister were visiting, his father came to the nursing station and asked if someone had visited his son (Resident 13)and gave him some drugs. He returned to the nursing station and reported his son was in pain. He came back to the nursing station and reported his son was having chest pain. LVN 1 documented without a specific time in the progress notes on 4/10/15 that he went to Resident 13's room and assessed Resident 13 for changes in his vital signs such as an in increase pulse rate, blood pressure, and respiratory rate, and change in cardiac rhythm. He documented only the changes observed, Resident 13's blood pressure was 76/48 (normal blood pressure 120/80). He went back and checked on Resident 13 and his blood pressure was still low. He notified the doctor who ordered transfer of Resident 13 via 911 to the acute hospital for further evaluation and treatment. According to the nurses notes, Resident 13 was transferred to the acute hospital via 911 ambulance on 4/10/15 at 10:20 p.m. Review of the acute hospital Emergency Department Notes dated 4/10/15 at 11:13 p.m., showed Resident 13 was just recently discharged from the hospital five days prior and now returned with [MEDICAL CONDITION] (low blood pressure), altered mental status (any measure of arousal other than normal) and rigor ( shivering and chills). The ER notes indicated Resident 13 had developed with what appeared to be [MEDICAL CONDITION] (potential life threatening infection) or septic shock, (a condition that occur when a body wide infection lead to dangerous low blood pressure). Resident 13's abdomen was distended (swollen), [MEDICAL CONDITION] bag full of white brown stool and gas. According to the ER notes, Resident 13 arrived covered with feces from upper legs and to mid-torso and soiled dressing on the multiple skin ulcerations and had massive stage 4 decubitus ulcers (Full thickness tissue loss with exposed bone, tendon or muscle, slough (layer of skin off) or eschar (dead tissue) may be present on some parts of the wound bed) extending up to mid-[MEDICATION NAME] (middle back) spine covered in feces with pus draining from at least one area on the right buttock. The acute hospital History and Physical report documented that Resident 13 was admitted to intensive care unit on 4/10/15 for treatment of [REDACTED]. The hospital surgery consultant wrote on 4/11/15, Resident 13 was known to have a large stage four pressure sore that required a loop [MEDICAL CONDITION] a couple weeks ago and the loop [MEDICAL CONDITION] did not completely divert the stool resulting in leakage of stool through the rectum, contaminating his sacral wounds. A second review of Resident 13's closed record at the facility on 5/6/15 showed that the facility did not developed a plan of care to monitor Resident 13 [MEDICAL CONDITION] bag or to monitor him for regular bowel movements from his rectum. Review of Resident 13's closed record on 4/27/15 showed that on 4/10/15 the wound doctor assessed his pressure sores at the facility. She wrote treatment orders for the staff to cleanse the wounds with normal saline, pat dry and apply Silver alginate (used to assist with management of infected wounds), cover with dry clean dressing daily to the stage four pressure sores on his lower back, left and right ischium (sitting bone), sacrum (bone at the bottom of the spine); his right and left heel, and the stage three pressure sore (Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible) to his left and right lower leg. The treatment sheet was reviewed and showed orders dated 4/8/15 instructing the staff to cleanse Resident 13's pressure sores with normal saline, pat dry, apply calcium alginate dressing( used on wounds that ooze bodily fluids) and cover with Meplex (a foam dressing that absorbs wound fluid) dressing one time a day. There was no indication on the treatment sheets the staff did any treatments on April 8, 9 and 10, 2015 to Resident 13's stage IV pressure sore on his lower back, left and right ischium, right and left heel and the stage III pressure sore back of his left and right lower leg. The treatment sheet further revealed that the staff did not implement the new treatment orders the wound doctor ordered for Resident 13's pressure sores on 4/10/15. During an interview on 4/27/15 at 3:00 p.m., Nurse consultant 1 was not able to show where the treatment orders the wound doctor wrote on 4/10/15 for Resident 13's pressure sores were transcribed to the new sheet. During an interview on 5/15/15 at 2:00 p.m. Resident 13's sister said, That evening (4/10/15) when we went to visit my brother (Resident 13) he didn't recognize us. My father thought something was wrong with him. So he asked the nurse if something was wrong or if he (Resident 13) had taken some kind of drugs. On 5/6/15 at 8:45 a.m. during an interview at the facility, C.N.A. 7 was asked about Resident 13's condition prior to going to the acute hospital on [DATE]. C.N.A. 7 said, I never changed him. When I came in at 3:00 p.m. I did rounds. He had his head covered. There was nothing in his [MEDICAL CONDITION] bag. I told the nurse he (Resident 13) didn't want to be touched and his bag was empty. Later when (Resident 13's) parents got here they told the charge nurse he was shaking and not himself. During an interview with LVN 1 on 5/6/15 at 3:40 p.m. he said, The (Resident 13's) father came in and went to the room and then came to the nursing station and said someone came and gave him drugs. After a few minutes I went into the room to see what the father was talking about. The father came back and said Resident 13 was complaining of pain. I medicated him for pain. He was ok he was talking. The [MEDICAL CONDITION] bag was closed. The father came back and said he was complaining of chest pain. I went to assess him his blood pressure was low. I gave him his medication for low blood pressure. I checked his blood pressure again and it was still low. I asked him how he was feeling, he said so, so. I called the doctor and the doctor said transfer him to the hospital, 911. When the paramedic were transferring him from the bed to the gurney, I seen the bowel movement on the bed. I told the paramedic he had a [MEDICAL CONDITION] bag. I said the bag may have open that's why the feces is there. I told them to wait but they were rushing to take him. When LVN 1 was asked about Resident 13 having stools from his rectum he said, I'm not aware of that, he has a [MEDICAL CONDITION]. That was my first day working with him since he came back from the hospital. No one told me he was having stools from his rectum. (Cross reference F281 #2) (re: Complaint 4) 4. During an interview on 5/4/15 at 2:30 p.m., Resident 14 said, When the hospital was ready to discharge me back to my facility (Facility B) but they said they have an infection and no one could come in. They asked me to come here until the infection clear up. When I came here they told me they would have some of my medication but not all of my medication. The next day the nurse didn't have my [MEDICATION NAME] ([MEDICATION NAME]). I told the nurse if she couldn't give me my medication I would have to go to the hospital. They didn't give me my medication. I was hurting, so, I called my facility (Facility B) and they told me if they can't give me the medication to call 911. So I called 911. Review of Resident 14's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 5/7/15 at 8:30 a.m., LVN 3 said, The C.N.A. told me the morning of 5/3/15 he (Resident 14) wanted his medication. I checked if his medication had arrived. None had arrived. I went to his room and told him his medication had not arrived, so he said , I need my medication. Let me go to the hospital. I told him I called the pharmacy, the doctor, and Facility B where he had been. He (Resident 14) said he needed his [MEDICATION NAME]. He was shaking and felt like he was going to die. I called the pharmacy and they said it would be on the 8:00 a.m. delivery today. I called the doctor and told him we needed authorization to use the [MEDICATION NAME]. The doctor told me he would call the pharmacy and give authorization. The Resident didn't want to wait so he called 911. The pharmacy called and did not give authorization [MEDICATION NAME] because we didn't have the dosage in the emergency kit. During an interview on 5/7/15 at 1:30 p.m. the pharmacy consultant said, They could have taken the medication from the emergency kit. They have five and ten milligram of [MEDICATION