Every finding on record at Bear Valley Community Hospital D/P SNF

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition for 20 of 20 residents when, 1. Five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a date.2. Nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator (42 days expired).3. Two of two ovens were found with significant accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks. These failures had the potential to lead to the growth of harmful microorganisms, including bacteria, viruses, and fungi, and cause food-borne illness (occurs when you consume contaminated food or beverages) to 20 residents served by the kitchen. Findings:1. During an observation on June 1, 2026, at 11:51 AM, in the kitchen, five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a dateDuring a concurrent observation and interview on June 1, 2026, at 11:53 AM, with the Kitchen Supervisor (KS), the KS confirmed the findings and stated that all items stored in the refrigerator must be labeled and dated.During a concurrent interview and record review on June 1, 2026, at 3:52 PM, with the KS, the facility's policy and procedure (P&P) titled, Food Storage, undated, was reviewed. The P&P indicated, Procedure: . 7. b. Food should be dated as it is placed on the shelves . c. Date marking should be visible . 13. Refrigerated food storage . f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded . The KS acknowledged the facility's P&P was not followed when five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a date.During a concurrent interview and record review on June 2, 2026, at 9:22 AM, with the Director of Kitchen (DOK), the facility's P&P titled, Food Storage, undated, was reviewed. The DOK acknowledged the P&P was not followed and stated her expectation is that all food items are clearly labeled and dated before being placed in the refrigerator.2. During an observation on June 1, 2026, at 11:59 AM, in the kitchen, nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator.During a concurrent observation and interview on June 1, 2026, at 12:01 PM, with the KS, the KS confirmed the findings and stated that the nine bags of tortillas with an expiration date of April 19, 2026, should have been promptly discarded after the expiration date rather than stored in the refrigerator.During a concurrent interview and record review on June 1, 2026, at 3:55 PM, with the KS, the facility's P&P titled, Food Storage, undated, was reviewed. The P&P indicated, .13. Refrigerated food storage . f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. The KS acknowledged the facility's P&P was not followed when nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator.During a concurrent interview and record review on June 2, 2026, at 9:22 AM, with the DOK, the facility's P&P titled, Food Storage, undated, was reviewed. The DOK acknowledged the P&P was not followed and stated her expectation is that all expired food items must be promptly discarded and not stored in the refrigerator after the expiration date.3. During an observation on June 1, 2026, at 12:18 PM, in the kitchen, oven #1 and oven #2 were found with accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks.During a concurrent observation and interview on June 1, 2026, at 12:21 PM, with the KS, the KS confirmed the findings and stated that all kitchen equipment, including the stoves, should be wiped clean daily at the end of each day prior to closing. The KS further stated that a deep cleaning of the kitchen equipment should be performed weekly, in accordance with the Cleaning Logs.During a concurrent interview and record review on June 1, 2026, at 3:58 PM, with the KS, the facility's P&P titled, Cleaning Instructions: Ovens, undated, was reviewed. The P&P indicated, Policy: Ovens will be cleaned as needed and according to the cleaning schedule . Spills and food particles will be removed after each use . Procedure: 1. Remove the oven racks . 2. Apply oven cleaner and let the racks stand per the oven cleaner directions. 3. Wipe off any loosened grease and particles with paper towels . 7. Wipe off any loosened grease and particles from inside the oven and the oven door . 10. Clean the outside of the oven including the shelf above the stovetop and the oven handles. 11. Remove spills and food particles after each oven use as needed . The KS acknowledged the facility's P&P was not followed when oven #1 and oven #2 were found with accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks.During a concurrent interview and record review on June 2, 2026, at 9:35 AM, with the DOK, the facility's Daily Kitchen Cleaning Schedule and Weekly Cleaning Shift Duties, undated, were reviewed. The Daily Kitchen Cleaning Schedule specified that ovens should be deep cleaned once on Saturday and once on Sunday, as indicated by an X for each day; however, there was no date and no signature or initial to confirm task completion. Similarly, the Weekly Cleaning Shift Duties did not provide specific information regarding the date and timing of task completion and lacked any signature or initial to verify that ovens cleaning had been performed. The DOK acknowledged the absence of signatures to verify completion on both documents and stated that, oven #1 and oven #2 had not been cleaned according to the cleaning schedules.During a concurrent interview and record review on June 2, 2026, at 3:58 PM, with the DOK, the facility's P&P titled Cleaning and Sanitation of Dining and Food Service Areas, undated, was reviewed. The P&P indicated, Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas throughout compliance with a written, comprehensive cleaning schedule. Procedure: 1. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department . 5. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. 6. Staff will be held accountable for cleaning assignments. The DOK acknowledged the P&P was not followed when over #1 and oven #2 were found with accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks. The DOK stated her expectation is that all staff consistently adhere to the cleaning schedule and fully comply with the facility's policies and procedures.A record review of the 2022 Food Code U.S. Food and Drug Administration (FDA), dated January 18, 2023, Chapter 1 Purpose and Definitions. 1-201.10 indicates . Equipment means an article that is used in the operation of a FOOD ESTABLISHMENT such as a freezer, grinder, hood, ice maker, MEAT block, mixer, oven, reach-in refrigerator, scale, sink, slicer, stove, table, TEMPERATURE MEASURING DEVICE for ambient air, VENDING MACHINE, or WAREWASHING machine.A record review of the 2022 Food Code U.S. Food and Drug Administration, dated January 18, 2023, Chapter 4 Equipment, Utensils, and Linens. 4-601.11 indicates, .(C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. in addition, .The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.

Based on observation and interview, the facility failed to maintain the garbage storage area in a sanitary condition for 21 of 21 residents, staff, and the public when the facility's refuse (trash/garbage) was not properly disposed in the designated, covered outdoor container.This failure to properly dispose of refuse in the designated, covered outdoor container demonstrated noncompliance with established sanitation protocols, potentially increasing the risk of environmental contamination and pest infestation, and thereby compromising the health and safety of residents, staff, and visitors.Findings:During an observation on June 3, 2026, at 7:11 AM, a routine inspection was conducted at the outdoor trash disposal area located behind the facility's main building next to the emergency room parking lot. During this observation, one clear plastic bag filled with trash was found on the ground adjacent to the dumpster and was clearly visible from the parking area. Additionally, two more clear plastic bags filled with trash were discovered on the ground behind the same dumpster. The three bags of trash were not properly placed inside the covered outdoor dumpster, which upon inspection had sufficient capacity to accommodate additional waste.During a concurrent observation and interview on June 3, 2026, at 9:20 AM, of the outdoor trash disposal area located behind the main building, with the Director of Maintenance (DOM), the DOM confirmed three bags filled with trash were found on the ground next to and behind the dumpster, and stated that refuse not contained within the dumpster creates conditions conducive to pest infestation, foul odors, and environmental contamination. The DOM further stated that all trash must be placed in designated covered refuse containers and the outside trash collection areas must be kept clean, sanitary, and free of loose refuse.During a concurrent observation and interview on June 3, 2026, at 9:23 AM, of the outdoor trash disposal area located behind the main building, with the Environmental Services Supervisor (EVSS), the EVSS confirmed three bags filled with trash were found on the ground next to and behind the dumpster, and stated that the trash improper placement not only detracts from the overall appearance of the premises but also increases the risk of attracting pests and wild animals, which can pose health and sanitation concerns. The EVSS further stated that all trash must be placed in the covered container and not on the ground.During a concurrent observation and interview on June 3, 2026, at 9:26 AM, of the outdoor trash disposal area located behind the main building, with the Infection Preventionist (IP), the IP confirmed three bags filled with trash were found on the ground next to and behind the dumpster, and stated that it is expected that all trash must be discarded inside the dumpster and confirmed that trash should not be stored on the ground in the disposal area. The IP further acknowledged that trash placed outside the dumpster could attract pests and create an unsanitary environment for the residents, visitors and staff.During an interview with the ADON on June 4, 2026, at 2:16 PM, the ADON stated that unsanitary storage of refuse has the potential to affect residents, staff, and visitors by increasing the risk of pest infestation, foul odors, and contamination in areas used for waste handling. The ADON further stated that to maintain a clean and safe environment, it is essential that all waste be securely disposed of inside the designated dumpsters at all times. The ADON stated the facility does not have a Policy and Procedure regarding Refuse Disposal, Waste Management or Environmental Hazards.A review of the 2022 Food Code US Food and Drug Administration (FDA), dated January 18, 2023, indicated, Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils.

Based on observation and interview, the facility failed to ensure that required daily nurse staffing information for licensed and unlicensed nurses was posted in a location readily visible and accessible to all 20 of 20 residents and visitors to review.This failure resulted in residents and visitors being unable to verify whether the unit was staffed appropriately for the day.Findings:During a concurrent observation and interview on June 2, 2026, at 10:45 AM, with the Assistant Director of Nursing (ADON), in the skilled nursing facility's nursing station, the Direct Hours Per Patient Day (DHPPD-the average number of hours per day that licensed/unlicensed nursing staff spend providing hands-on care to each resident in a facility) was not visibly posted. The ADON acknowledged the DHPPD hours were not visible posted for residents and visitors to view but stated the DHPPD hours are kept inside a binder at the nursing station.During an interview on June 4, 2026, at 10:54 AM, with the Director of Staff Development (DSD), the DSD stated the staffing hours should be visibly posted and acknowledged the staffing hours were not visibly posted.During an interview on June 4, 2026, at 11:05 AM, with the ADON, the ADON stated the staffing hours are not visibly posted, but they should be posted. The ADON further stated, the facility does not have a policy for posting staffing hours and just follow the federal regulations. The ADON further stated the regulations were not followed and it is important to have staffing hours visibly posted for residents and visitors because they need to know what type of staff are working and present on the floor each day.

Based on observation and interview, the facility failed to post the results of the most recent survey of the facility in a place readily accessible for all 21 of 21 residents, family members, and legal representatives of residents to review. This failure had the potential to prevent residents, family members, and legal representatives from being informed about the facility's compliance with state and federal requirements, which could limit their ability to make fully informed decisions regarding the residents' care.Findings:During an interview on June 2, 2026, at 10:30 AM, in the Resident Council Meeting (an organized meeting of facility residents and family members who meet regularly to discuss and address concerns about quality of care in the nursing home), residents expressed concerns regarding the visibility and accessibility of the most recent survey results of the facility. Furthermore, multiple residents reported that they were unaware of the location where these results were posted.During an interview on June 2, 2026, at 11:00 AM, with the Director of Nursing (DON), the DON acknowledged the most recent survey results of the facility must be visibly posted in an unobstructed area and be accessible to the residents and the public in the Skilled Nursing Facility (SNF) area of the Hospital. The DON was unable to specify or demonstrate the location where the most recent survey results of the facility were posted within the SNF area.During a concurrent observation and interview on June 2, 2026, at 11:05 AM with the Assistant Director of Nursing (ADON), the ADON confirmed that all residents have the right to review the results of the most recent Federal or State survey of the facility, along with any current plan of correction. The ADON explained that these survey results are maintained in 3 ring binders, with one binder displayed in the Hospital Main Lobby and another located in the Activity Room within the SNF. The Hospital Main Lobby was observed as inaccessible to SNF residents due to a locked door, an additional set of swing double doors, and three intervening hallways, which posed a barrier for residents who use wheelchairs or have limited mobility. The ADON acknowledged that the binder was inaccessible. There was no binder observed in the SNF activity room. The ADON was unable to provide the binder and could not provide further clarification regarding its whereabouts.During an interview on June 2, 2026, at 3:30 PM, with the ADON, the ADON confirmed that, in accordance with the State regulations and requirements, the facility was required to make the most recent survey results accessible to residents, family representatives, visitors, and the public by posting them in a location within the Skilled Nursing Facility (SNF) area that was both easily accessible and unobstructed. The ADON acknowledged that the results of the most recent survey had not been made available to residents in the SNF section of the hospital, thereby failing to meet the regulatory requirement.

Based on observation, interview, and record review, the facility failed to ensure resident was treated with respect and dignity for one resident (Resident 1) when the facility staff spoke to Resident 1 using language and tone as if one might address a child and refused Resident 1 to receive a shower at his preferred time.This failure resulted in Resident 1 feeling put down and embarrassed which could potentially affect his care from his lack of trust or doubt with the facility staff to participate in treatment plan.Findings:During a review of a Medical Doctor (MD) Progress Note, dated August 27, 2024, the MD progress note indicated Resident 1 has history of congestive heart failure (a serious condition in which the heart doesn't pump blood through the body as efficiently as it should), seizure disorder (a sudden burst of electrical activity in the brain and can cause changes in behavior, movements, feelings and levels of consciousness), stroke (a serious medical emergency that happens when blood flow to the brain is interrupted, either by a blockage or a rupture of a blood vessel), hypothyroidism (when the thyroid gland isn't producing enough thyroid hormones and many bodily functions slow down), and hypertension (when the force of the blood pushing on the blood vessel walls is too high and the heart has to pump harder). During a review of the facility's document title, Report of Suspected Dependent Adult/Elder Abuse (SOC 341-a form that the facility is required to report suspected abuse), dated June 11, 2025, the SOC 341 indicated that there was potential for verbal abuse from a Certified Nurse Assistant (CNA1) towards Resident 1. The SOC 341 also indicated that a CNA spoke to a resident in a belittling and demeaning manner, using language and tone comparable to how one might address a child. This occurred after the resident requested a shower in the evening, having declined one earlier in the day.During an interview on June 20, 2025, at 10:51 AM, with Resident 1, Resident 1 stated I wanted a shower, and [CNA1] was Snooty. [CNA1] said I tried to get you to the shower earlier and I said I'm sorry. I just didn't want to shower in am and would rather know what I did for [CNA1] to yell at me like that. [CNA1] came down like a cat out hell. She was mean and vulgar. Resident 1 stated that CNA1 yelled at him in front of the facility staff and other residents which made him feel not too good.During an interview on June 20, 2025, at 11:52 AM, with RN1, RN1 stated Resident 1 did not want to shower at the scheduled time and CNA1 responded in a very unprofessional tone and was brazen with him.During an interview on June 20, 2025, at 12:17 PM, with the Director of Nursing (DON), the DON stated that Resident 1 live here, and CNA1 was rude and didn't need to be.During an interview on July 7, 2025, at 11:22 AM, with CNA2, CNA2 stated Resident 1 asked about a shower and CNA1 scolded [Resident 1] like a child because he was asking for a shower and CNA1 asked 'why are you asking me now, it's late.' CNA2 further stated It was disturbing. It didn't sit right. CNA2 added, He was aware of her behavior, and he asked, 'why are you talking to me like that'. CNA2 stated, He was completely silent after that. I think he got embarrassed and left [the area]. It was embarrassing to him because other people were around. I wouldn't want to be treated like putting me down with others around.During a concurrent interview and record review on July 7, 2025, at 11:42 AM, with the Assistant Director of Nursing (ADON) and DON, the facility's policy and procedure (P&P) titled, Resident Rights, undated, was reviewed. The P&P indicated, POLICY: [The facility] will assure that all residents are treated with respect and dignity in a manner and environment that promotes their quality of life while promoting their right to self-determination whereby their care choices are respected . PROCEDURE: .3. The right to be assisted by all staff in maintaining and enhancing their self-esteem and self-worth .15.The right to choose their own schedule and have their needs accommodated in relation to: .15.3. Their bathing times and schedule . The ADON and DON acknowledged that the right to be treated with dignity and respect as well as the right to make his own schedule was not followed.

Based on observation, interview, and record review, the facility failed to ensure food was stored to conserve nutritive value (measure of a well-balanced diet) and maintain professional standards of food safety for all 21 residents admitted in the facility when: 1. There was an unlabeled bag of minced beef in the refrigerator. 2. There was an open and unlabeled bag of tortilla flour in the refrigerator. These failures had the potential to cause unsafe food consumption for all 21 vulnerable residents in the facility from possible allergenic substances in food products and consume food beyond the use date (expired date), which can negatively affect resident's health from allergic reaction or foodborne illness (illness caused by ingestion of contaminated food or beverages). 3. For Resident 7, a serving of pureed cauliflower was not palatable or had comparable taste to regular serving of cauliflower. This failure had the potential to cause Resident 7, who was on pureed texture diet order, to experience a decrease in food intake which could lead to unintentional weight loss, malnutrition (not having enough food to eat), and resulting in actual physical harm. Findings: 1. During a concurrent observation and interview on [DATE], at 11:07 AM, with the Executive Chef (EC), the shelf to the left side of the refrigerator had a bag of minced beef with no label. The EC stated the bag of minced beef should have been labeled and dated. During a concurrent interview and record review on [DATE], at 11:45 AM, with the Director of Nutrition Services (DNS), the facility's policy and procedure (P&P) titled, Food Storage, dated [DATE], was reviewed. The P&P indicated. Procedure:13. Refrigerated food storage: f. All food should be covered, labeled and dated and routinely monitored to assure that food (including leftovers) will be consumed by their use by dates, to frozen (where applicable) or discarded The DNS verified and confirmed that the facility staff did not follow the P&P. The DNS stated that the bag of minced beef in the refrigerator should have been labelled and dated. The DNS further stated that not labeling and dating the bag of minced beef increases the risk of foodborne illness. 2. During a concurrent observation and interview on [DATE], at 11:10 AM, with the EC, the shelf to the left side of the refrigerator was observed to have an open unlabeled bag of flour tortillas without, open date, beyond the use date, or description of product. The EC stated the bag of flour tortilla should have been labeled and dated with a description of the product. During a concurrent interview and record review on [DATE], at 11:30 AM, with the DNS, the facility's P&P titled, Food Storage, dated [DATE], was reviewed. The P&P indicated. Procedure:13. Refrigerated food storage: f. All food should be covered, labeled and dated and routinely monitored to assure that food (including leftovers) will be consumed by their use by dates, ot frozen (where applicable) or discarded The DNS verified and confirmed that the facility staff did not follow the P&P. the DNS stated that the bag of flour tortilla in the refrigerator should have been labeled and dated. The DNS further stated that not labeling and dating the bag of flour tortilla increases the risk of foodborne illness. 3. During a review of Resident 7's Admission Record(contains demographic and medical information), the Admission Record indicated, Resident 7 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD-a group of lung disease that block airflow and make it difficult to breathe) and dementia (a progressive decline in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life). During a review of Resident 7's Physician Order for diet, dated February 23, 2022, the Physician Order indicated, Resident 7 had an order for a regular diet with pureed texture. During an observation on [DATE], at 11:40 AM, with a Kitchen Staff (Cook 1) and the DNS, cook 1 was observed preparing the pureed cauliflower in blender by using only hot water. During a concurrent observation and interview on [DATE], at 12:06 PM, with the EC, the sample taste trays of regular diet (no restriction on food) and pureed diet for lunch were observed and tested for palatability (the taste of food), texture and temperature. The sample trays consisted of cilantro chicken, refried beans, Spanish rice, cauliflower and tres leche cake. The regular diet vegetables tasted buttery flavor and were not comparable to the pureed vegetable served. The EC stated that the pureed cauliflower tasted watery and bland and did taste like the regular diet cauliflower. During an interview on [DATE], at 1:00 PM with [NAME] 1 and the DNS, [NAME] 1 stated that she only added hot water to make cauliflower pureed, I should have followed the recipe and should have added small amount of gravy sauce, vegetable juice, water, fruit juice, milk or half & half to meet desired taste and consistency. The DNS further stated that the pureed diet meals should taste like regular diet meals for the residents and [NAME] 1 did not follow the recipe. During a concurrent interview and record review on [DATE], at 9:08 AM, with the DNS, the facility's P&P titled, The Dining Experience, dated February 2023, and PU4 Cauliflower (fzn) (P4U Cauliflower) recipe, undated, were reviewed. The P&P indicated, .Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutrition and/or special dietary needs and food preferences and are served at a safe and appetizing temperature . The P4U Cauliflower recipe indicated, .Measured desired # of servings into food processor. Blend until smooth. Use Drip Test and Spoon Tilt Test to confirm texture is within IDDSI (International Dysphagia Diet Standardization Initiative) Level 4 Specifications. Add small amounts of gravy, sauce, vegetable juice, water, fruit juice, milk, or half & half to meet desired consistency. Drain & Discard excess fluid that has separated from solid food pieces The DNS stated, the pureed cauliflower should taste the same as regular diet textured cauliflower, we did not follow our facility's policy and procedure to provide each individual with nourishing and palatable meal.

Based on observation, interview, and record review, the facility failed to provide special assistive devices during mealtimes for three of 21 sampled residents (Resident 3, 7 and 15) when: 1. Residents 3 and 7 were not provided with a plate guard (a clip onto the edge of a plate to prevent spilling of food) and [NAME] Anti Spill Cup (KCup-allows the cup to be easily filled, once the lid is screwed on, the liquid will not slip even if the cup is turned completely upside down) during lunch. 2. Resident 15 was not provided with KCup as ordered. These failures had the potential to cause Resident 3, 7, and 15 to experience a decrease in food intake without appropriate assistive devices which could lead to unintentional weight loss (not having enough food to eat) and resulting in actual physical harm and medical complications. Findings: 1a. During a review of Resident 3's Admission Record (contain demographic and medical information), undated, the Admission Record indicated, Resident 3 was admitted to the facility on [DATE], with the diagnoses which included hemiplegia (a condition characterized by severe or complete paralysis on one side of the body), and right side hemiparesis (muscle weakness or partial paralysis on one side of the body). During a review of Resident 3's Physician Order for diet, dated April 25, 2022, the physician order indicated, Resident 3 had an order for a plate guard and KCup. 1b. During a review of Resident 7's Admission Record, undated, the Admission Record indicated, Resident 7 was admitted to the facility on [DATE], with the diagnoses which included chronic obstructive pulmonary disease (COPD-a group of lung disease that block airflow and make it difficult to breathe) and dementia (a progressive decrease in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life). During a review of Resident 7's Physician Order for diet, dated April 23, 2022, the physician order indicated, Resident 7 had an order for a plate guard and KCup. During a concurrent observation and interview on May 5, 2025, at 12:15 PM, with a Certified Nursing Assistant (CNA 2), in the residents' dining room, Resident 3 and 7 were not given a plate guard and KCup for eating during lunch. Resident 3 and 7 had meal tickets which indicated a plate guard and KCup were ordered to be used during mealtimes. CNA 2 verified and confirmed that Resident 3 and 7 did not have a plate guard and KCup during the entire lunch time. CNA 2 further stated that Resident 3 and 7 should have a plate guard and KCup during meal and snack time. During a concurrent interview and record review on May 8, 2025, at 9:08 AM, with the Director of Nutrition Services (DNS), the facility's policy and procedure (P&P) titled, Assistance with Feeding SNF [Skilled Nursing Facility], undated, was reviewed. The P&P indicated, . [Facility Name] shall ensure that all residents who require assistance with eating receive appropriate support in manner that maintains their dignity, independence, safety, and nutritional well-being . The DNS stated, Resident 3 and 7 should have been provided with a plate guard and KCup, the facility staff did not follow the P&P. 50754 2. During a review of Resident 15's Admission Record, undated, the Admission Record indicated, Resident 15 was admitted to the facility on [DATE], with diagnoses which included dementia (brain condition that effects thinking memory and behavior), depression (mental health condition persistent feeling of sadness, hopelessness, and loss of interest), anemia (low red blood cells to carry oxygen throughout the body), anxiety (feeling of fear, dread and uneasiness), osteoporosis (bones become thin, weak, and fragile), and Parkinson's disease (a disorder of the central nervous system that affects movement, tremors). A review of Resident 15's Physician Order, dated February 20, 2025, indicated Resident 15 had an order for KCup three times a day with meals. During an observation on May 5, 2025, at 12:09 PM, in the dining room, Resident 15 was observed sitting at one of the dining tables without a KCup. Resident 15's meal ticket, at the bottom, indicated KCup should be on Resident 15's meal tray. During a follow-up concurrent observation and interview on May 5, 2025, at 12:50 PM, with CNA 1, Resident 15 was observed without a KCup, and CNA 1 assisted Resident 15 with meal. Resident 15 drank supplement drink and water through a straw. CNA 1 confirmed and stated that Resident 15 did not have a KCup and should have. During a concurrent interview and record review, on May 6, 2025, at 4:39 PM, with the Director of Nursing (DON), the facility's P&P, undated, was reviewed. The P&P indicated, .Subject: Assistance with Feeding SNF [Skilled Nursing Facility], Policy: [Facility Name] shall ensure that all residents who require assistance with eating receive appropriate support in a manner that maintains their dignity, independence, safety, and nutritional well-being . The DON confirmed Resident 15 should have had her KCup with her meal to encourage the patient to become stronger and CNA 1 should have made sure Resident 15 had her KCup. The [NAME] stated that the P&P was not followed by CNA 1.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with respect and dignity to enhance quality of life for two of two residents (Resident 12 and 15) when the Certified Nursing Assistant (CNA) were observed standing over Resident 12 and 15 during mealtime. This failure had the potential to make Resident 12 and 15 to feel devalue and disrespected which could cause Resident 12 and 15 to distrust the health care provider and would negatively impact the treatment plan. Findings: a. During a review of Resident 12's Admission Record (contains demographic and medical information), undated, the Admission Record indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During an observation on March 5, 2025, at from 12:09 PM through 12:50 PM, in the activity/dining room, Resident 12 was observed sitting in a high back wheelchair next to a table while CNA 2 was standing over Resident 12 feeding her lunch. During an interview on March 5, 2025, at 1:10 PM, with CNA 2, CNA 2 stated No I did not sit while feeding [Resident 12] lunch meal. CNA 2 further stated, the reason to sit with the residents during mealtime is to make it more of a homely environment for the residents. b. During a Review of Resident 15's Admission Record, undated, the Admission Record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses of dementia (brain condition that effects thinking memory and behavior), depression (mental health condition persistent feeling of sadness, hopelessness, and loss of interest), anemia (low red blood cells to carry oxygen throughout the body), anxiety (feeling of fear, dread and uneasiness), osteoporosis (bones become thin, weak, and fragile), and Parkinson's disease (a disorder of the central nervous system that affects movement, tremors). During anobservation on March 5, 2025, from 12:09 PM through 12:50 PM, in the activity/dining room, Resident 15 was observed sitting in a wheelchair next to a table while CNA 1 was standing over Resident 15 feeding her lunch. During an interview on March 5, 2025, at 12:50 PM, with CNA 1, CNA 1 stated, I am supposed to sit and have eye to eye contact and verbalized the importance to make sure the resident has a good experience and give them with dignity. During a concurrent interview and record review on May 6, 2025, at 4:45 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Assistance with Feeding SNF, undated, was reviewed. The P&P indicated, Policy: [Facility Name] shall ensure that all residents who require assistance with eating receive appropriate support in a manner that maintains their dignity, independence, safety, and nutritional well-being . Engage with the resident calmly and respectfully . The DON stated it was unacceptable for CNAs to be standing while feeding Residents 12 and 15. The DON further stated the staff did not follow the P&P and CNA 1 and CNA 2 should have made sure that they were seated and engage with Resident 12 and 15, calmly and respectfully.