NAME] in the kits. During an observation of the medication storage on 5/6/15 at 2:30 p.m. with the California Department of Public Health Pharmacy and the facility's DON, the emergency medication kit had eight tablets of [MEDICATION NAME] 5 mg and 10 tablets of [MEDICATION NAME] 10 mg. LVN 3 documented in the progress notes on 5/3/15 at: 8:30 a.m. Resident 14 complained of feeling shaky and That he was going to die if he did not get his medication. She explained to him that the medication were ordered last night and would arrive today. At 9:30 a.m. Resident 14 called 911, the ambulance arrived and took him to the acute hospital. At 11:00 a.m. the acute hospital called and said they would give him his [MEDICATION NAME]. At 3:43 p.m. Resident 14 was transported back to he facility from the acute hospital. Review of the Pharmacy shipment summary record showed that on 5/3/15 at 2:10 p.m. the facility received 35 tablets of [MEDICATION NAME] 10 mg. (Cross reference F431 #5) (re: Complaint 9) 5. Resident 29 was admitted to the facility on [DATE] for treatment of [REDACTED]. According to the wound assessment dated [DATE] at 2:45 Resident 29 had a stage IV pressure ulcer on his coccyx (tailbone) that was 0.7 cm by 0.4 cm with a depth of 0.4 cm. During an observation and interview at the bedside on 5/21/15 at 12 p.m., Resident 29 was having his right arm placed in a splint by the Occupational Therapist (OT) and her assistant. The OT told the assistant not to put the splint on over his elbow, and Leave the wound open. The resident had a round open area that presented as a shallow crater over the bony area of his outer elbow. The OT stated that she had told the DSD about the sore on 5/20/15. A review of the medical record revealed that there was no new pressure sore on the right elbow identified, and there was no treatment ordered. The wound was uncovered and unattended. In an interview with DSD on 5/21/15 at 4 p.m. he said that he was unaware of a new pressure sore on Resident 29. The DSD returned and provided a Non-Pressure Skin Condition Report that revealed Resident 29 had a right elbow skin tear first observed on 5/20/15 that was measured on 5/21/15 to be 1 cm by 0.7 cm with a depth of 0.1 cm. The DSD could not explain why a round open area over a bony prominence on a limb that had been splinted would be documented as a skin tear. 6. Resident 30 was admitted to the facility on [DATE] for trauma aftercare of a fractured lower left leg, and rehabilitation. On 5/20/15 at 2:45 p.m. Resident 30 was sitting up in his wheelchair in his room. His left foot was wrapped in an elastic bandage with a metal pole that protruded up the front of his leg that was attached to a metal pin that went through the front of his shin bone. The area where the pin and pole connected there was a thin piece of gauze covering his leg. The resident pulled the gauze aside to reveal an open sore around the pin area with had depth and was moist and yellow. He said, they were putting some antibiotic ointment on it. In an interview with the DSD on 5/20/15 at 4:10 p.m. he stated that he was waiting for iodine/[MEDICATION NAME] to come in. He said that the order for pin site care came from the hospital and the resident was to go back in two weeks for an appointment. He presented the order that was from a doctor's visit on 5/14/15 that reflected, .Pin site care daily with dressing changes. We will see him in one week. He is to start a 2 week course of abt. (antibiotic) The DSD further stated that he did not clarify the order with the prescribing physician, nor did he call the attending physician to receive and start the order. He also did not perform a skin assessment, nor was he aware of the open area at the pin site. A review of the Treatment Record (TAR) for May 2015 revealed that the resident's treatment beginning 5/15/15 was for pin site care daily and as needed at the left foot, to clean with hydrogen peroxide solution, apply gauze pads around pin site, and monitor for signs and symptoms of an infection every shift. On 5/2/15 there was an entry added, Clean pin sites with NSS (normal saline solution) pat dry then cover with gauze, change PRN (as needed) soiled.

Based on observation, interview and record review for two (Residents 7 and 12) of 19 sampled residents and one (Resident 21) of five randomly selected residents, the facility failed to ensure the residents were free of significant medication errors. Resident 12 did not receive five doses (5/1 through 5/5) Triumeq (an [MEDICAL CONDITION] medication) necessary to slow down the replication [MEDICAL CONDITION](Human immunodeficiency Virus, [MEDICAL CONDITION] that weakens the immune system by destroying important cells that fight disease and infection) which and can lead to Acquired Immune Deficiency Syndrome, also known as AIDS (an often fatal condition in which the immune system breaks down and does not respond normally to infection), as ordered. Resident 7 did not receive 4 doses of IV(intravenous) and 2 doses IM (intermuscular) [MEDICATION NAME] (an antibiotic medicine), once a day, prescribed for osteo[DIAGNOSES REDACTED] (infection of the bone and bone marrow usually caused by bacteria), which could result in increase the risk of further infection that is resistant to antibiotics. During an extended survey, on 5/21/15, Resident 7's 9 am dose of IV [MEDICATION NAME] was administered at 11:23 a.m., more than two hours after it was due. Resident 21 received two doses of Tylenol instead of aspirin which thins the blood and prevent clots which can lead to a stroke (blood clot blocking an artery which can cause brain damage). The RAdmin was notified of the Immediate Jeopardy (IJ) on 5/6/15 at 12 p.m. The IJ could not be lifted by the end of the standard survey, which was then extended due to substandard care. The RAdmin was notified again by telephone on 5/13/15 at 10:54 a.m. of the IJ and to make corrections. During the extended survey on 5/20/15 and 5/21/15, a deficiency, see example 2. The facility managers, including RAdmin were informed during the exit conference on 5/26/15 at 2:45 p.m. that the IJ could not be lifted because of the continued significant medication errors. During an on-site visit on 6/8/15 the IJ was abated and at 11:30 a.m. the Administrator was informed in an exit conference. Findings: 1. Review of the clinical record, on 5/5/15, showed Resident 12 was admitted from home to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation and concurrent interview of med pass for Resident 12, on 5/5/15 at 8:45 a.m., LVN (licensed vocational nurse) 6 stated the Triumeq (an [MEDICAL CONDITION] medication) 600-50-300 mg (milligrams) was not in the medication cart because it had not been delivered from the pharmacy. Resident 12 did not receive the Triumeq scheduled for 9 am. Review of the MAR (medication administration record) dated 5/5/15, on 5/5/15, showed that Resident 12 received one dose of Triumeq on 5/4/15, administered by LVN6. During an observation, interview and concurrent record review, on 5/5/15 at 1:30 p.m., LVN 6 stated that she had not given the Triumeq on 5/4/15 as it was documented in the MAR but she had found the medication. LVN 6 removed the Triumeq from the medication cart and stated she would be giving it to Resident 12. In a telephone interview, on 5/5/15 at 3:20 p.m., the PIC (Pharmacist in Charge) at the facility's contracted pharmacy stated they received an order from the facility for Triumeq on 5/4/15 at 4:32 p.m. and it was shipped on 5/5/15 at 1 am for delivery to the facility. Review of the facility's record of the pharmacy's shipping document showed on 5/5/15 at 5:46 a.m. the Triumeq was delivered to the facility. During an observation and interview, on 5/7/15 at 10:55 a.m., RN4 was asked if Resident 12 had received the 9 am dose of Triumeq. RN4 stated Resident 12 did not get the medication because it was not there. The surveyor asked RN4 to check the other drawers of the medication cart, RN4 stated, It wouldn't be here. When RN4 opened the top drawer of the medication cart, the Triumeq was there. A subsequent review of the MAR indicated [REDACTED]. A total of fives doses from 5/1/15 through 5/5/15 had not been administered. During a telephone interview, on 5/7/15 at 10:30 a.m., RN (registered nurse) 15, who worked at [MEDICAL CONDITION] which followed Resident 12, stated it is important [MEDICAL CONDITION] to take the daily prescribed dose of [MEDICAL CONDITION] medications. One or two missed