Based on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for two of four residents (Residents 16 and 19) when: 1. Resident 16's quarterly RAI/MDS assessment was completed on March 18, 2025 (52 days late). 2. Resident 19's quarterly RAI/MDS assessment was not completed on March 13, 2025 (92 days late) These failures had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day-to-day operations and emergencies for Residents 16 and 19. Findings: 1. During a review of Resident 16's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated July 2024, the H&P indicated, Resident 16 was admitted to the facility on [DATE], with diagnoses which included hypertension (a condition where the heart is working harder to pump blood), type 2 diabetes mellitus (high blood sugar), and cerebrovascular accident (blood flow to the brain is blocked). During an interview on May 8, 2025, at 9:09 AM, with the Director of Nursing (DON), the DON stated one of her duties is to complete the resident's MDS. The DON further stated the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on May 8, 2025, at 9:15 AM, with the DON, Resident 16's quarterly MDS assessment data, dated December 2024, was reviewed. The DON stated the last quarterly assessment was completed on December 18, 2024. The DON further stated she did not complete the quarterly assessment that was due on March 18, 2025 (52 days late). During a concurrent interview and record review on May 8, 2025, at 9:19 AM, with the DON, the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated February 2017, was reviewed. The P&P indicated, .2.3 A Quarterly review will be conducted within 92 days of the ARD of the previous assessment. Not less than once every three months . The DON stated the policy was not followed and should have because it provides accurate reimbursement for the facility and care planning for the residents. 47332 2. During a review of Resident 19's H&P, dated September 6, 2024, the H&P, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses of dementia (a progressive decline in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life). During an interview on May 8, 2025, at 9:09 AM, with the DON, the DON stated one of her duties is to complete the residents MDS. The DON further stated that the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review, on May 8, 2025, at 9:15 AM, with the DON, Resident 19's quarterly MDS assessment dated [DATE], was reviewed, the DON stated the last quarterly assessment was completed on December 04, 2024, the DON further stated she did not complete the quarterly assessment that was due on March 13, 2025 (92 days late). During a concurrent interview and record review on May 8, 2025, at 9:19 AM, with the DON, the facility's P&P titled, Resident Assessment Instrument (RAI), dated February 2017, was reviewed. The P&P indicated, 2.3 A Quarterly review will be conducted within 92 days of the ARD of the previous assessment. Not less than once every three months . The DON stated that policy was not followed and should have been because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview and record review, the facility failed to ensure the quarterly (every 3 months) Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was transmitted (submitted) to CMS in accordance with federal submission timeframes, for three of four residents (Resident 5,12, and16) reviewed for resident assessment when: 1. Resident 5's quarterly RAI/MDS assessment completed on February 14, 2025, has not been transmitted as of May 8, 2025 (69 days late). 2. Resident 16's quarterly RAI/MDS assessment dated [DATE], was transmitted on January 8, 2025 (7 days late) and quarterly MDS assessment due March 18, 2025, was not transmitted (37 days late from the due date). 3. Resident 12's comprehensive RAI/MDS assessment was due on March 30, 2025 but was not transmitted (81 days late) These failures resulted in inadequate monitoring of Residents 5, 12, and 16's progress or decline and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. During a review of Resident 5's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated June, 2023, the H&P indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses which included schizencephaly (birth defect in the brain) and spastic quadriplegia (severe condition affecting movement and posture). During an interview on May 8, 2025, at 9:09 AM, with the Director of Nursing (DON), the DON stated one of her duties is to transmit the resident's MDS once completed. The DON further stated the expectation for the quarterly assessment is to be submitted within 14 days of completion. During a concurrent interview and record review on May 8, 2025, at 9:11 AM, with the DON, Resident 5's quarterly MDS assessment data, dated February 2025, was reviewed. The DON stated the quarterly assessment was completed on February 14, 2025, and was supposed to be submitted by February 28, 2025 (69 days late) but was not. 2. During a review of Resident 16's H&P, dated July 2024, the H&P indicated, Resident 16 was admitted to the facility on [DATE], with diagnoses which included hypertension (a condition where the heart is working harder to pump blood), type 2 diabetes mellitus (high blood sugar), and cerebrovascular accident (blood flow to the brain is blocked). During an interview on May 8, 2025, at 9:09 AM, with the DON, the DON stated one of her duties is to transmit the resident's MDS once completed. The DON further stated the expectation for the quarterly assessment is to be locked and submitted within 14 days of completed. During a concurrent interview and record review on May 8, 2025, at 9:15 AM, with the DON, Resident 16's quarterly MDS assessment data, dated December 2024 and March 2025, were reviewed. The DON stated the quarterly assessment for December 2024 was completed on December 18, 2024. The DON confirmed that the quarterly assessment should have been submitted by January 1, 2025, but it was submitted on January 8, 2025 (7 days late). The DON stated the quarterly assessment for March 2025 completed and transmitted on March 18, 2025, and should have been transmitted by April 1, 2025 (37 days late). During a concurrent interview and record review on May 8, 2025, at 9:19 AM, with the DON, the facility's P&P titled, Resident Assessment Instrument (RAI), dated February 2017, was reviewed. The P&P indicated, . The completed MDS will be transmitted electronically to CMS QIES-ASAP system within 14 days . The DON stated the policy was not followed and should have been because it provides accurate reimbursement for the facility and care planning for the residents. 47332 3. During a review of Resident 12's H&P, dated March 3, 2022, the H&P indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses of Severe disability post anoxic encephalopathy (a medical emergency that occurs when the brain doesn't receive enough oxygen, even when blood flow is adequate. It can lead to lifelong brain damage). During an interview on May 8, 2025, at 9:09 AM, with the DON, the DON stated one of her duties is to transmit the resident's MDS once completed. The DON further stated the expectation for the quarterly assessment is to be submitted within 14 days of completion. During a concurrent interview and record review on May 8, 2025, at 9:11 AM, with the DON, Resident 12's Comprehensive MDS assessment data, dated February 12, 2025, was reviewed. The DON stated comprehensive assessment was completed on February 12, 2025. The DON further stated she completed the assessment but did not submit, it was due on March 30, 2025 (81 days late). During a concurrent interview and record review on May 8, 2025, at 9:19 AM, with the DON, the facility's P&P titled, Resident Assessment Instrument (RAI), dated February 2017, was reviewed. The P&P indicated, . The completed MDS will be transmitted electronically to CMS QIES-ASAP system within 14 days . The DON stated the policy was not followed and should have been because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan (an individualized plan that includes residents' health problems, preferences and goals) for one of three residents (Resident 12) when Resident 12 did not have a care plan developed or implemented to address an ongoing psychotropic (mind altering) medication. This failure had the potential for Resident 12 to have unidentified medical needs, delay in treatment and lack of coordinated care related to psychotropic drugs which can negatively affect Resident 12's mental state. Findings: During a review of Resident 12's Admission Record (contains demographic and medical information), the Admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During a review of Resident 12's Physician Order for Abilify (medication for mental health condition such as depression), dated January 29, 2025, the Physician Order for abilify indicated, Resident 12 was ordered 15 milligram (mg-unit of dosing medication) to be given at bedtime (HS), started on January 29, 2025 for BPSD (behavioral and psychological symptoms of dementia). During a concurrent interview and record review on May 8, 2025, at 9:35AM, with Licensed Vocational Nurse (LVN 2), Resident 12's care plan, undated, was reviewed. There was no documented evidence addressing Resident 12's dementia. LVN 2 verified and confirmed, there was no care plan for Resident 12's dementia. LVN 2 stated, they should have coded it correctly for depression and dementia instead being coded as none. During a concurrent interview and record review on May 8, 2025, at 11:25 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Nursing Care Plan-SNF [Skilled Nursing Facility], undated, was reviewed. The P&P indicated, [Facility Name] will develop and implement a person-centered comprehensive Car Plan for each resident that includes measurable goals and timeframes to meet the resident's medical, nursing and mental/psychological needs that are identified on the comprehensive assessment. The person-centered Care Plan Policy states (4) will address many areas in (4.1) states Psychotropic medicated used will be addressed in the person-centered Care Plan. A person-centered comprehensive Care Plan is updated with any change to the resident's care needs. (6) the Care Plan is updated with any change to the resident's care needs . The DON acknowledged and confirmed that the staff did not follow the care plan policy. The DON stated that the nurses should have developed a care plan to address dementia diagnosis.

Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration was provided in accordance with the facility's policy and procedure (P&P) for one of two sampled residents (Resident 8) when Resident 8's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date it was changed. This failure had the potential to result in a respiratory infection leading to a decline in Resident 8's health status. Findings: During a review of Resident 8's clinical records, Progress Note, April 2025, the Progress Note indicated, Resident 8 was admitted on [DATE], with diagnoses which included dementia (loss of ability to think or remember), diabetes (high blood sugar), and osteoarthritis of multiple joints (a condition that causes the hands, legs, hips to become stiff and painful). During an observation on May 5, 2025, at 11:09 AM, Resident 8 was in his room, lying in bed, and receiving oxygen via oxygen tubing running at three liters per minute. The oxygen tubing was not labeled to indicate the last time it was changed. During a concurrent observation and interview on May 5, 2025, at 11:15 AM, with a Licensed Vocational Nurse (LVN 1) in Resident 8's room, LVN 1 inspected Resident 8's oxygen tubing and stated it did not have a label or date on it. LVN 1 further stated the oxygen tubing was supposed to be changed weekly and the date must be written on it. During a concurrent interview and record review on May 6, 2025, at 4:06 PM, with the Director of Nursing (DON), the facility's P&P titled, Oxygen Use in the SNF [Skilled Nursing Facility], undated, was reviewed. The P&P indicated, .3. All oxygen humidifier bottles, and tubing shall be changed every Sunday night by the Licensed Nurse . 3.1. A label shall be attached to both the humidifier bottle and oxygen tubing noting the date and time these were changed with the Licensed Nurse's initials . The DON stated oxygen tubing should be changed and labeled every Sunday and further stated the facility staff did not follow the policy.

Based on interview and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Medication Cart 1). This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 21 residents. Findings: During a concurrent interview, and record review on May 7, 2025, at 6:20 AM, with a Licensed Vocational Nurse 2 (LVN 2), at the nurse's station, the Medication Cart 1's Controlled Medication Shift Count (CMSC-form used by the facility to verify counting of controlled medications at the change of shift by oncoming and off going licensed nurses), dated April 23 2025, through May 4, 2025, was reviewed. The CMSC indicated that there were two missing signatures on April 26, 2025, for the night shift (7:00 PM to 7:00 AM). LVN 2 confirmed two missing signatures and stated the expectations for the CMSC to be counted by two nursing staff, filled out, and signed every shift change. During a concurrent interview and record review on May 7, 2025, at 10:15 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Controlled Drugs, undated, was reviewed. The P&P indicated, .2.3. Skilled Nursing narcotic counts are conducted at shift change by verification with two licensed nurses . The DON stated the policy was not followed and should have been to find out if there are any discrepancies.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for drug storage for one of one medication refrigerator in the medication storage room when the daily medication temperature log for the refrigerator was missing two staff signatures for two shifts. This failure had the potential for medications to be less effective due to the temperature of the medications being out of range. Findings: During a concurrent observation and interview on May 07, 2025, at 9:30 AM, with the Director of Nursing (DON), in the medication storage room, across from the nursing station, one medication refrigerator was observed with a document titled, Daily Temperature Log for Refrigerator, with two missing signatures. The DON verified there were missing signatures for the refrigerator temperature checks on March 12, 2025, and March 30, 2025. During a concurrent interview and record review on May 07, 2025, at 10:32 AM, with the DON, the facility's P&P titled, Drug Storage Temperatures, undated, was reviewed. The P&P indicated, . All refrigerators used for the storage of vaccines shall be monitored twice daily . The DON stated the policy was not followed because there was no proof of staff monitoring the refrigerator's temperature and further stated the medications need to be kept at the correct temperatures for the safe use of the medications.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed for all 21 residents in the facility when two cups with brown liquid were found on the folding table/desk in the laundry room. This failure had the potential to result in spilling which can cause contamination to from uncleaned cloths and wetness can create mold and mildew to further compromised all 21 vulnerable residents in the facility. Finding: During a concurrent observation and interview on March 7, 2025, at 7:01 AM, with an Environment Service (EVS) and Environment Service-Trainee (EVS-T), the laundry room across from the Nurse's station in Unit B was observed. There was a brown cup with a sippy lid and a clear cup, containing brown liquid inside, located on the folding table. EVS and EVS-T acknowledged the two brown liquid cups on the folding table inside the laundry room. EVS stated he was informed that the coffee cup was allowed. During an interview on March 7, 2025, at 8:10 AM, with the Director of Facilities (DOF), the DOF stated they are not supposed to have personal drinks/beverages in the laundry room. The DOF confirmed yes, it is an infection control issue. The DOF stated it is important to not have personal drinks in the facility areas, this prevents infections and contamination. During a concurrent interview and record review on May 8, 2025, at 11:53 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Infection Prevention- Skilled Nursing Facility (SNF), dated June 25, 2015, was reviewed. The P&P indicated, . [Facility Name] shall promote the maintenance of a safe environment for both residents and employees and provides appropriate care for residents to prevent the spread of infection. The skilled Nursing Facility provides care to residents of varying ages and disease processes. When infections occur, they can be devasting to residents as well as staff members. Staff and health care providers play a crucial role in protecting themselves and our residents . The DON confirmed the P&P was not followed and should have been. The DON stated drinks should not have been in the laundry care area in the staff personal area or in the break area.

Based on interview and record review, the facility failed to ensure residents or resident representatives (RP) were informed of psychotropic medication (medications that affect the mind, emotions, and behaviors) treatment for three of 12 sampled residents (Resident 2, 8, and 12) when: 1. Resident 2's informed consent (document signed by resident or representative to give permission for a proposed psychotropic medication and possible risks and benefits expected) was not updated and obtained for Resident 2's new order of Trazodone Deseryl (Trazodone-antidepressant medication) 50 milligram (MG-unit of measurement) and NF-Aripiprazole Av PAK (Aripiprazole-antipsychotic medication which is used to treatment of a wide variety of mood and psychotic disorders) 2.5 MG. 2. Resident 8's informed consent was not updated and obtained for Resident 8's new order of Risperidone (Risperdal-antipsychotic medication) 0.5 MG and Escitalopram (Lexapro-antianxiety medication to help you relax) 10 MG. 3. Resident 12's informed consent for Abilify (medication for mental health condition such as depression)15 MG PO Every Evening for BPSD (for diagnosis behavioral psychological symptoms in dementia) Start date of January 29, 2025, prescribed by physician, Consent signed by representative (son) on November 21, 2024, medication states Abilify 2mg po QHS. The consent does not match the order. These failures resulted in Residents 2, 8, and 12's right to be violated. Residents 2, 8, 12 and their representatives were not informed of psychotropic medications risks, benefits, adverse reactions, and the right to refuse the administration of medications. Findings: 1. During a review of Resident 2's Admission Record (clinical record with demographic information), undated, the Admission Record indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included depression (constant feeling of sadness and loss of interests), hyperlipidemia (elevated levels of fat in the blood), and hypertension (high blood pressure). A review of Resident 2's physician order, dated March 12, 2025, indicated Resident 2 had an order for Trazodone Desyrel 50 MG at night for inability to sleep and NF-Aripiprazole Av PAK 2.5 MG at bedtime for psychosis (a state where someone loses touch with reality). During a review of Resident 2's Informed Consent, dated August 28, 2024, the Informed Consent indicated, Trazadone 25 MG as needed for insomnia and Aripiprazole 15 MG daily for psychosis were signed on August 28, 2024. During an interview on May 7, 2025, at 8:29 AM with a Licensed Vocational Nurse (LVN 2), LVN 2 stated she was unable to find an updated consent reflecting the dosage changes for Trazadone and Aripiprazole. 2. During a review of Resident 8's Admission Record, undated, the Admission Record indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses which includes behavioral and psychological symptoms of dementia (a combination of agitation, anxiety, hallucinations with episodes of mania or depression) and type 2 diabetes mellitus (high blood sugar). A review of Resident 8's physician order, dated April 29, 2024, indicated Resident 8 had an order for Escitalopram 10 MG every day for mood and Risperidone 0.5 MG daily for agitation, impulse control, and hypersexual behavior. During a review of Resident 8's Informed Consent, dated January 26, 2024, the Informed Consent indicated, Lexapro 5 MG at bedtime was signed on January 26, 2024. A follow-up review of Resident 8's Informed Consent, dated May 19, 2024, the Informed Consent indicated, Risperdal 0.5 MG BID twice daily was signed on May 19, 2024. During an interview on May 7, 2025, at 8:32 AM with LVN 2, LVN 2 stated she was unable to find an updated consent reflecting the dosage changes for Escitalopram and Risperidone. During further concurrent interview and record review, on May 8, 2025, at 08:00 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Informed Consent Psychotropic Medications SNF [Skilled Nursing Facility], undated, was reviewed. The P&P indicated, .5. The Informed Consent is updated with any change in psychotropic medications . The DON stated the facility staff did not follow the policy. 50754 3. During a review of Resident 12's Admission Record, undated, the Admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During a concurrent interview and record review on May 8, 2025, at 9:35 AM, with LVN 2, Resident 12's Informed Consent for Abilify, dated November 21, 2024, was reviewed. The Informed Consent for Abilify indicated, Abilify 2 MG PO HS was noted and signed by RP 1. LVN 2 verified and confirmed Resident 12's informed consent. During a follow-up concurrent interview and record review on May 8, 2025, at 9:35 AM, with LVN 2, Resident 12's Physician Order for Abilify dated January 29, 2025, was reviewed. The Physician Order for Abilify indicated, Resident 12 was ordered 15 MG to be given HS, started on January 29, 2025, for BPSD. LVN 2 stated, the physician order for Abilify and consent did not match so it indicated that Resident 12 and RP 1 were not informed of the change in psychotropic medication. During a concurrent interview and record review on May 8, 2025, at 11:25 AM, with the DON, the P&P titled, Informed Consent Psychotropic Medication SNF, undated, was reviewed. The P&P indicated, . 5. The informed consent is updated with any change in psychotropic medications. 6. Up to date and appropriate consents are validated during the interdisciplinary care plan (IDCP) conference as needed . The DON verified and confirmed the P&P. The DON stated, it is her expectation and written in the policy that residents' informed consent needs to be updated for any changes in psychotropic medications with residents, resident representatives, or power of attorney (POA). The DON further stated, residents, resident representatives, or power of attorney should be informed of the side effects of any changes in psychotropic medications.

Based on interview and record review, the facility failed to ensure a comprehensive minimum data set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessment was completed and submitted to CMS in accordance with the required federal submission timeframe for one of eight sampled residents (Resident 12). This failure resulted in inadequate monitoring of progress or decline for Resident 12 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 12's Admission Record (contains demographic and medical information), the Admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During an interview on May 8, 2025, at 9:35 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was responsible for the MDS staff to ensure the MDS assessments were completed correctly. LVN 2 stated, it is very important to have residents' diagnoses accurately reflect residents' current condition in the updated resident assessment instrument (RAI-a standardized assessment tool that measures health status on nursing home residents) to identify residents' needs and goals. During a follow-up concurrent interview and record review on May 8, 2025, at 9:40 AM, with LVN 2, Resident 12's MDS with an assessment reference date (ARD-the last day of the observation period used for an assessment) on February 12, 2025, was reviewed. The MDS indicated, Resident 12 was assessed as NONE for depression and dementia. LVN 2 verified and stated Resident 12's MDS was incorrectly assessed. LVN 2 confirmed and stated, Resident 12 was on a psychotropic (mind altering) medication and the MDS did not accurately reflect Resident 7's current condition. During a review of Resident 12's Physician Order for abilify (medication for mental health condition such as depression), dated of document, the Physician Order for abilify indicated, Resident 7 was ordered 15 milligram (mg-unit of dosing medication) to be given at bedtime (HS), started on January 29, 2025, for BPSD (behavioral and psychological symptoms of dementia). During an interview on May 08, 2025, at 11:25 AM, with the Director of Nursing (DON), the DON stated that the MDS should have been completed accurately and reflected the current condition of residents. During a concurrent interview and record review on May 8, 2025, at 11:26 AM, with the DON, the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), undated, was reviewed. The P&P indicated .RAI assessment process will be conducted for all SNF [Skill Nursing Facility] residents as an ongoing process to appropriately assess each resident's functional mobility and health status and in a timely fashion, to identify and address any potential significant change in status . PROCEDURE: (2) (2.3) states A Quarterly review will be conducted within 92 days of the ARD of the previous assessment. Not less than once every three months and (7) states the completed MDS will be transmitted electronically to [Name of electronic system] system within 14 days. (7) (7.1) further states Validation reports for transmitted MDS will be retained in the DON office . The DON verified and stated the MDS staff did not follow the RAI policy in correctly filling out the RAI so the RAI did not provide an accurate picture of the residents. The DON further stated, the MDS staff should have had the diagnosis, and their assessment documented accurately and in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure for one of one sampled resident (Resident 4) Percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach to provide food, water, and medications) tube placement and residual were checked before administering medications. This failure had the potential to affect the health and well being for Resident 4. Findings: During a review of Resident 4's clinical record, the history and physical (a document that contains basic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included PEG tube. During a concurrent medication pass observation, and interview on March 13, 2024, at 8:01 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 was administering medications through the PEG tube. LVN 1 did not check Resident 4's PEG tube placement and residual before administering the medications. When asked why she did not check Resident 4's tube placement and residual, she stated knows she has to do it and they usually check it once a shift. She further stated she knows the right way is to check placement and residual every medication administration. She stated unfortunately she missed some steps. During a review of the facility's Policy and Procedure (P&P) undated, titled, Tube Feeding, indicated, .Pull the syringe back to check for residual feeding/fluid, if greater than 50 ml hold feeding, clamp the tube, close the flap. Document in EMR and notify MD.

Based on interview, and record review, the facility failed to ensure an order for Clonazepam ( a psychotropic medication that affects how the brain works and causes changes in mood, awareness, feelings and behavior) PRN (give only as needed) was renewed by the physician within 14 days for one of three sampled residents (Resident 17). This failure had the potential for Resident 17 to continue to receive PRN doses of Clonazepam, that may no longer be necessary and could cause changes in Resident 17's fatigue, mood and memory problems. Findings: During a review of Resident 17's History and Physical (H&P- a document that includes a Resident 17's medical assessment performed by a medical provider), the H&P indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses including severe deconditioning (mental and physical decline that results from physical inactivity), anxiety (feeling of fear, dread and uneasiness that can cause physical stress), and hypertension (HTN- high blood pressure). During a concurrent interview and record review on March 19, 2024, at 10:23 AM, with Pharmacist, the Interdisciplinary Care Plan (ICDP) Notes- Quarterly dated 10/18/2023 was reviewed. The ICDP Notes-Quarterly indicated, .reduce [Clonazepam] 0.5 QHS (every night at bedtime) and 0.25 in am (the morning) with 0.25 PRN (only as needed). The Pharmacist stated, Resident 17's Clonazepam dose had been decreased during a gradual dose reduction (GDR- an assessment performed by a facility to reduce the dose of antipsychotic medication a resident is taking) in October 2023. Resident 17's morning dose was cut in half from Clonazepam 0.5 mg (milligrams- units of measure) to Clonazepam 0.25 mg, and Clonazepam 0.25 mg was added with the intention to stop the PRN dose if Resident 17 tolerated this well. The Pharmacist also stated he did not know if the order had been renewed or if the attending physician had reevaluated Resident 17 for continued used of this medication. During a concurrent interview and record review on March 19, 2024, at 2:14 PM, with Physician (MD), Resident 17's Order Summary was reviewed. The Order Summary indicated, .Clonazepam 0.25 mg tab oral PRN daily start date: 10/18/2023 stop date 3/18/2024. Indication: anxiety Instructions: PRN daily at noon . The MD stated, Resident 17's Clonazepam was reduced in October 2023 as part of the GDR. The MD stated, he did not know that PRN psychotropic medications need to be renewed every 14 days and an evaluation of the patient needed to be done for the renewal of apsychotropic medication. During a review of the facility's policy and procedure (P&P) titled, Gradual Dose Reduction (GDR Psychotropic Medications, undated, indicated .All residents receiving psychotropic medications will receive the appropriate dose and duration to minimize the risk of adverse consequences. The purpose of GDR is to determine the optimal dosage of medication or whether continued use of the medication is benefiting the residenT .

Based on observation, interview, and record review, the facility failed follow their policy and procedure for one of three sampled residents (resident 20) when Resident 20's PRN (as needed) oxygen physician order did not include indication. This failure had the potential to cause Resident 20 to receive inadequate oxygen and place Resident 20 at higher risk of insufficient oxygenation. Findings: During a record review of the facility's face sheet (a document containing resident's demographic and medical information) of resident 20,the face sheet indicated Resident 20 was admitted with a diagnosis which included Congestive Heart failure (a chronic condition which causes low oxygen level because the heart cannot pump enough oxygen the way it should). During an observation on March 12, 2024, at 9:00 AM, in Resident 20's room, Resident 20 was observed lying in bed with a nasal cannula (NC-a medical device that provides supplemental oxygen therapy to Resident 20) set at 2 liters (unit of measurement) per minute. During a review of Resident 20's Physician Orders, dated March 13, 2024, it indicated, oxygen at 2 liters per minute via NC PRN. Further review of Resident 20's oxygen physicians order, it was noted that there was no indication for its use. During an interview on March 14, 2024, at 11:36 AM, in the nursing station with Licensed Vocational Nurse (LVN 1), LVN 1 acknowledged Resident 20 had no indication for oxygen use. LVN 1 further stated there was no documented administration and indication for oxygen use. During an interview on March 19, 2024, at 4:00 PM, in the Director of Nursing's office with the Director of Nursing (DON), DON acknowledged Resident 20's PRN order for oxygen administration does not have an indication. During a record review of facility's policy and procedure (P&P), undated, title,Oxygen Use in the SNF, the P&P indicated, All resident sreceiving oxygen in the Skilled Nursing Facility (SNF) shall have an order from a provider noting the L (liter)/MN (minute) and designated as nasal cannula or mask (type) as well as continuous or PRN. Further review of the P&P, it indicated, 1.1 SpO2 [oxygen saturation - a measurement of how much oxygen is the blood carrying] monitoring shall be done on a weekly basis for all residents receiving oxygen PRN 1.2 The provider shall be notified with any SpO2 < (less than) 90% for residents receiving oxygen. [generally, indicate the need for the supplemental oxygen.]