does per month could make the patient resistant to the medication and the medication would no longer be effective. (Treatment adherence, taking [MEDICAL CONDITION] when and how you are supposed to, is extremely important because it affects how well [MEDICAL CONDITION] decrease your [MEDICAL CONDITION] load. Adherence also helps prevent drug resistance. If you skip a dose of your medication-even once- [MEDICAL CONDITION] can take that opportunity to replicate, and make more HIV.) (Reference: www.aids.gov <http://www.aids.gov>) 2. Review of the clinical record, on 5/4/15 at 1:30 p.m., showed Resident 7 was admitted to the facility with multiple medical [DIAGNOSES REDACTED].) Resident 7 was scheduled for placement of a PICC (peripherally inserted central venous catheter, used for long- term fluid and medication administration) line on 5/5/15, following an unsuccessful insertion attempt on 5/2/15. Record review of physician's orders [REDACTED]. Another order, dated 5/1/15, for [MEDICATION NAME] Solution Reconstituted 1 GM (gram) intramuscularly (IM, injected into the muscle) one time a day for up to 7 days until PICC line is successfully placed, with a start date of 5/2/15. Review of the progress notes, dated 5/4/15, showed PICC line placement orders received from the acute care facility were to give medications prior to leaving the facility on 5/5/15. Review of the MAR (Medication Administration Record) dated 5/5/15, for Resident 7 showed the IV [MEDICATION NAME] was scheduled to be given at 9 am and the IM [MEDICATION NAME] was scheduled to be given at 1 pm. The MAR indicated [REDACTED]. (Skipping doses of [MEDICATION NAME] may increase the risk of further infection that is resistant to antibiotics.) (Reference: Drugs.com) An observation during an extended survey, on 5/21/15 at 9:10 a.m., the empty IV [MEDICATION NAME] bag for Resident 7, dated 5/20/15, was hanging on an IV pole in the resident's room. The IV [MEDICATION NAME] scheduled for 9 am had not been given. During subsequent observations at 10 am, 10:50 a.m. and 11:05 a.m., the empty [MEDICATION NAME] bag dated 5/20/15 was still hanging on the IV pole and the 5/21/15 9 am dose had not been given. During an observation, record review and concurrent interview, at 11 am, NC (nurse consultant) 2 stated the IV [MEDICATION NAME] was not given because there was no RN available to give the medication. At 11:15 a.m., RN18 entered Resident 7's room and began preparations to hang the medication that was due at 9 am. RN18 stated she was told to report to work for 11 am. The IV [MEDICATION NAME] was administered to Resident 7 at 11:23 a.m. Review of the facility's policy and procedure titled Medication Administration dated 1/1/12, indicated .The Licensed Nurse will prepare medications within one hour of administration.Medications may be administered one hour before or after the scheduled medication administration time. 3. During the medication pass on 5/5/15 at 8:10 a.m. Resident 21 received the following nine individual tablets of medication: Tylenol 325 mg two tablets, [MEDICATION NAME] (high blood pressure) tablet 10 mg one tablet, Multi Vitamin/Minerals one tablet, [MEDICATION NAME] Acid (vitamin C) 500 mg one tablet, [MEDICATION NAME] Sodium (stool softner) 100 mg two capsules, [MEDICATION NAME] (for [MEDICAL CONDITION]-nerve disease) 300 mg one capsule, and [MEDICATION NAME]-[MEDICATION NAME] 325 mg (pain medication) one tablet. Review of the May, 2015 physician orders [REDACTED]. On 5/6/15 at 9:40 LVN 2 was asked to what bottle did she use to give the Aspirin to resident 21 on 5/5/15 and she picked up the bottle of Tylenol 325 mg. LVN 2 said she gave Resident 21 his medication today and she gave him the Tylenol again today instead of the Aspirin 325 mg. She further stated that she was going to go to the medication storage and get the Aspirin 325 mg.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for 3 ( Residents 5, 10, and 16) of 19 sampled residents. Resident 5's pain was not assessed or monoitored and there was a delay in the administration of new pain medicaiton. For Resident 16, the facility failed to perform a complete pain assessment and were not aware of the reason for his pain. For Resident 10, the facility failed to follow the physician's orders [REDACTED]. ([MEDICAL TREATMENT] - process to remove waste and excess water from the blood) These failures resulted in unnecessary pain, inability to accurately track the status of the pain, and potential injury to vital organs. ( the heart and lungs) Findings: 1. Record review on 6/1/15 at 11:06 a.m., of the document titled, Order Summary Report, dated 5/12/15, showed the facility admitted Resident 5 on 3/20/15 with a [DIAGNOSES REDACTED]. In an interview on 5/4/15 at 10:45 a.m., Resident 5 was asked about her care. Resident 5 stated she was, In pain. They give me pain pills and it takes the edge off but it is not enough. I have rib pain and pain at the top part of my stomach. It has been happening for a week now. In an interview on 5/6/15 at 8:30 a.m., Resident 5 was asked about her pain. Resident 5 stated she had, Pain all over. I had pain medication at 5 a.m. They, (the staff), said it is not time for me to have it again. In an interview on 5/6/15 at 1:00 p.m., Resident 5 was asked to describe her level of pain. Resident 5 stated she was not, Feeling great today. I did get the pain medication at 9 a.m. which helped a little. In an interview on 5/6/15 at 1:35 p.m., Licensed Vocational Nurse 5, (LVN 5), was asked to describe Resident 5's pain. LVN 5 stated she, (Resident 5), Has pain all the time. She has bad anxiety and shortness of breath. I think her anxiety contributes to her pain. She has pain medication every 4 hours. It is ordered on an as-needed, (PRN). She, (Resident 5), says that the pain medication works but then she will ask for it before the 4 hours are up. She stays in bed a lot. I suggested that she get up out of bed and go to activities. In an interview on 5/6/15 at 2:15 p.m., Resident 5 was asked if she believed that her anxiety was contributing to her pain. Resident 5 stated, My anxiety does not cause my pain. I fell at a previous facility and fractured my ribs and had 3 staples in my head. I was in the hospital. I am trying to rehabilitate so I can get home to my kids. Having this pain impacts my ability to move. I stay in bed if it hurts so bad. The pain medication takes the edge off but I need it by the third hour and the staff tells me I have to wait. Record review on 5/7/15 at 2:05 p.m. of the document titled, Nurses' Weekly Look Back Summary, dated 5/3/15, showed Patient 5 was alert and oriented times 3. (knew her name, the time, the date, and where she was). Under the section titled, Facial Pain Scale, Resident 5 was described as Hurts a Little More. There was no documented numbered pain scale. (pain scale/level: 0 = no pain, 10 being the highest number to describe the level of pain). Record review on 5/14/15 at 12:29 p.m., of the facility's policy and procedure titled, Pain Management, showed the purpose of the policy was to Ensure accurate assessment and management of the resident's pain. Nurses will complete the pain flow sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen. Nursing Staff will implement timely interventions to reduce the increase in severity of pain. Record review on 5/18/15 at 2:31 p.m., of the facility policy and procedure titled, Administration of Pain Medication, showed, Residents who receive PRN medication routinely will be reassessed for around-the-clock, (ATC), pain medication to ensure the highest level of comfort. Further record review showed under the section titled, Documentation, licensed facility nurses were to, Document the administration of PRN pain medication on the Pain Flow Sheet. Document the resident's response to and the effectiveness of the pain medication in the resident's medical record. Record review on 5/13/15 at 11:03 a.m. of Resident 5 's Medication Administration Record, [REDACTED] 5/1/15 at 3:49 p.m. - Nursing Note showed Tylenol (pain medication) had been given this morning with relief. There was no documented pain assessment. 5/1/15 7:58 p.m. - Nursing note showed Tylenol had been given with relief. No documented pain assessment 5/2/15 9:26 p.m. - 2 Tylenol tablets given. Pain level described as 3 out of 10. (10 being the most pain) No further documented pain assessment. No documentation showing effectiveness of the pain medication. 