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free of significant medication errors, when the facility did not renew and administer Resident 2's scheduled Keppra (a medication used to treat and prevent seizures [which are involuntary muscle movements] for 16 medication administration opportunities, from December 3, 2022, 9:00 AM, through December 10, 2022, 4:00 PM. This failure resulted in Resident 2 sustaining a grand mal seizure (also known as a tonic-clonic seizure, characterized by intense muscle contractions and loss of consciousness), which could have jeopardized the health and safety of Resident 2. Findings: During a review of Resident 2's Coding Summary, (a document that contains a resident's demographic and medical information), ,dated February 2, 2023, the Coding Summary indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage that leads to complete paralysis of half of the body) and hemiparesis (a weakness of one side of the body caused by brain damage) following other cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue) and other epilepsy (group of disorders marked by problems in the normal functioning of the brain, causing seizures) . During a concurrent observation and interview on February 13, 2023, at 9:43 AM, in Resident 2's room, Resident 2 was observed lying in bed with a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and glasses on. Resident 2 stated, this one, this one, and this one is good, but that one is not. Resident 2 was asked, who were this one and that one, and Resident 2 was unable to identify who they were. Resident 2 was unable to focus with the interview questions. During a telephone interview on February 13, 2023, at 2:20 PM, received by the surveyor from a family member (FM 1) of Resident 2, FM1 stated Resident 2's seizure medication fell off the system and Resident 2 was without seizure medication for eight to nine days and had a grand mal seizure. FM 1 stated, they were called about Resident 2's seizure and told that the facility would investigate the occurrence. During a review of Resident 2's medication administration record (MAR), 5 Day MAR - Final, dated from November 28, 2022, to December 12, 2022, the MAR indicated, Resident 2's Keppra medication order was 1,000 mg (mg-milligrams, unit of measurement) to be given by mouth twice a day, with start date of December 3, 2021, and stop date of December 3, 2022. The MAR indicated, the Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. During a review of Resident 2's Order Chronology (Physician Orders), dated February 15, 2023, the Physician Orders indicated, Resident 2 's physician order for Keppra, oral tablet, 1,000 mg, one tablet taken by mouth twice a day, start date was from December 11, 2022, at 8:33 AM. During a review of Resident 2's 5 Day MAR - Final (MAR), dated from November 28, 2022, to December 2, 2022, the MAR indicated, Resident 2's Keppra medication order was last administered on December 2, 2022, at 4:09 PM. The MAR dated from December 3, 2022, to December 7, 2022, indicated, Resident 2's Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. The MAR, dated from December 8, 2022, to December 12, 2022, indicated, Resident 2's Keppra medication order was next administered on December 11, 2022, at 9:10 AM. Resident 2's MAR indicated, 16 consecutive scheduled Keppra medication administrations were not given to Resident 2, between December 3, 2022, to December 10, 2022. During a review of Resident 2's Long Term Care Plan (Care Plan- specific interventions to provide effective and person-centered care to meet the resident's needs), dated February 14, 2023, the Long Term Care Plan indicated, Resident 2 has a potential for alteration in health maintenance related to diagnosis of epilepsy/seizure problem. The Long Term Care Plan indicated Resident 2 did not receive her Keppra as ordered due to a system error for renewal of medication Resident 2 had a seizure on December 11, 2022, no injuries noted as a result of the seizure, MD was notified and Keppra was reordered. During an interview on February 14, 2023, at 8:20 AM, with Minimum Data Set Nurse (MDS Nurse - a nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), MDS Nurse stated, Resident 2 was not given multiple scheduled Keppra medication administrations during a COVID-19 (a highly contagious respiratory disease) outbreak in the facility. MDS Nurse stated, Resident 2 was noticed by the night nurse on December 11, 2022, at 5:52 AM, to be having a seizure and at that time it was noticed that Resident 2 had not been receiving their Keppra medication. MDS Nurse stated, the Keppra for Resident 2 had been removed by the electronic health record (EHR) system automatically. MDS Nurse stated, the facility completed an investigation and notified family when Resident 2 had the seizure. MDS Nurse stated, Resident 2's seizure had occurred during the night shift, early morning of December 11, 2022. During an interview on February 14, 2023, at 3:30 PM, with Registered Nurse 1 (RN1), RN 1 stated, the system in place to prevent missed medication was the monthly review with the pharmacist and RN 1. RN 1 stated, at the time of the occurrence, the electronic health record system would send a report to the printer at the nurses' station notifying the nurses of medications that had a stop date that would soon occur. The printed page would then be placed on the nurses' station desk where the medication nurse would determine the next action which may include faxing the pharmacy if a refill is needed. RN 1 stated, they are unable to verify where the report indicating Resident 2's Keppra medication stop date had been placed. During a concurrent interview and record review on February 15, 2023, at 2:32 PM, with the Director of Nursing (DON), the DON stated, Resident 2 was the only resident listed on the facility's undated document titled Patients Receiving Seizure Medications in the facility. During a review of Resident 2's Patient Progress Notes, dated December 11, 2022, at 5:52 AM, indicated, Resident 2 had a witnessed grand mal seizure, lasting approximately one and half minutes. The Patient Progress Notes indicated, Resident 2 suddenly raised up left arm, became stiff and started shaking mildly and was unresponsive throughout the seizure and confused following the seizure. During an interview on February 15, 2023, at 3:47 PM, with the Pharmacist (RPH), the RPH stated, the monthly medication regimen review (MRR - an evaluation of the medication regimen of a resident) is completed by the RPH. The RPH stated, the stop dates for medications were not looked at prior to Resident 2's medication error. The RPH stated, order recapitulations (a report completed by the medical doctor with their decision to continue or discontinue an order) are forwarded to the medical doctor (MD 1). The RPH stated, the recap process had stopped due to staff not completing the recap process at the time of Resident 2's medication error. The RPH stated, the stop date for Resident 2's Keppra been noted he would have referenced his concerns to the Director of Nursing (DON) and/or the interdisciplinary team (a group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident). During an interview on February 15, 2023, at 5:08 PM, with the Director of Nursing (DON), the DON stated, they noticed on the day of Resident 2's seizure that the EHR system was automatically discontinuing medications based on the stop dates in the EHR system. The DON stated, MD 1 was able to review the orders in the EHR system and choose whether to continue or discontinue any orders, including medication orders. The DON stated the report with all orders was printed and included all medications and the medication stop dates. The DON was asked if the stop date had been noticed prior to Resident 2's seizure, would Resident 2's seizure been avoidable? The DON replied, Resident 2 had a history of refusing medications before and did not know if Resident 2's missed Keppra medication administrations had caused Resident 2 to sustain their grand mal seizure. During a review of Resident 2's Pharmacist Monthly Medication Review/Consultation, dated December 2022, the document indicated, Resident 2 had seizure condition and Resident 2's indicated medication to treat the seizure condition was Keppra. The document further indicated in the discussion notes with nursing, Resident 2 had a seizure this month and appeared to be related to Resident 2 not receiving their Keppra. During a review of the facility's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, the P&P indicated, Procedure: 1.All SNF residents nursing and medication orders shall be renewed on a monthly basis. 7.The following shift is to verify orders for completion and accuracy. 8. All skilled nursing charts will be checked for new orders every 24 hours during the night shift by a licensed staff member for accuracy and completion of orders . During a concurrent interview and record review on February 16, 2023, at 10:47 AM, with the DON, the DON was asked if the facility's policy and procedure (P&P) titled, Physician's Orders - SNF, undated, was followed in reference to item 1(one), which indicated, All SNF residents nursing and medication orders shall be renewed on a monthly basis. The DON stated, this was a system error and was not completed for Resident 2.

Based on interview and record review, the facility failed to follow their abuse policy and procedure when one of three sampled residents (Resident 1) was subjected to verbal abuse by a Certified Nursing Assistant (CNA 2) while providing care. This failure caused Resident 1 to experience psychosocial harm and had the potential for other residents residing in the facility to be subjected to abuse. Findings: On (MONTH) 18, (YEAR), at 10:45 AM, an interview was conducted with the Interim Director of Nursing (IDON) for the facility's Inpatient Acute Care unit, and the Dependent Part/Long Term Care Skilled Nursing Unit. The IDON stated, on (MONTH) 12, (YEAR), she received a report under her office door, describing an event in what appeared to be a potential allegation of verbal abuse involving a Certified Nursing Assistant (CNA 2) and Resident 1 of the Skilled Nursing Unit (SNU). The IDON stated she had not received any other communication from the nursing staff regarding the event. The IDON concurrently stated the contents of the report contained information from CNA 1, who had overheard CNA 2, yelling loudly, rollover in order to place a bedpan under Resident 1. During this time, Resident 1 asked CNA 2 to fix her pillow. CNA 1 overheard CNA 2 yelling No! It is fine where it is. I am not adjusting it every time I come in here. Do not remove your pillow, I am not fixing it. A review of an email received by the IDON dated, (MONTH) 13, (YEAR), revealed the Licensed Vocational Nurse (LVN 1) informed the IDON of the event that occurred between CNA 2 and Resident 1. LVN 1 wrote in the email of CNA 2's rudeness, condescending attitude, and that CNA 1 can be extremely brusque and unfriendly. On (MONTH) 18, (YEAR), at 11:30 AM, during an interview with CNA 1, he confirmed he had placed the written statement, with the allegations of CNA 2's verbal abuse, under the IDON's office door. CNA 1 stated he heard CNA 2 yelling from Resident 1's room I told you not to touch your pillow, now you fix it. During the interview with CNA 1, he stated that in the past he had made an anonymous call to the Ombudsman (Long Term Care Ombudsman Program, independent, trained and certified advocates for residents living in long-term care facilities) reporting abuse and then reported the abuse to the Director of Nurses (DON). The DON responded by yelling at him, stating he was not to call the Ombudsman; he was to inform her (the DON) first, so she can address the problem. She then pulled a sheet of paper off her office wall with a five star rating and stated See these stars, thank you, you just dropped us one star. CNA 1 stated the DON crumpled up the paper and threw it at him. CNA 1 stated he left the DON's office and she followed him out of her office, continuing to yell at him in the nursing station, in front of the night and day shift nursing staff. CNA 1 stated the DON then turned to the nursing staff and said No one is to call the Ombudsman unless you talk to me first. I will take care of the situation. CNA 1 stated after the incident, the Restorative Nurse Assistant (RNA - a nursing assistant who helps with patient mobility and ambulation) told him to go home that the DON did not want him there. CNA 1 stated he did not go to her for any issues, because her response was always I'll take care of it, or I don't have time to talk right now, I'm very busy. CNA 1 stated he is fearful of reporting issues of abuse to the DON for fear of retaliation, and that is why he waited so long to report the event that occurred between CNA 2 and Resident 1. During an interview with the Director of Staff Development (DSD) on (MONTH) 20, (YEAR), at 10:30 AM, she stated CNA 2 always tried to change her assignment with other CNA's. CNA 2 always walked by resident's call lights, and other CNAs will have to attend to the resident's needs. The DSD stated after the incident between Resident 1 and CNA 2, she had interviewed Resident 1 who told her she does not feel safe and does not want CNA 2 to care for her. The DSD stated Resident 1 grabbed her hand requesting, Don't let her touch me. The DSD stated she did not report the conversation to the DON for a couple of days. During an interview with LVN 2, conducted on (MONTH) 20, (YEAR), at 11:03 AM, she stated CNA 2 has an aggressive personality, displayed an attitude while providing care, and always wanted to change with another CNA when Resident 1 is assigned to her. During an interview with Certified Nursing Assistant 3 (CNA 3), conducted on (MONTH) 20, (YEAR), at 11:50 AM, she stated she was present during the event when the DON was Mad at CNA 1, she came out of her office stating anytime we call the state, no matter what time of day, we have to call her first. CNA 3 stated this made her uncomfortable and nervous to report anything. During an interview with Resident 1, conducted on (MONTH) 20, (YEAR), at 1:05 PM (with difficulty articulating) she stated, CNA 2 hates me. All the time, she is mean to me, and to others too. A lot of the time, she puts me down. It is a million things. She yells at me and puts me down all the time. I do not want her when I need to go to the bathroom. It's the words she says, she doesn't like me, she told me that . During an interview with LVN 2, conducted on (MONTH) 20, (YEAR), at 1:20 PM, she stated CNA 2 has a hostile attitude toward Resident 1 and she is extremely unfriendly to the residents. LVN 2 stated Resident 1 did not want CNA 2 to care for her, stating, I don't want her touching me, she is mean to me, she calls me names and I do not feel safe. During an interview with Resident 2 (roommate of Resident 1), conducted on (MONTH) 20, (YEAR), at 4:15 PM, she stated CNA 2 was yelling really loud, and it was upsetting. Resident 2 stated she finally had enough and through the drawn curtain requested CNA 2 to lower her voice. Resident 2 said CNA 2 told her to Shut-up. Resident 3 stated this made her feel angry and embarrassed. She said CNA 2 offered no apology. During an interview with Resident 3 conducted on (MONTH) 20, (YEAR), at 4:40 PM, he stated there were times when CNA 2 does not understand, accept, or was empathetic with our limitations. Resident 3 stated when he would ask her to do something for him, CNA 2 would respond by stating she was here to do what she needs to do, I'll take care of my responsibilities. Resident 3 stated he felt like she was on her own agenda and she does not respond to interruption. She is different from the others, she is authoritative. A review of the facility document titled California Department of Aging-Long -Term Care Ombudsman Program - Elder Abuse with a Copyright date of 2007 State of California, revealed the following: .California State Law and the Federal Nursing Home Reform Act clearly state that the resident has the right to be free from abuse. Ombudsman must view elder abuse as a priority and constantly be on the alert of its occurrence, as well as work to prevent any and all elder abuse .California law also requires Ombudsmen to receive reports of alleged and suspected abuse of dependent adults in long-term care facilities . A review of the facility document titled Bear Valley Community Healthcare District - New Employee Receipt Checklist dated (MONTH) 8, 2005, and signed by (name of CNA 2,) acknowledged by signature receipt of the Employee Statement - Dependent Adult Abuse Reporting. A review of the facility policy titled Elder-Dependent Abuse Policy - SNF -SNF revised, and approved date of (MONTH) 25, (YEAR), defines the following: Purpose: To insure proper reporting of resident/patient abuse. Policy: It is the policy of the facility to maintain an environment free of abuse and neglect. The resident/patient has the right to be free from verbal .mental abuse .Residents/patients will not be subjected to abuse by any one including .facility staff .Procedure: A. All potential new employees and volunteers will be screened for a history of abuse, neglect or mistreatment of [REDACTED].within their hearing distance, regardless of their age, ability to comprehend, or disability .Mental Abuse: This includes, but is not limited to humiliation .D. All employees or volunteers will receive education, training, and periodic in-service training, about: 2. How staff should report their knowledge of allegations without fear of reprisal .F. The facility will identify, correct and intervene in situations in which abuse, neglect .A general analysis of the facility's risk for those incidents will include: .3. The Supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, and ignoring residents during care .I .All allegations of abuse will be reported by telephone immediately, or within 24 hours, to the proper authorities by the employee who witnessed the incident: For the Skilled Nursing Facility report to the Ombudsman or local law enforcement . On (MONTH) 18, (YEAR) at 5:10 PM, an Immediate Jeopardy (IJ- a situation with the potential to harm the health and safety of the residents) was called under 483.12, Freedom from abuse, neglect, and exploitation, in the presence of the facility Chief Executive Officer (CEO), the Interim Director of Nursing (IDON) and the Risk Compliance Officer (RCO). The CEO, IDON, and the RCO were verbally notified of the IJ situation identified based on the facility's failure to ensure residents were free from verbal abuse. An acceptable corrective action plan was provided by the facility on (MONTH) 19, (YEAR), at 4:18 PM. The corrective action plan included the following components: 1. The facility has implemented a Just Culture (a culture of behavior that encourages employee self-disclosure and continual delivery of high quality services for patients, employees, and the community it serves) program to promote a non-punitive environment that encourages a culture of reporting suspected forms of abuse. 2. Coaching of all Skilled Nursing Facility (SNF) staff and staff involved, on reporting abuse, timeliness of reporting, mandated reporter requirements and chain of command. 3. Punitive Action for (name of CNA 2). 4. Formal coaching with (name of CNA 1) and the Licensed Vocational Nurse (LVN) involved with the incident to include the following: a. Mandated Reporter guidelines and duties, b. Timeliness of reporting abuse, c. Avenues/options for reporting abuse d. Chain of command at the facility. After review and verification that each component of the corrective action was in place, the IJ was lifted on (MONTH) 20, (YEAR) at 10:00 AM, in the presence of the CEO, CNO, and the IDON.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance was provided to one of two sampled residents (Resident A) to prevent an accident due to failure to identify and evaluate hazards and risks for falls by conducting periodic (such as quarterly, annually, and as needed) fall assessments and bowel and bladder assessments. This failure resulted in the facility's inability to develop, modify and update the plan of care to reduce risks for falls based on current a comprehensive assessment. Resident A sustained a fracture (break) of the left pubic ramus (bone located on the lower inner buttock area) requiring further treatment and pain management. Findings: On June 2, 2015 at 11:40 AM, an observation and interview with Resident A on June 2, 2015 was conducted. Resident A was sitting on a recliner chair beside the bed in her room. Resident A was alert and oriented to name, time, and place, and was able to answer questions verbally. When asked about the fall incident (on September 13, 2014), Resident A stated, I fell in the bathroom almost a year ago because I tried to go by myself with my walker and I was not able to get to the toilet on time and had an accident right there (in the bathroom) and I fell on the floor. Resident A explained, I don't want to scold them (the staff) I tried to call for help, I turned my call light on but they don't come right away. What should I do, I'm going to have an accident so I have to go (by herself to the bathroom). A review of the facility's incident report dated September 15, 2014, indicated Resident A did not use the call light for help, she walked to the bathroom by herself and fell to the ground (floor inside her room). The report indicated Resident A fractured her left pelvis (left pubic ramus), and was given medication for pain. During an interview with Certified Nursing Assistant (CNA) 1 on June 2, 2015 at 11:45 AM, regarding Resident A's fall incident on September 13, 2014, CNA 1 stated she had been taking care of Resident A. CNA 1 stated the resident had been always incontinent of urine and bowel because of the resident's bowel condition ([DIAGNOSES REDACTED]. CNA 1 explained Resident A needed assistance with toileting but would not ask for help and would only use the call light at times. When asked if Resident A had been on a scheduled toileting program such as toileting supervision and/or assistance on scheduled times (such as upon arising in the morning; before lunch; before dinner; before bedtime) prior to the fall, CNA 1 stated Resident A was never on any scheduled toileting program but she (CNA 1) had offered or taken the resident to the bathroom every two hours. In an interview with the Licensed Vocational Nurse (LVN) 1 on June 2, 2015 at 11:55 AM, regarding Resident A's fall incident, she was asked about the resident's plan of care to prevent falls during toileting prior to the incident of the fall. LVN 1 stated she was not sure if Resident A was on any toileting program prior to the fall (on September 13, 2014) to present (June 2, 2015). A review of Resident A's clinical record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing assessments for Fall Risk Assessments and Bowel and Bladder assessments showed the last fall assessment for Resident A was conducted by facility staff on June 2013 (3 years ago). The assessment showed Resident A had minimal risk for incontinence and had a total score of 9 (a score of 9 + indicated high risk for fall). There was no current and periodic documentation of bowel and bladder assessments and fall assessments to identify and evaluate Resident A's current risk of an accident, including the need for supervision. There was no documentation of care plan interventions developed or modified by the interdisciplinary team (members include the Registered Nurse (RN), LVN, CNA, Social Services, Activity, Dietary, and the resident) based on the resident's current comprehensive fall and bowel bladder assessments to ensure safe toileting and to prevent falls. Resident A's plan of care for fall prevention dated June 12, 2013 and modified on September 22, 2014 (9 days after the fall incident), indicated Resident A was at risk for injury (from falls) related to Arthritis and impaired mobility. Care plan interventions included to encourage the resident to call for assistance as much as possible; to answer call light promptly; and to anticipate needs (such as need to go the bathroom due to frequent loose stools). There was no documentation of a plan of care that addressed risks of falls, including safe toileting. The plan of care to prevent falls had not been modified and/or updated based on the resident's current identified fall risks and health condition. In an interview with the Director of Nursing (DON) on June 2, 2015 at 12:15 PM, she was asked how the facility conducts resident fall risk assessments and bowel bladder assessments. The DON stated fall assessments and bowel and bladder assessments had to be done annually and as needed for fall assessment if there was a fall incident. The DON reviewed the resident's clinical record and acknowledged there was no documentation of bowel and bladder assessments nor a fall assessment conducted since 2013 (past 3 years). The DON further acknowledged there was no plan of care developed to prevent falls based on the resident's current fall and bowel and bladder assessment.