5/3/15: 2:38 a.m. 1 [MEDICATION NAME], (pain medication) given. Pain level: 8/10. No further documented pain assessment. No documentation showing effectiveness. 5/3/15: 6:25 a.m. [MEDICATION NAME] given. Pain level 8/10. No documented pain assessment or description of effectiveness. 5/3/15 1:19 p.m. Pain level: 8/10. No documented pain assessment or effectiveness. 5/3/15: 6:10 p.m. Pain level: 4/10. [MEDICATION NAME] given. No documented pain assessment. No documentation showing effectiveness. 5/4/15 -1:31 a.m. Pain level 8/10. [MEDICATION NAME] given. No documented pain assessment or level of effectiveness. 5/4/15 7:28 a.m. Pain level 9/10. [MEDICATION NAME] given. No documented pain assessment or level of effectiveness. 5/4/15 10:27 a.m. Pain level 6/10 [MEDICATION NAME] given. No documented pain assessment or level of effectiveness. 5/4/15 4:48 p.m. Pain level 8/10. [MEDICATION NAME] given. No documented pain assessment or level of effectiveness. 5/4/15 9:38 p.m. Pain level 6/10. [MEDICATION NAME] given. No documented pain assessment or level of effectiveness. In an interview and concurrent record review on 5/7/15 at 1:50 p.m., the Medical Records Supervisor, (MRS), was asked to show this surveyor where the facility's licensed nursing staff document the type of PRN medication that was given, why it was given, and the effectiveness of the medication. The MRS was observed looking into the computer and stated, They, (the staff), are not filling out the progress note text on the computer screen. They are not writing what medication they gave as a PRN, why they gave it, and the effectiveness. Record review of the staff computer training document titled, Course Number: CLN-DE-15, showed, when licensed nursing staff were preparing to give a medication, they were required to open the Resident's Administration page and select the PRN button. Following administration of the medication, staff are then prompted to enter a progress note to document why they administered the PRN. Staff are then required to hit the Follow Up, button in order to record the effectiveness of the medication. In an interview on 5/6/15 at 2:20 p.m., the Director of Nursing, (DON), was asked what staff do if a resident's pain is not being controlled. The DON stated, If the resident is having a lot of pain medication and it is not controlled as a PRN, then there needs to be an assessment and the pain medication should be scheduled around the clock and not PRN. A pain assessment needs to be done. First ask the resident where the pain is located. Is it sharp or dull pain? Is the pain consistent, (on-going), or does it come and go? The doctor needs to be called. In an interview on 5/13/15 at 12:11 p.m., Resident 5's doctor, (MD), was given the information regarding the number of PRN doses of [MEDICATION NAME] and Tylenol given to Resident 5 and was asked what his expectation was from staff. The MD stated, What I try to teach the staff is to watch the PRN dose and see if the resident would like a regularly scheduled dose as opposed to as-needed. If someone is getting more than 3 PRN doses per day, then the doctor should be called and the resident should be offered pain medication on a regular schedule. Resident 5 is capable of telling the staff if a regular schedule would be better. Staff did not call me in regards to the extensive use of the PRN medication for Resident 5. Record review on 5/14/15 at 9:14 a.m. of Resident 5's plan of care, dated 3/27/15, showed no documented focus on pain. In an interview on 5/20/15 at 1:15 p.m., the MD was asked about Resident 5's pain. The MD stated he had decided to, Start her, (Resident 5), on [MEDICATION NAME]. ([MEDICATION NAME]: a pain medication) Record review of the document titled, Physician's telephone order, dated 5/20/15 at 3:00 p.m., and signed by Registered Nurse 19, (RN 19), showed MS Contin, ([MEDICATION NAME]), 15 milligrams by mouth two times per day had been ordered by the MD. In an interview on 5/21/15 at 11:30 a.m., Resident 5 was asked about her pain level and the new order for [MEDICATION NAME]. Resident 5 stated, Yes, they started me on [MEDICATION NAME] yesterday. I am still in pain. The [MEDICATION NAME] is not here yet. In an interview on 5/21/15 at 12:20 p.m., Licensed Vocational Nurse 24, (LVN 24), was asked about Resident 5's order for [MEDICATION NAME]. LVN 24 stated she did not give the morning dose to Resident 5 on 5/21/15 because it was, Not in the cart. In an interview on 5/21/15 at 12:25 p.m., Resident 5 was asked if she had received the [MEDICATION NAME]. Resident 5 stated, I got the [MEDICATION NAME], (another pain medication), just now. It was an hour early. Resident 5 was asked if the [MEDICATION NAME] relieved her pain. Resident 5 stated she, Just started [MEDICATION NAME] 2 days ago. It does not work. I am waiting for the [MEDICATION NAME]. My pain is at a 10 out of 10. The director of Nursing just came in and told the staff to give me the [MEDICATION NAME]. (10 out of 10 - pain scale: 1 is the lowest amount of pain and 10 is the highest) In an interview on 5/21/15 at 1:25 p.m., RN 19 was asked to describe the steps she took after she received the [MEDICATION NAME] order from the MD. RN 19 stated she sent a copy, To the pharmacy. I talked to the PM, (evening shift), nurses. I put it on the 24 hour report. (24 hour report: documents communications between the different shifts) In an interview on 5/21/15 at 1:55 p.m., RN 19 was asked to show this surveyor fax confirmation that the [MEDICATION NAME] order had been sent to the pharmacy. RN 19 stated she, Had no fax confirmation that Resident 5's [MEDICATION NAME] order went through. I gave the information to the nurse. I spoke to the pharmacist today and they told me it will be delivered tonight. Record review on 5/27/15 at 3:46 p.m., of Resident 5's Medication Administration Record, [REDACTED]. Record review of the facility's policy and procedure titled, Pain Management, dated December 2014, showed, Nursing staff will implement timely interventions to reduce the increase in the severity of pain. 2. The facility admitted Resident 16 on 3/13/15 with a [DIAGNOSES REDACTED]. (abscess - a collection of pus due to an infection that has built up within the body tissue) Record review on 5/7/15 at 2:05 p.m. of the document titled, Nurses' Weekly Look Back Summary, dated 5/2/15, showed Resident 16 was alert and oriented times 3. (aware of name, date, time, location). Resident 16's memory was described as being within normal limits. During medication pass on 5/5/15 at 8:12 a.m., Licensed Vocational Nurse 5, (LVN 5), administered to Resident 16 his daily dose of [MEDICATION NAME]. ([MEDICATION NAME] - used as both pain medication and an anti-addictive for drug addicts). LVN 5 asked Resident 16 if he was in pain. Resident 16 said, Yes. LVN 5 then said, Give me a number. (pain level number: on a scale of 1 to 10, what is the level of pain with 10 being the highest level) Resident 16 stated, 8 out of 10 shoulder pain. This surveyor then asked LVN 5 why Resident 16 had pain. LVN 5 stated, He has a history of drug abuse. He gets [MEDICATION NAME] for his drug abuse. LVN 5 did not further assess the pain. in an second interview at 8:25 a.m., LVN 5 was asked if there were any other reasons for Resident 16's pain. LVN 5 looked at the computer screen and stated, Oh. He has a muscle abscess on his spine. In an interview on 5/7/15 at 10:15 a.m., Resident 16 was asked to describe his pain. Resident 16 was observed lifting his right arm and running his left hand from the back of his neck down his right arm and stated the, Pain is going to my shoulder. I told the nurse. But she still just gives me Tylenol. It does not help. In an interview on 5/7/15 at 1:10 p.m., Licensed Vocational Nurse 2, (LVN 2) was asked about Resident 16's pain. LVN 2 stated the, Last time he got Tylenol for pain was on 5/3 and 5/4/15. LVN 2 was asked if she knew why he had the pain. LVN 2 stated, No. I don't know why. I don't know how to look back into the computer to see why he got the pain medication. LVN 2 was asked if she had gotten a report at shift change in regards to Resident 16's pain. LVN 2 stated, No. In an interview with Resident 16 on 5/7/15 at 1:20 p.m., Resident 16 was asked if he continued to have pain. Resident 16 stated, Yes. He was observed grabbing his right shoulder and running his hand up to the back of his neck. Record review of the Medication Administration Note dated 5/4/15 at 6:48 p.m., showed Resident 16 received PRN medication and it was effective. There was no medication name listed or why the medication was given. There was no documented pain assessment. Record review of Resident 16 's plan of care on 5/14/15 at 9:17 a.m., dated 3/16/15, showed no documented pain focus. In an interview on 5/12/15 at 10:33 a.m., Resident 16 ' s doctor, (MD), was asked why Resident 16 was having pain. The MD stated, He gets 3-4 out of 10 pain due to his abscess. 