Based on observation, interview and record review, the facility failed to conduct a minimum data set comprehensive assessment (MDS, a tool used by long-term care facilities to assess and plan care and treatment for [REDACTED]. This failure resulted in actual harm to a resident as follows: 1. Unsampled Resident A, with [DIAGNOSES REDACTED]. complained of chest pain on June 4, 2013. This chest pain was not followed up on in a timely manner, resulting in the chest pain not being assessed or treated. There was no MDS assessment for this resident since January 20, 2012, a period of 17 months. The following failures resulted in a potential for harm and/or death, for other residents, as follows: 2. Resident 4, with [DIAGNOSES REDACTED]. There had not been a comprehensive assessment for Resident 4 since March 1, 2012, a period of 15 months. This resulted in the potential for further decline in her psychosocial mental health status, including a potential for suicide. 3. Resident 5, with [DIAGNOSES REDACTED]. The failure to conduct a comprehensive assessment for more than 34 months, resulted in the potential for skin breakdown, pressure ulcers (bedsore, injury to the skin and/or tissue that usually occurs over a bony prominence) or infection for Resident 5. 4. Resident 6, with [DIAGNOSES REDACTED]. The failure to conduct a comprehensive assessment for 27 months resulted in Resident 6 having declines in her activities of daily living (ADL's), including her mobility. 5. Unsampled Resident B, with [DIAGNOSES REDACTED]. This failure had the potential that Resident B's depression had worsened without appropriate intervention. 6. Unsampled Resident C, with [DIAGNOSES REDACTED]. Resident C had not had a comprehensive assessment for 20 months. This failure had the potential that Resident C's contractures had not been assessed for the degree of assistance with ADL's needed or that resident C was at risk of injury. 7. Unsampled Resident D, with [DIAGNOSES REDACTED]. This failure resulted in the potential for skin breakdown, pressure sores, or infection due to incontinence (loss of bladder control). 8. Unsampled Resident F, with [DIAGNOSES REDACTED]. Unsampled Resident F had been having moderate to severe generalized pain. There had not been a comprehensive for 27 months. It could not be determined if the resident's level of pain had worsened. 9. Unsampled Resident G, with [DIAGNOSES REDACTED]. Resident G was identified as having had a history of [REDACTED]. Since there had not been an assessment for Resident G for 20 months, this failure resulted in the potential for an untreated UTI, which could have lead [MEDICAL CONDITION] (a potentially deadly medical condition in which the body has a severe response to bacteria or other germs). 10. Unsampled Resident H, with [DIAGNOSES REDACTED]. 11. Unsampled Resident J, with [DIAGNOSES REDACTED]. Resident J was identified as being "bedfast" (not able or not willing to get out of bed) and at high risk for pressure sores. Since there was not an assessment available, the planning of care, based on the comprehensive assessment, had the potential for the development of pressure sores. 12. Unsampled Resident K, with [DIAGNOSES REDACTED]. Resident K was using supplemental oxygen (considered a drug, oxygen is administered from the source through a plastic tubing to the patient's nose or mouth to help patients with lung disease breathe easier). Since there had been no comprehensive assessment completed, there had not been care planning for the use of supplemental oxygen to facilitate his breathing. 13. Unsampled Resident M, with [DIAGNOSES REDACTED]. The lack of a full comprehensive assessment for this resident had the potential for his [MEDICAL CONDITION], depression, and hypertension to worsen without appropriate care planning and treatment. The facility staff's failure to assess the resident's medical and psychological health placed the residents at risk for poor outcomes. Due to the failure of the staff to perform and complete these crucial, required assessments, limited their ability to identify progress and declines in the residents' health status, for varying periods of time, ranging from months to years. On June 5, 2013 at 6:01 PM, an Immediate Jeopardy (IJ) was called in the presence of the Chief Executive Officer (CEO), the President of the Hospital Board, the Chief Nursing Officer (CNO) and the survey team. The CEO, President of the Hospital Board and CNO were informed the IJ was called because the resident MDS comprehensive assessments had not been completed, per regulatory requirements, for periods of 1 to 7 years for 13 residents in a universe of 20. Findings: 1. During a medication pass observation, conducted on June 4, 2013 at 8:00 AM, Unsampled Resident A was observed, and heard, to complain of pain at a level of '10' on a scale of 1 to 10 (10 was the highest level of pain on the scale) to Licensed Vocational Nurse (LVN) 1. LVN 1 documented Unsampled Resident A's pain at a level of '0' (Refer to F-309). When Unsampled Resident A was asked where the pain was, she held her hand to the upper left side of her chest. Pain to the upper left side of the chest can be a sign of an impending [MEDICAL CONDITION] or a sign of [MEDICAL CONDITION] (a symptom of [MEDICAL CONDITION] caused by decreased blood flow to the heart), both of which could have serious health consequences, including death (reference, 'Healthwise', April 14, 2011). LVN 1 then stated to Unsampled Resident A, "Don't you mean itching?". Unsampled Resident A then stated, "No, Pain". LVN 1 then stated, "I'll get you some itch medication". LVN 1 did not follow up on the resident's complaint of pain she was experiencing in the upper left chest, as the resident had indicated by placing her hand on her chest. On June 4, 2013 at 8:35 AM, LVN 1 was observed to go to the treatment cart (a cart on wheels with locking drawers which contained medications and dressing supplies for skin treatments) and obtained [MEDICATION NAME] cream (a medication for treatment of [REDACTED]. LVN 1 then stated she was going to take Unsampled Resident A to the bathroom to apply the cream. Following the observation, a record review, of Unsampled Resident A's medical record, was conducted at approximately 9:30 AM to follow up on the pain assessment. Unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The medication administration records (MAR) for April, May and June, 2013, showed documentation that the licensed nurses had been documenting for at least 3 months that Resident A was not having any pain. It is unknown how many times the resident had complained of pain since admission, when it had gone unrecognized and not treated based on the observation that had taken place June 4, 2013, during the medication pass. Section J0100 of the MDS provides for the assessment of pain. The record review revealed there had not been a full comprehensive assessment of Unsampled Resident A completed since January 20, 2012, 17 months ago. The assessment for Resident A's pain had not been completed, therefore a plan of care for pain for Resident A was not in place. 2. On June 4, 2013, a record review noted Resident 4 was admitted [DATE], with [DIAGNOSES REDACTED]. Resident 4 had no full comprehensive assessment since March 1, 2012, for the past 15 months. A review, of Resident 4's medical record, revealed the following nurses' notes: "12/18/12 --- Resident refused all oral medications and insulin for this shift." 1/7/13 --- Resident refused all meds (medications) x (times) 3. 2/9/13 --- Resident refused 0800 (8 AM) insulin. 3/10/13 --- Remains inconsistent and non-compliant with her medications, her insulin and her diet. 3/23/13 --- Resident has remained in a negative mood. 4/15/13 --- Refused adamantly to take either her medication or inhalation (a type of respiratory treatment) treatment. 4/19/13 --- Resident refused her medications, her insulin and her evening dinner tray. (Resident stated), 'Just get out and leave me alone'. 4/20/13 --- Continues in a negative vein and is rude to staff members." Resident 4 had been documented as being in a, "negative mood" and had been refusing medications and meals. Sections 'D' and 'E' of the MDS are used for the assessment of a resident's mood and behavior. The behaviors and mood had not been identified in an assessment to trigger a need for psychiatry (the medical field which treats patients with mental health issues). This failure to conduct a timely current assessment resulted in the facility's failure to identify and prevent a potential weight loss, the resident's refusal of medications and meals and to identify and prevent a potential deteriorating mental health status, and putting Resident 4 at risk for self harm. 3. The clinical record review for Resident 5 was conducted on June 4, 2013. The record review noted that Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. There had not been a comprehensive assessment since September 25, 2010, more than two years ago. Observation, from June 3, 2013 to June 5, 2013, showed Resident 5 had been in bed or in a wheelchair, with adult diapers on for incontinence. Section H of the MDS assesses for urinary and bowel incontinence. The failure to conduct a comprehensive assessment for more than two years resulted in the facility's failure to identify and monitor Resident 5's duration and frequency of the incontinence. This resulted in the potential for skin breakdown, pressure ulcers or infection. 4. On June 4, 2013, a record review for Resident 6 was conducted. Resident 6 was admitted to the facility July 20, 2001, with [DIAGNOSES REDACTED]. Resident 6 had not had a comprehensive assessment since March 12, 2011, a period of 27 months. Resident 6 was identified, during the initial tour of the facility on June 3, 2013 at 11:00 AM, and on the facility's Roster Sample Matrix (a form provided by the facility which lists all residents and medical and psychological areas of concerns identified for each resident) as needing increased assistance with activities of daily living (ADL's). Since Resident 6 had not had a comprehensive assessment for more than 24 months, and the amount of assistance and specific areas the resident needed assistance in had not been determined. Resident 6 was observed in bed, on her back, on June 6, 2013 at 9:30 AM, 12:05 PM and 2:55 PM; and on June 7, 2013 at 7:30 AM and 1:15 PM. Impaired mobility can lead to many health issues, including skin breakdown and pressure ulcers. Additionally, Resident 6 had a [DIAGNOSES REDACTED]. These difficulties could lead to undesired weight loss for the resident. Section G0110 of the MDS provides for assessment of the functional status of the resident. Section A, "Bed Mobility", noted, "how the resident moves......" and Section H, "Eating", noted ,"how resident eats and drinks". The care planning and treatment for [REDACTED]. An interview was conducted with the Director of Nurses (DON)/Minimum Data Assessment Nurse (MDS, a tool used by skilled nursing facilities to assess and plan treatment and care for the residents) on June 5, 2013 at 12:30 PM. The DON/MDS nurse was asked about the missing comprehensive assessments. The DON/MDS nurse replied, "Do you want me to print them out for you?" No additional MDS' were printed or provided by the facility. On June 5, 2013 at 12:45 PM, the DON approached and asked, "Do you have a minute?" The DON was followed to the Chief Nursing Officer's (CNO) office. The CNO and DON were present. The DON closed the door to the CNO's office. The DON then was observed to be tearful and stated she had something she needed to say. The DON then stated she had not been performing or transmitting the resident MDS assessments for a while. The DON further stated she had been, "stretched to the limits". During a concurrent interview with the CNO, the CNO stated she had just learned of the failure to assess the residents, "two seconds" before. 5. A record review, conducted on June 4, 2013, noted Unsampled Resident B was admitted [DATE], with [DIAGNOSES REDACTED]. Section D0500 of the MDS provides for the assessment of the resident's mood. Letter B assesses for the residents' feelings of "appearing down, depressed, or hopeless". Letter I assesses for the feeling of "life isn't worth living, wishes for death, or attempts to harm self." The resident had not had an MDS assessment for 21 months; this failure had the potential that Resident B's depression had worsened without appropriate intervention based on a mood assessment not being completed, which could have resulted in the potential for a decline in Resident B's mental health status. During an interview with the Director of Staff Development/Registered Nurse (DSD/RN) on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 6. A record review, conducted on June 4, 2013, noted Unsampled Resident C was admitted [DATE], with [DIAGNOSES REDACTED]. During the initial tour, conducted on June 3, 2013 at 11:00 AM, Resident C was identified as having contractures of her hand joint. Resident C was also identified, on the facility's roster sample matrix, as needing increased assistance with ADL's. Section G0400 of the MDS assesses for limitation in range of motion (the distance and direction a joint can move to its full potential) that, "interfered with daily functions or placed resident at risk of injury". A hand contracture would impact the ability of the resident to perform her ADL's and negatively impact her quality of life. Resident C had not had a comprehensive assessment in 20 months. This failure had the potential that Resident C's contractures had not been assessed for the degree of assistance with ADL's needed or that Resident C was at risk of injury. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 7. A record review, conducted on June 4, 2013, noted Unsampled Resident D was admitted [DATE], with [DIAGNOSES REDACTED]. There was not a full comprehensive assessment since August 10, 2011, for the past 22 months. Resident D had a [DIAGNOSES REDACTED]. Due to the lack of a comprehensive assessment the duration and frequency of the incontinence had not be determined. This resulted in the potential for skin breakdown, pressure ulcers or infection. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 8. A record review, conducted on June 4, 2013, noted Unsampled Resident F was admitted [DATE], with [DIAGNOSES REDACTED]. A full comprehensive assessment had not been completed since March 18, 2011, for the past 27 months. During the initial tour, on June 3, 2013 at 11:00 AM, Resident F was identified as having arthritis (inflammation of the joints) pain of moderate to severe intensity. Section J of the MDS allows for the assessment of pain. Since Resident F had not had a full MDS completed for 27 months, it could not be determined if the resident's level of pain had worsened and if it was being treated appropriately. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 9. A record review, conducted on June 4, 2013, noted Unsampled Resident G was admitted [DATE], with [DIAGNOSES REDACTED]. No full comprehensive assessment had been done since October 9, 2011, for the past 20 months. During the initial tour of the facility, conducted on June 3, 2013, at approximately 11:00 AM, Resident G was identified as having had a history of [REDACTED]. The DON, during the tour, stated she was uncertain when the resident had the most recent UTI. Section I 2300 of the MDS, under, "Infections", allows for the assessment of UTI's to be documented so that care and treatment can be implemented. An untreated UTI could lead [MEDICAL CONDITION] (a potentially deadly medical condition in which the body has a severe response to bacteria or other germs). The failure of Resident G not having a current MDS assessment could lead to the resident having urinary or bladder (the organ that collects urine before urination) health problems. This failure may have resulted in the potential for Resident G to have bladder problems that had not been identified in an assessment for care planning and treatment. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 10. A record review, conducted on June 4, 2013, noted Unsampled Resident H was admitted [DATE], with [DIAGNOSES REDACTED]. There was no full comprehensive assessment since May 27, 2012, for the past 12 months. Resident H was identified as having a history of falls. Section J1700 - J1900 of the MDS is the part of the assessment which allows for assessment of falls and the subsequent planning of care to prevent future falls. Section J1800 states, "Has the resident had any falls since admission or the prior assessment, whichever is more recent?". During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 11. A record review, conducted on June 4, 2013, noted Unsampled Resident J was admitted [DATE], with [DIAGNOSES REDACTED]. During the initial tour, conducted on June 3, 2013, with the DON, Resident J was identified as being, "bedfast" (not able or not wanting to get out of bed) and at high risk for pressure ulcers (bedsore, injury to the skin and/or tissue that usually occurs over a bony prominence). Section M0100 thru M1200 of the MDS allows for assessment of the skin condition. Section M0150 states, "Is this resident at risk of developing pressure ulcers?". There was no comprehensive assessment available to review since Resident J's admission, February 6, 2006. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 12. A record review, conducted on June 4, 2013, noted Unsampled Resident K was admitted [DATE], with [DIAGNOSES REDACTED]. During the initial tour on June 3, 2013 at 11:00 AM with the DON, observation showed Resident K was using supplemental oxygen (considered a drug, oxygen is administered from the source through a plastic tubing to the patient's nose or mouth to help patients with lung disease breathe easier). Section O100 of the MDS allows for documentation of, "Special treatments, procedures, and programs". Sections C. thru G. assess for, "Respiratory treatments". There was no MDS assessment available for Resident K since her admission, April 2, 2008, therefore, the assessment and treatment plan for use of the supplemental oxygen had not been developed. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. 13. A record review, conducted on June 4, 2013, noted Unsampled Resident M was admitted [DATE], with [DIAGNOSES REDACTED]. Section D0500 of the MDS provides for the assessment of the resident's mood. Letter B assesses for the residents' feelings of "appearing down, depressed, or hopeless". Letter I assesses for the feeling of "life isn't worth living, wishes for death, or attempts to harm self." This failure had the potential that Resident M's depression had worsened without appropriate intervention based on the lack of a mood assessment being completed timely. During an interview with the DSD/RN on June 5, 2013 at approximately 5:20 PM, the DSD/RN was asked about the missing MDS. The DSD/RN confirmed the missing MDS. During an interview with the CNO on June 7, 2013, at approximately 3:00 PM, the CNO was asked if the facility had a policy and procedure in place for MDS assessments. The CNO stated the facility did not have a policy available for MDS assessments. On June 7, 2013 at 4:07 PM, the IJ was abated, in the presence of the CNO.