3. A review of the clinical record, on 5/15/15 at 12:10 p.m., showed Resident 10 was admitted to the facility with multiple [DIAGNOSES REDACTED].) Resident 10 received [MEDICAL TREATMENT] (procedure to remove waste products from the blood of patients with kidney disease) treatments three times per week. Review of the facility's policy and procedure titled, [MEDICAL TREATMENT] Care, with a revision date of 1/1/12, indicated the IDT (Interdisciplinary Team) would ensure that the resident's care plan (measurable objectives and timeframes to meet residents ' physical, mental, and psychosocial needs) included documentation of the resident's renal condition and necessary precautions (e.g. shunt site, weights, dietary and fluid restrictions, observe for signs and symptoms of infection.) Review of Resident 10's care plan, on 5/7/15, did not include a focus, goal or interventions related to the resident's renal condition or [MEDICAL TREATMENT] care. Review of the physician orders, dated 3/22/15, indicated Resident 10 was to have monitoring of fluid intake and output every shift and the evening shift was to document 24 hour totals. During an observation and concurrent interview, on 5/7/15 at 1:45 p.m., CNA (certified Nurse assistant) 13 demonstrated how the residents' intake and output was charted by the CNAs. CNA 13 stated the amount of food and fluids Resident 10 consumed, was charted into the computer system. CNA 13 stated she was not to able access the intake and output totals for the resident. On 5/7/15 at 1:50 p.m., a copy of the input and output record for Resident 10 for the month of May was requested from the MRS (medical records supervisor.) MRS was unable to provide the input and output for Resident 10 and stated there was no documentation of this information in Resident 10's record. During a record review and concurrent interview, on 5/7/15 at 1:55 p.m. the [MEDICAL TREATMENT] Communications Records, located in the [MEDICAL TREATMENT] communication binder (method for the facility and [MEDICAL TREATMENT] center to communicate information for the resident), the facility nurses' documentation showed on 5/1/15 and 5/4/15, vital signs were documented in the section designated for changes or new information. There was no indication if the vital signs were done prior to or after [MEDICAL TREATMENT]. The section for documenting the pre-[MEDICAL TREATMENT] and post [MEDICAL TREATMENT] vital signs was blank. The documents did not indicate the name or title of the person who completed the forms. On 5/6/15, the resident's current weight was not documented. The section for documenting pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] vital signs was blank. The DON (Director of Nursing) confirmed the documents were incorrect and incomplete. Review of the facility's policy and procedure titled, [MEDICAL TREATMENT] Care under the section titled Communication and Collaboration, showed the nursing staff would communicate in writing to the [MEDICAL TREATMENT] Staff the resident's current vital signs and weight. A pre/post [MEDICAL TREATMENT] assessment form was to be used to convey the information to the [MEDICAL TREATMENT] provider.

Based on interviews and record review, for one (Resident 1) of three sampled residents, the facility failed to communicate to a wound care physician that Resident 1 was taking anticoagulant (blood thinners) medications prior to the physician performing surgical wound debridement (removal of tissue from a wound by a surgical instrument). This failure resulted in Resident 1 being hospitalized for [REDACTED]. Definitions: Pressure/Decubitus Ulcer: any lesion or sore caused by unrelieved pressure that result in damage to the underlying tissue(s). Undermining: the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface. Tunneling: a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. Sinus tract: a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound. Purulent exudate: any product of inflammation that contains pus. Slough: necrotic (dead) tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy (at times). Eschar: thick, leathery, frequently black or brown in color, necrotic tissue that has lost it usual physical properties and biological activity. Granulation tissue: the pink-red moist tissue that fills an open wound when it starts to heal Sero-Sanguineous: a thin watery drainage composed of blood and serum Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage IV: full thickness tissue loss with exposed bone, tendon or muscle. Unstageable (UTD): Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue) in the wound bed. Deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-filled blister. Findings: Review of the clinical record, on 4/2/14, showed Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MD'S, assessment tool), dated 2/27/14, reflected on admission Resident 1 had three unstageable pressure ulcers covered with slough and/or eschar, and two unstageable pressure ulcers with deep tissue injury. The MDS showed Resident 1 required total assistance with maintaining nutrition, grooming personal and oral hygiene from the facility. The admission order, dated 2/22/14, included Aspirin (thins blood to reduce formation of blood clots) 81 mg (milligrams) one tablet one time a day related to [MEDICAL CONDITION] disease, and [MEDICATION NAME] (prolongs clotting time to reduce fomation of unwanted clots in blood vessals)75 mg one tablet one time a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) prevention, related to [MEDICAL CONDITION] disease. Review of the facility's policy titled, "Skin and Wound Management Program" dated 6/23/06, showed, "Residents receive care and services necessary to promote and maintain optimum skin integrity. A plan of care addressing skin integrity alterations, risk factors and co-morbidities is developed and implemented by the Interdisciplinary Team with ongoing assessment to ensure optimum outcome." The facility had a contract with a wound care clinic (Provider) that provided professional wound care services to skilled nursing facilities. Review of the services agreement between the facility and the Provider, dated 7/29/13, showed the Provider would provide services to the residents of the facility as requested by the facility. A physician's orders [REDACTED]. In an interview, on 5/6/14 at 11:30 a.m., PCP1 stated when a consult was requested, he expected the Provider to proceed with adequate care of the patient and give treatment as they saw fit. PCP 1 stated he spoke with LVN (licensed vocational nurse) 1 who told him the Provider said the wounds looked bad and he wanted to proceed with debridement (removal of non-healthy tissue from a wound). The PCP stated he told LVN1, "Okay." PCP1 was asked if the Provider consulted him on Resident 1's health history. PCP1 stated, "No, usually the nurse does wound care rounds, goes through the chart and reviews the patient (with the doctor)." The patient assessment note, dated 3/11/14, reflected the Provider did a new/initial assessment of Resident 1, and identified the sacrum wound as a Stage 3 pressure ulcer. The assessment showed the length was 7, width 13 and depth UTD (unable to determine). The units of the measurements were not given (inches or centimeters). There was no undermining; there was moderate purulent exudate with a mild odor and no exposed features (tendon, muscle, bone, or joint). There was no slough: percent of wound base (viable tissue layer) 50% and black eschar: percent of wound base 50%. The note showed, "Still discolored (wound) but better. No evidence of DTI (deep tissue injury) at this point." The assessment form had spaces to check if the resident had diabetes, or was on anticoagulant therapy. (each could negatively affect the status of pressure ulcers) The spaces were not checked. There was a space titled, "Laboratory/Diagnostic Review". The space was left blank. The patient assessment note, dated 3/18/14, reflected the Provider performed, "Surgical debridement (also known as sharp debridement, used a scalpel or scissors)" but it was not clear what area was debrided. The assessment note for the sacrum indicated the pressure ulcer was staged as "UTD". The length was 6, width 13 and depth UTD. The units of the measurements were not given. It showed no undermining, moderate purulent exudate with a mild odor and no exposed features. There was slough: percent of wound base 20% and black eschar: percent of wound base 80%. The progress notes, dated 3/25/14, by the Provider showed, "Today the right side was covered with 100% slough and this was sharply debrided. Oozing was noted, and the wound was packed." The patient assessment note, dated 3/25/14, by the Provider indicated the sacrum pressure ulcer was Stage 3. The measurements were length 7, width 13 and depth 3 (units not given). It showed undermining, large purulent exudate with a strong odor and exposed muscle. There was slough: percent of wound base 100% and no black eschar. "Surgical debridement- skin subcutaneous muscle 100% bleeding severe. Patient on [MEDICATION NAME]. IV started Transferred to hospital acutely". (John Hopkins Medicine advised, for sharp debridement check for bleeding or clotting problems. Debridement is contraindicated for coagulation disorders. Reference: www.hopkinsmedicine.org/gec/series/wound_care.html <http://www.hopkinsmedicine.org/gec/series/wound_care.html>) During an interview, on 4/2/14 at 1:15 p.m., LVN 2 stated she was present when the Provider performed the wound debridement on Resident 1. LVN 2 stated the procedure was done between 11 am and 12 p.m. and she observed the Provider clean the wound then cut some of the tissue and the wound started bleeding. The Provider packed the wound with gauze but it didn't stop bleeding. LVN 2 stated the Provider packed the wound and then went to see the next resident. LVN 2 stated she was not aware Resident 1 was on blood thinners. During an interview, on 4/2/14 at 1 p.m., LVN1 stated on 3/25/14 she went to lunch at 11 a.m. and returned at 11:30 a.m... She stated LVN2 covered for her and was with the Provider when the debridement was done. LVN1 stated when she returned from lunch, she went to check on Resident 1. LVN 1 stated there was blood all over the bed sheet and chux pad (disposable pad). LVN1 stated when she turned Resident 1 on her side, blood was gushing, flowing, but she couldn't see where the blood was coming from. LVN 1 stated she got gauze and applied pressure to try to stop the bleeding then asked the PCP1 and MD 1 to come look at Resident 1. LVN 1 stated PCP1 and MD 1 tried to stop the bleeding and MD 1 told her to call 911. The EHR (electronic health record), dated 3/25/14 at 1:56 p.m., showed LVN 1's documented, "Resident has a wound to right and left buttock which was debrided today by the wound doctor (Provider) which lead to severe bleeding; the bleeding did not stop with several attempts. PCP1 gave an order to transfer the resident to the hospital." In an interview, on 4/2/14 at 12:05, the DON (director of nursing) was asked if the Provider reviewed charts before performing a procedure on a resident. The DON stated, "Honestly, they don't review the resident's charts." She stated she told the Provider Resident 1 was on aspirin and [MEDICATION NAME] after they discovered the resident was bleeding. The DON stated the staff did not assist the Provider when debridement was done. She stated the staff would assess the resident after the procedure was completed. The DON was requested to provide the facility's policy and procedure for debridement. The DON was unable to provide a policy and procedure for wound debridement. During a telephone interview, on 6/25/14 at 3:35 p.m., the Provider stated he was a representative of the wound health company contracted with this facility. The Provider stated the facility staff would take him to the residents but did not assist him with procedures. They didn't do anything but stand there, watch and bring any supplies he may need for the procedure. The Provider stated Resident 1 had a large decubitus ulcer with dead tissue on top. He stated he made the decision to debride Resident 1's wound. He debrided the wound as he generally did, put in some packing but it didn't seem like a lot of bleeding at first. The Provider stated while he was with another patient; two of the house physicians went to see Resident 1 and when they turned her over, there was a lot of bleeding and pressure was applied. One of the house physicians thought it was arterial bleeding (blood from a vessel that carries blood away from the heart) and an IV (intravenous, through the vein usually to administer fluids or medication) should be started. The Provider stated, "I did not review her chart. The Resident had been on [MEDICATION NAME]. That clearly contributed to what happened." The facility's wound care services agreement with the Provider indicated the following: "Coordination of Care: Facility shall maintain resident's plan of care, medication orders and other information relevant to resident care. Upon execution of appropriate consents from residents (and/or resident family members where appropriate), the Facility shall transmit information to Provider necessary to assist and support the delivery of the Services provided under this Agreement." Review of the acute care hospital records, on 7/7/14, showed Resident 1 arrived in the emergency roiagnom on [DATE] at 12:40 p.m.. The emergency room physician notes indicated Resident 1's vital signs were temperature 38.9 ? Celsius (102.9? Fahrenheit), heart rate of 150, blood pressure 97/27 and respirations 36. Normal vital sign ranges for the average healthy adult while resting are: ? Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg ? Breathing: 12 - 18 breaths per minute ? Pulse: 60 - 100 beats per minute ? Temperature: 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit Review of the laboratory results, dated 3/25/14, for Resident 1 showed PT ([MEDICATION NAME] Time which measure time needed for blood to clot) was 14.5 seconds. The record indicated the normal range was 9.4 to 11.4 seconds. The INR (International Normalized Ration which shows the relationship of the patient's PT to a normal control) was 1.4. The record showed the normal range for INR was 0.8 to 1.2. ________________________________________________________________ Class "B" Citation #02-2593- 69-F The facility violated the aforementioned regulation by failing to communicate to a wound care physician that Resident 1 was taking anticoagulant (blood thinners) medications prior to the physician performing surgical wound debridement (removal of tissue from a wound by a surgical instrument). This failure resulted in Resident 1 developing uncontrolled bleeding after debridement. The doctors in the facility could not stop the bleeding. The facility called 911 and sent Resident 1 to the acute care hospital emergency room for evaluation and treatment.Review of the clinical record, on 4/2/14, showed Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, assessment tool), dated 2/27/14, reflected on admission Resident 1 had three unstageable pressure ulcers covered with slough and/or eschar, (dead tissue) and two unstageable pressure ulcers with deep tissue injury (purple or maroon localized area of discolored intact skin, indicates tissue death beneath the intact skin.)The MDS showed Resident 1 required total assistance with maintaining nutrition, grooming personal and oral hygiene from the facility.The admission order, dated 2/22/14, included Aspirin (thins blood to reduce formation of blood clots) 81 mg (milligrams) one tablet one time a day related to [MEDICAL CONDITION] disease, and [MEDICATION NAME] (prolongs clotting time to reduce formation of unwanted clots in blood vessels) 75 mg one tablet one time a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot) prevention, related to [MEDICAL CONDITION] disease. A physician's orders [REDACTED].The facility had a contract with a wound care clinic (Provider) that provided professional wound care services to skilled nursing facilities. Review of the services agreement between the facility and the Provider, dated 7/29/13, showed the Provider would provide services to the residents of the facility as requested by the facility. In an interview, on 5/6/14 at 11:30 a.m., PCP 1 stated when a consult was requested, he expected the Provider to proceed with adequate care of the patient and give treatment as they saw fit. PCP 1 stated he spoke with LVN (licensed vocational nurse) 1 who told him the Provider said the wounds looked bad and he wanted to proceed with debridement (removal of non-healthy tissue from a wound). PCP 1 stated he told LVN 1, "Okay." PCP 1 was asked if the Provider consulted him on Resident 1's health history. PCP1 stated, "No, usually the nurse does wound care rounds, goes through the chart and reviews the patient (with the doctor)." The patient assessment note, dated 3/11/14, reflected the Provider did a new/initial assessment of Resident 1, and identified the sacrum wound as a Stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), the length was 7, width 13 and depth UTD (unable to determine). The units of the measurements were not given (inches or centimeters). There was no undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface.) There was moderate purulent (pus) drainage with a mild odor and no exposed features (tendon, muscle, bone, or joint). There was no slough: percent of wound base (viable tissue layer) 50% and black eschar: percent of wound base 50%. The note showed, "Still discolored (wound) but better. No evidence of DTI (deep tissue injury) at this point." The assessment form had spaces to check if the resident had diabetes, or was on anticoagulant therapy (each could negatively affect the status of pressure ulcers). The spaces were not checked. There was a space titled, "Laboratory/Diagnostic Review". The space was left blank. There was no documentation to show the Provider reviewed Resident 1's clotting time and blood sugar before starting the treatment.The patient assessment note, dated 3/18/14, reflected the Provider performed, "Surgical debridement (also known as sharp debridement, used a scalpel or scissors)" but it was not clear what area was debrided. The assessment note for the sacrum indicated the pressure ulcer was staged as "UTD". The length was 6, width 13 and depth UTD. The units of the measurements were not given. It showed no undermining, moderate purulent drainage with a mild odor and no exposed features. There was slough: percent of wound base 20% and black eschar: percent of wound base 80%. The progress notes, dated 3/25/14, by the Provider showed, "Today the right side was covered with 100% slough and this was sharply debrided. Oozing was noted, and the wound was packed." The patient assessment note, dated 3/25/14, by the Provider indicated the sacrum pressure ulcer was Stage 3. The measurements were length 7, width 13 and depth 3 (units not given). It showed undermining, large purulent drainage with a strong odor and exposed muscle. There was slough: percent of wound base 100% and no black eschar. "Surgical debridement- skin subcutaneous muscle 100% bleeding severe. Patient on [MEDICATION NAME]. IV started Transferred to hospital acutely". (John Hopkins Medicine advised, for sharp debridement check for bleeding or clotting problems. Debridement is contraindicated for coagulation disorders. Reference: www.hopkinsmedicine.org/gec/series/wound_care.html )During an interview, on 4/2/14 at 1:15 p.m., LVN 2 stated she was present when the Provider performed the wound debridement on 3/25/14. LVN 2 stated the procedure was done between 11 a.m. and 12 p.m. and she observed the Provider clean the wound then cut some of the tissue and the wound started bleeding. The Provider packed the wound with gauze but it didn't stop bleeding. LVN 2 stated the Provider packed the wound and then went to see the next resident. LVN 2 stated she was not aware Resident 1 was on blood thinners.During an interview, on 4/2/14 at 1 p.m., LVN1 stated on 3/25/14 she went to lunch at 11 a.m. and returned at 11:30 a.m. She stated LVN 2 covered for her and was with the Provider when the debridement was done. LVN1 stated when she returned from lunch, she went to check on Resident 1. LVN 1 stated there was blood all over the bed sheet and chux pad (disposable pad). LVN1 stated when she turned Resident 1 on her side, blood was gushing, flowing, but she couldn't see where the blood was coming from. LVN 1 stated she got gauze and applied pressure to try to stop the bleeding then asked the PCP 1 and MD 1 to come look at Resident 1. LVN 1 stated PCP1 and MD 1 tried to stop the bleeding and MD 1 told her to call 911.The EHR (electronic health record), dated 3/25/14 at 1:56 p.m., showed LVN 1's documented, "Resident has a wound to right and left buttock which was debrided today by the wound doctor (Provider) which lead to severe bleeding; the bleeding did not stop with several attempts. PCP1 gave an order to transfer the resident to the hospital." In an interview, on 4/2/14 at 12:05, the DON (director of nursing) was asked if the Provider reviewed the resident medical history before performing a procedure. The DON stated, "Honestly, they don't review the resident's charts." She stated she told the Provider Resident 1 was on Aspirin and [MEDICATION NAME] after they discovered the resident was bleeding. The DON stated the staff did not assist the Provider when debridement was done. She stated the staff would assess the resident after the procedure was completed. The DON was requested to provide the facility's policy and procedure for debridement. The DON was unable to provide a policy and procedure for wound debridement.During a telephone interview, on 6/25/14 at 3:35 p.m., the Provider stated he was a representative of the wound health company contracted with this facility. The Provider stated the facility staff would take him to the residents but did not assist him with procedures. They didn't do anything but stand there, watch and bring any supplies he may need for the procedure. The Provider stated Resident 1 had a large decubitus ulcer with dead tissue on top. He stated he made the decision to debride Resident 1's wound. He debrided the wound as he generally did, put in some packing but it didn't seem like a lot of bleeding at first. The Provider stated while he was with another patient; two of the house physicians went to see Resident 1 and when they turned her over, there was a lot of bleeding and pressure was applied. One of the house physicians thought it was arterial bleeding (blood from a vessel that carries blood away from the heart) and an IV (intravenous, through the vein usually to administer fluids or medication) should be started. The Provider stated, "I did not review her chart. The Resident had been on [MEDICATION NAME]. That clearly contributed to what happened." Review of the facility's policy titled, "Skin and Wound Management Program" dated 6/23/06, showed, "Residents receive care and services necessary to promote and maintain optimum skin integrity. A plan of care addressing skin integrity alterations, risk factors and co-morbidities is developed and implemented by the Interdisciplinary Team with ongoing assessment to ensure optimum outcome." The facility's wound care services agreement with the Provider indicated the following:"Coordination of Care: Facility shall maintain resident's plan of care, medication orders and other information relevant to resident care. Upon execution of appropriate consents from residents (and/or resident family members where appropriate), the Facility shall transmit information to Provider necessary to assist and support the delivery of the Services provided under this Agreement." Review of the acute care hospital records, on 7/7/14, showed Resident 1 arrived in the emergency roiagnom on [DATE] at 12:40 p.m. The emergency room physician notes indicated Resident 1's vital signs were temperature 38.9 ? Celsius (102.9? Fahrenheit), heart rate of 150, blood pressure 97/27 and respirations 36. Normal vital sign ranges for the average healthy adult while resting are:Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg Breathing: 12 - 18 breaths per minute Pulse: 60 - 100 beats per minute Temperature: 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit Review of the laboratory results, dated 3/25/14, for Resident 1 showed PT ([MEDICATION NAME] Time which measure time needed for blood to clot) was 14.5 seconds. The record indicated the normal range was 9.4 to 11.4 seconds. The INR (International Normalized Ration which shows the relationship of the patient's PT to a normal control) was 1.4. The record showed the normal range for INR was 0.8 to 1.2. Therefore the facility failed to provide the physician information about Resident 1 being on an anticoagulant medication, [MEDICATION NAME], before he performed the debridement procedure.

Based on observation, interview and record review, the facility failed to ensure that staff did not neglect one of two sampled residents (10) when he asked for a bedpan. Resident 1 called for staff to give him a bedpan and CNA (certified nurses aide) 1 entered the room, turned off the call light and told the resident she would get his CNA. Resident 1 had to wait for 45 minutes resulting in being incontinent of stool and becoming very angry, screaming for help. Findings: During a complaint visit on 2/27/13 at 12:30 p.m. Resident 1 was lying in bed watching television. He stated that he was in the facility because he had an operation on his foot and was receiving intravenous antibiotic treatment. He said that he could not bear weight on his affected foot. He could transfer to the toilet with assistance but stated he had to use a bedpan because the toilet was not working. There was sign on the bathroom door "Toilet Not Working." During the interview there was a urinal standing on his overbed table that was adjacent to his bed that was full. The graduated urinal bottle held 1000 milliliters. Resident 1 said that last evening (2/26/13) he put his call light on because he needed the bedpan, which was out of his reach. His bed pan was observed on 2/27/13 hanging off the opposite end of his bedside stand out of his reach. He stated that a nurse came about 45 minutes later and he asked her to hand him the bedpan. She told him she would tell his nurse, turned off the call light and left the room. The resident then said he thought to himself, "I'm just going to go on myself, and just crapped on myself, the door was open and I was cold and wet. I felt bad I'm laying in my own crap. When I first got here the CNAs tried to put diapers on me, I refused." Resident 1 became very upset and angry over this incident and said he was screaming for help. A review of Resident 1's medical record on 2/27/12 revealed that he was admitted to the facility on [DATE] which a [DIAGNOSES REDACTED]. His activities of daily living record for February 2013 revealed that he is continent of both bowel and bladder, and that he was independent for transfers and on the evening shift he needed limited assistance with the help of one person to use the toilet. According to a care plan written on 2/16/13 for the resident's activities of daily living function, he had the goals, "...Will maintain ability to participate with self care at current level...Maintain dignity and self-esteem every day..." The approaches were, "...Be sure call light is within reach and encourage to use it for assistance. Respond promptly to all requests for assistance...Provide necessary equipment and adequate time for self performance or participation with daily care tasks..." During a telephone interview with CNA (certified nurses aide) 1 on 3/12/13 at 10:21 a.m. she stated that she was Resident 1's CNA on the evening shift. She stated that he was continent,and she remembered the evening when he was incontinent. She said that on that evening there were only two CNAs working (CNA 1 and CNA 2). CNA 1 was assigned to the dining room for dinner and when she came out, CNA 2 told her that Resident 1 was yelling and that his light was on. CNA 1 went to his room but his light was off and he was screaming that the CNA came in and turned off the light and wouldn't hand him his bedpan and he had to go in the bed. CNA 1 said she told him she was "so sorry," but she was in the dining room. She then cleaned him up. She opened the side door because of the smell. She went on to said that they usually have 3 CNAs on the evening shift but that evening there were only two. She couldn't remember how many residents she had but thought it was between 10 or 11. CNA 2 stated in a telephone interview on 3/12/13 at 12:22 p.m. that on 2/26/12 she was in room [ROOM NUMBER] with one of her resident's when she heard a "voice" from room [ROOM NUMBER]. She went into room [ROOM NUMBER] and Resident 1 asked to be changed. She told him, "give me a minute," then she went to room [ROOM NUMBER] and told CNA 1. She also stated that it was very hard that evening because there were a lot of high risk for falls residents on station 1 and the were short of staff. According to the assignment sheet for 2/26/12 at 3 p.m., Station #1 had one charge nurse and two CNAs assigned. Another CNA (CNA 3) was noted "OFF." The two remaining CNAs had to pick up the extra assignment giving them 13 residents each instead of their usual 8 to 10 residents. A review of the facility's Abuse Prevention, Investigation and Reported policy dated 1/2010, "...neglect...will not be tolerated in this facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident."

The facility violated the aforementioned regulation by failing to provide adequate supervision for one resident (1) who had a history of [REDACTED]. This deficient practice resulted in Resident 1 sustaining a ? of an inch laceration of unknown origin, on her forehead, and abrasions to her knees. Resident 1, an [AGE] year old female, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She also had communication problems and was only sometimes able to understand or be understood. She had a problem of wandering which was not easily altered. She was able to transfer and ambulate independently. According to the nursing note on 4/10/10 at 10:00 p.m. the resident was wandering in the hallway and several times tried to go out of the facility. She was confused and had an episode of agitation. A care plan was written on 4/12/10 to address the problem of, " Elopement risk, carries bags of belongings, " for which the interventions were to place a wander guard (device that when worn on either the wrist or ankle will cause an alarm to sound at the doors equipped with the corresponding device) on her wrist, secured egress unit, frequent visual monitoring, and check behind staff when entering or exiting unit. The nurse ' s note on 5/2/10 at 4:30 p.m. indicated that the CNAs (certified nursing assistants) reported resident went out of the building, the alarm went off from the main door, the CNAs ran after her the resident, and were able to bring her back inside the facility. The note further indicated, " Will continue to monitor and continue with the plan of care, wander guard in place all the time ... " On 9/30/10 the Behavioral Medicine nurse practitioner visited and documented that the resident " Sometimes packs up her belongings and wants to leave - it can be a problem to prevent her from exiting. " During the latest care plan conference dated 10/26/10 the Interdisciplinary Team (IDT) identified Resident 1 ' s accident risk as, poor safety awareness and an elopement risk. The care plan was not updated with any new interventions, and the care plan interventions dated 4/12/10 remained unchanged. The nurses ' notes on 11/20/10 indicated that at 1:00 p.m. Certified Nursing Assistant (CNA) reported that Resident 1 did not eat her lunch and was not in her room. The staff was alerted and a search began. The doctor, Administrator, and Director of Nurses (DON) were all notified. The RN stated in an interview on 11/30/10 at 1:30 p.m. that CNA 1 told her that she delivered the lunch tray to Resident 1 in her room but the resident was not there. They began a search and she called the police, in addition to the others listed in her nurse ' s note dated 11/20/10 at 2:00 p.m. In an interview with CNA 1 on 12/1/10 at 9:30 a.m. she said that on 11/20/10 at around 12:45 she was feeding Resident 2, and when she was finished she went to help pass the second cart of trays that came out for station 1. When she took Resident 1 ' s tray to her room she was not there. She checked in the bathroom and she was not there, so she reported to the charge nurse RN, and then everybody started to search for Resident 1. CNA 2 was assigned to Resident 1 on the day shift of 11/20/10. He stated in a telephone interview on 12/2/10 at 9:25 a.m. that when he arrived to work at 7:00 a.m. on 11/20/10 Resident 1 was already trying to get out through the front door, where she usually tried to go out. He stated that Resident 1 was independent with most of her care, and she was already dressed when he got to work that day. He last saw Resident 1 sitting on her bed in her room between " 10:50 to 11:00 a.m. " Sometime after 1:00 p.m. he heard CNA 1 tell everyone that Resident 1 was missing. According to the nurse ' s note dated 11/20/10 at 2:00 p.m., the police reported that the missing resident (1) was found at the hospital. The emergency room nursing record dated 11/20/10 at 12:35 p.m. indicated that Resident 1 was found wandering the street by the police and had a laceration to her forehead, and abrasions to her knees. She was confused, did not speak English and was unable to say her name. According to the police report, Resident 1 was found on 11/20/10 at 12:09 p.m. walking down the street, and bleeding from the head. Her location was 4.4 miles away from the facility, in the next city which is bordered by water. She had a laceration about ? of an inch long, above her right eye brow. Resident 1 did not speak English and would only respond with " bababa " and " no no no. " A translator arrived and attempted to speak with her in Cantonese, Mandarin, Vietnamese, Laotian and Cambodian to no avail, and she kept repeating " bababa " while smiling. The police officer writing the report did not see anyone else in the area that appeared to be involved. The officer concluded that " it appears that Resident 1 traveled to (city A) from (city O), possibly by bus. It is unknown how Resident 1 sustained her injury. It is unknown how or where the injury occurred or if it was caused by an accident or a criminal act. " Violation of the regulation is evidenced by the facility ' s failure to: Supervise the resident with a known risk for accidents due her wandering behavior and prevent her from wandering away from the facility, where something happened to cause a laceration on her forehead and abrasions to her knees.