Based on observation, interview, and record review, the facility failed to ensure that each resident was provided with the care necessary to maintain their highest practicable physical well-being for 2 of 8 sampled residents (Residents 1 and 3) and 1 of 14 unsampled residents (Unsampled Resident A) as follows: 1. After Unsampled Resident A complained of pain at a level of '10' on a scale of 1 - 10 (10 is the highest level on the pain rating scale), during a morning medication pass, the nurse documented the resident's pain level at '0'. There was not any follow up or care plan for Unsampled Resident A's complaint of pain. This failure resulted in the resident suffering unidentified, untreated pain until the resident was transferred, at approximately noon on June 7, 2013, to the emergency room of the acute hospital and admitted to the hospital with [REDACTED]. 2. For Resident 3, the facility failed to implement appropriate interventions to ensure care and treatment for [REDACTED]. And, failed to address her needs when she complained of headaches, nervousness, and anxiety. And, verbalized multiple times to facility staff that she wanted to kill herself. These failures had the potential for harm or death for Resident 3. 3. For Resident 1, the facility staff failed to set up a urology consult ordered by the physician in a timely manner. This had the potential for Resident 1 to experience pain and a decline in health. Findings: 1. During a medication pass observation, conducted on June 4, 2013 at 8:00 AM, Unsampled Resident A was observed and heard to complain of pain at a level of '10' on a scale of 1 to 10 (10 was the highest level of pain on the scale) to Licensed Vocational Nurse (LVN) 1. When Unsampled Resident A was asked where the pain was, she held her hand to the upper left side of her chest. Pain to the upper left side of the chest can be a sign of an impending [MEDICAL CONDITION] or a sign of [MEDICAL CONDITION] (a symptom of [MEDICAL CONDITION] caused by decreased blood flow to the heart), both of which could have serious health consequences, including death (reference, 'Healthwise', April 14, 2011). LVN 1 then stated to Unsampled Resident A, "Don't you mean itching?". Unsampled Resident A then stated, "No, Pain". LVN 1 then stated, "I'll get you some itch medication". LVN 1 did not follow up on the resident's complaint of pain she was experiencing in the upper left chest, as the resident had indicated by placing her hand on her chest. On June 4, 2013 at 8:35 AM, LVN 1 was observed to go to the treatment cart (a cart on wheels with locking drawers which contained medications and dressing supplies for skin treatments) and obtained [MEDICATION NAME] cream (a medication for treatment of [REDACTED]. LVN 1 then stated she was going to take Unsampled Resident A to the bathroom to apply the cream. LVN 1 was then observed to document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Monitor for s/s (signs and symptoms) of pain", a "0" for no pain. She performed no pain assessments nor alerted the physician of the Unsampled Resident A's complaint of chest pain. An interview was then conducted with LVN 1 on June 4, 2013 at 8:40 AM. LVN 1 was asked about Unsampled Resident A's complaint of pain. LVN 1 stated Unsampled Resident A had dementia (a general term for a decline in mental ability severe enough to interfere with daily life). LVN 1 then stated, "It's really itching; she gets confused." During an interview with Unsampled Resident A on June 4, 2013 at 8:45 AM (10 minutes after she complained of pain to LVN 1) in the activity room, she was asked, by this surveyor, if she was having any pain. Resident A stated her pain was an '8' on a scale of 1 to 10. Resident then indicated, with her right hand, the pain was in her upper left chest. She denied complaint of itching and stated that it was pain. Unsampled Resident A was asked if she knew where she was; she stated, (name of town). Resident A was asked what day it was; she stated, "Monday, I think" (it was Tuesday). Unsampled Resident A was asked the names of other residents in the activity room; she was able to correctly (according to the Activity Director) state the names of other residents. A record review, of Unsampled Resident A's medical record, was conducted on June 4, 2013. Unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During further review of the medical record, on June 4, 2013, it was noted in a nurse's note dated December 29, 2012 at 10:00 PM by Registered Nurse 1 (RN 1), "She is without skin problems as such, but will use anti-itch cream for a prior Shingles (a [MEDICAL CONDITION] disease characterized by an intensely painful skin rash) problem." An interview was conducted with the Chief Nursing Officer (CNO) on June 6, 2013 at 2:50 PM. The CNO was asked what she would expect the nurse to do when a resident complained of pain. The CNO stated she would expect the nurse to do an assessment of the pain; look at the medications that were ordered and administer if ordered; then call the physician, if necessary. LVN 1 did not do a complete assessment of the resident's complaint of pain, did not administer any medication for pain and did not call the physician for Unsampled Resident A's complaint of pain. A record review of the MAR from June 4, 2013 to June 7, 2013 reflected Unsampled Resident A continued to be assessed with [REDACTED]. On June 7, 2013 at 12:05 PM, Unsampled Resident A was transferred and admitted to the general acute hospital emergency room with chest pain. During an interview with the RN, MDS (Minimum Data Set, a tool used to assess and plan care and treatment for [REDACTED]. The RN/MDS Coordinator stated when she complained of pain, it was under her armpit and breast on her right side. She then confirmed there had not been a recent full comprehensive MDS assessment within the past year, a care plan for pain, or an immediate pain assessment when Unsampled Resident A complained of pain in her left upper chest on June 4, 2013. The facility's policies and procedures were reviewed on June 7, 2013. The policy, "Pain Management", dated March 25, 2013, noted, "It is the policy of BVCHD (Bear Valley Community Hospital Distinct Part) that each resident will attain or maintain his/her highest practicable physical, mental and psychosocial well-being as per the resident's individual plan of care, assuring adequate pain control using a process of assessment, intervention and reassessment by utilizing a consistent established pain scale." Review of the facility's policy, "Administration of Medication", dated January 26, 2012, documented, "Specific medication dose should be written for MILD (0-3); MODERATE (3-7); SEVERE (7-10) pain levels". 2. A review of Resident 3's clinical record on June 4, 2013, noted that Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 3's Physician Orders for Life-Sustaining Treatment (POLST-a form that notes what kind of medical treatment patients want toward the end of their life,) completed on her admission, showed Resident 3 was not capable or responsible to make her own medical decisions. A review of Resident 3's Minimum Data Set (MDS-a comprehensive assessment of the resident), dated March 20, 2013, showed she had clear speech, was usually able to be understood and could understand others. Further review showed that she had a depression [DIAGNOSES REDACTED]. During an interview with Licensed Vocational Nurse 1 (LVN 1) on the initial facility tour, June 3, 2013, at 11:30 AM, she stated that Resident 3 was alert and interviewable and had "anxiety." Resident 3's room was observed to be at the end of the hall and one of the two rooms furthest from the nurse's station. During an interview with Resident 3 on June 5, 2013, at 9:38 AM, she stated, "I want to die; things are not going right." Resident 3 expressed that she was frustrated that her television (TV) headset was not charged, that she could not hear her TV, and that she did not have a hearing aid, which made her upset. A TV headset was observed on her dresser in a charger at that time. She further stated that she had previously attempted suicide (tried to kill herself) by swallowing a "handful of pills." During an interview with Certified Nursing Assistant 2 (CNA 2) on June 5, 2013, at 10:20 AM, she stated that Resident 3 was upset that her TV headset wasn't charged the previous night. She was unaware that Resident 3 had spoken of harming herself that morning, and stated, "Didn't you hear her (Resident 3) this morning, she was in her room cussing and yelling at the TV because she couldn't hear it." CNA 2 stated that she was aware that Resident 3 had spoken of harming herself in the past. When asked what she had done in the past when Resident 3 had verbalized that she wanted to harm herself, CNA 2 stated she would notify the LVN on duty, check on Resident 3 more frequently, and reassure Resident 3 by talking to her. During an interview with LVN 2 on June 5, 2013, at 10:40 AM, she stated that she was aware of episodes in the past in which Resident 3 stated that she had suicidal thoughts of harming/killing herself and that Resident 3 was "unhappy off and on." She stated that Resident 3's physician was aware of this and that the Licensed Marriage and Family Therapist (LMFT) had weekly sessions with Resident 3 and that was helping. LVN 2 further stated that when Resident 3 stated that she wanted to harm herself, LVN 2 would try and "divert her (Resident 3's) attention." LVN 2 stated that she would call the physician to notify him of the suicidal threat. During a review of Resident 3's nursing notes on June 5, 2013, documentation showed the following entries: January 12, 2013, at 1430, by LVN 2, ... "Social worker stated ...resident (Resident 3) stated, I want to kill myself, I don't want to live any longer, I am too anxious, MD (physician) notified. " January 26, 2013, at 0900, by LVN 2, ... " CNA reported at 0900 ...resident stated, I am nervous and I want to take my life. " January 26, 2013, at 11:15, by LVN 2, ... "CNA reported while bringing resident back from BR (bathroom), resident stated, 'I want to take my own life', MD notified, Social Service consult ordered. Social Worker (Licensed Marriage and Family Therapist, LMFT) said the medication needs to be reviewed. (LMFT) states she visits the resident Q (every) Friday. " February 5, 2013, at 1315 (1:15 PM), by LVN 2, ... "resident talking to (Activity Director), stated, 'I feel like taking my life'." On June 5, 2013, a care plan to address Resident 3's depression was reviewed. The care plan was initiated on April 10, 2012, and listed a target goal date of July 1, 2013. Her depression care plan noted the following: "Quality of Life compromised related to depression/sadness. Goals: Resident will experience enhanced self esteem and a sense of well-being by looking forward to events and speaking and interacting in a positive manner on a regular basis." Approaches to the goal included: "1. Anti-depressant, as ordered by MD 2. Licensed Clinical Social Worker (LCSW)/(Licensed Marriage and Family Therapist (LMFT)) intervention every week to work through feelings and identify strategies to improve thoughts and feelings. 3. Encourage (Resident 3) to discuss her feelings." On June 5, 2013, there was no documented evidence that the care plan had been updated with new interventions to address Resident 3's depression since the initiation date of April 10, 2012. There was no documentation that Resident 3 was discharged from the facility to a higher level of care from January, 2013 to the present day June 5, at 10:00 AM. Review of Resident 3's progress notes on June 5, 2013, showed documentation by the LMFT, as follows: February 3, 2013, "Pt. (Patient) informed that medication to be reviewed on Monday and plan to adjust and decrease anxiety ...Pt. (patient) encouraged to exercise patience and decrease anger outbursts towards staff and others, continue to monitor depression." February 8, 2013, "Pt. very irritable and demanding with staff. Pt. complaining about her anxiety and nervousness. Encouraged Pt. to exercise patience with staff. Pt. angry and couldn't be consoled. Continue plan." February 24, 2013, "Pt. continues to complain about significant nervousness. Review of medications do not indicate any changes. Pt. having difficulty with her hearing and feels frustrated about communication with others. Will review at care plan meeting." March 3, 2013, ..."her anxiety readily interferes with Pts. Ability to readily go to sleep at night. (Pt stated), "I would feel so much better if I could just relax", continue to monitor depression." May 25, 2013, " Pt. states that she has anxiety and that she doesn't want to live most days. She has difficulty hearing that makes her feel isolated and unable to communicate effectively... " May 31, 2013, "Pt. complaining of continued anxiety and that she doesn't see any reason for her living ... " Documentation from Resident 3's medical record showed that from January, 2013 through May, 2013, Resident 3 verbalized anxiety, nervousness and/or suicidal thoughts on nine separate occasions. On June 5, 2013, at 11:00 AM, an interview was conducted with the Director of Nurses (DON). The DON stated that she was aware of Resident 3's depression, and that there was no psychiatric consult (a referral to a psychiatrist for treatment of [REDACTED]. She further stated there was no place, locally or remotely, available to send Resident 3 for psychiatric care. The DON was asked what was being done by the facility to ensure Resident 3's safety when she verbalized that she was having suicidal thoughts. The DON stated that the LMFT, who is equivalent to a Licensed Clinical Social Worker, was involved and she came to speak with Resident 3 once a week, and that Resident 3 was taking antidepressant medications. The DON did not mention frequent visual checks for Resident 3. During the interview, when asked if there was any frequent checks that were ever done for Resident 3, she stated, "No." On June 24, 2013, an article titled "Measured Response to Identified Suicide Risk and Violence: What you Need to Know About Psychiatric Patient Safety", Published by the Oxford University Press, dated May, 2005, noted the following: "In many instances, deaths by suicide can be prevented. When a patient verbalizes a suicidal threat and the plan to use a lethal method, it is imperative that the patient be involuntarily committed for a minimum of 48 to 72 hours for assessment and observation-including one-on-one observation. Rapid assessment, timely crisis intervention, medication stabilization and placement in a secure facility...should be mandatory for all persons at imminent risk of suicide." During the interview with the DON on June 5, 2013, at 11:00 AM, she was unable to provide documentation in Resident 3's medical record that Resident 3's suicidal thoughts and the verbalizations were being discussed in IDCP (Interdisciplinary Care Plan-when facility staff meet to discuss the best way to care for the residents) meetings. When the DON was asked what had been done in regards to Resident 3's hearing difficulty, she stated that she would have to "Call the place again, and see if I can get them up here (for an auditory evaluation)." On June 4, 2013, documentation by the DON noted the following: June 3, 2013, at 4:00 PM, "Call placed to (name of hearing facility) regarding possibility of seeing (Resident 3's name) for auditory (hearing) eval (evaluation)." A document titled, "Interdisciplinary Care Plan Meeting (IDCP)", was provided on June 5, 2013, by the DON. It noted the following dates in 2013, when the IDCP met and discussed Resident 3's plan of care: "March 1, 2013, Reviewed hearing (for her hearing evaluation), unable to get company to come up mountain, MD will call and discuss no service on mountain." (signed by the DON). "April 19, 2013, Reviewed anti-depressant medication, change to [MEDICATION NAME]. Continue with Licensed Family Therapist "LMFT" to discuss concerns. Easily Redirected." (signed by the DON). During the interview with the DON on June 5, 2013, at 11:00 AM, she stated that March 1, 2013, and April 19, 2013, were the only documented IDCP meetings in Resident 3's medical record, for 2013. The DON expressed that there should have been more IDCP meeting for her to discuss interventions for Resident 3's depression and suicidal risk. On June 5, 2013, at approximately 3:50 PM, during an interview with LVN 3, (the PM nurse), she confirmed that she was informed by the AM nurse of Resident 3's statement earlier that day of wanting to kill herself and that she was unsure if the physician was notified of it. She stated that she had instructed the evening CNA to do frequent visual checks on Resident 3. LVN 3 proceeded to check Resident 3's medical record, and telephoned MD 1. LVN 3 stated that the physician had been notified earlier that day, and that the LMFT was going to come to speak with Resident 3 that night at the skilled nursing facility D/P (SNF-distinct part). On June 6, 2013, at approximately 10:15 AM, an interview was conducted with the CNO regarding Resident 3. The CNO stated that the LMFT had spoke to Resident 3 the night before (June 5th), which resulted in Resident 3's transfer out of the facility to the emergency room for her safety. The CNO explained that the ER would attempt placement where Resident 3's psychological well-being could be addressed. However, she stated that there were really no placement options, every facility was remotely located and at full capacity. The facility Pharmacist was interviewed on June 6, 2013, at approximately 3:20 PM, in regards to Resident 3's care. He stated that he would attend (Resident 3's) interdisciplinary care plan (IDCP) meetings. He further stated that the best thing for her would be "To get into some sort of psychiatric facility," however, that had not been discussed to his knowledge at Resident 3's IDCP meetings. On June 6, 2013, at 3:45 PM, an interview was conducted with the Chief Nursing Officer (CNO), at which time she confirmed that she frequently attended Resident 3's IDCP meetings. The CNO stated, "I don't remember anyone saying that she had suicidal thoughts." She further stated that there was "No psychiatrist to call," due to their remote location in the mountains. On June 6, 2013, when asked for a policy and procedure on how the facility handles a suicidal resident, the CNO stated that the facility had no suicide policy and procedure, however their practice had been to send the resident to the emergency room (ER) on a 5150 hold (a precautionary measure to closely observe a person for self harm). On June 7, 2013, at 10:35 AM, an interview was conducted with Resident 3's primary Physician (MD 1). MD 1 stated that he was not aware of any "acute change", meaning suicidal thoughts expressed by her until June 5, 2013, at which time he sent Resident 3 to the ER. MD 1 stated that he did not know the resident was having headaches. He stated that he did not order a psychiatric consult for the duration that Resident 3 had been at the facility. MD 1 stated that the facility could have sent her to see a psychiatrist (a physician who specializes in the treatment of [REDACTED]. The policy and procedure titled, "Skilled Nursing Facility Committee (IDCP)", dated revised March 25, 2013, was reviewed on June 10, 2013. It showed that a weekly IDCP meeting to review the residents' plan of care would be held "weekly", with attendees which will include, the DON, the Licensed Social Worker, and the Pharmacist. It further stated that psychosocial needs and medication regimes of each resident would be reviewed at least quarterly during the IDCP meetings. On June 7, 2013, a review of the facility policy and procedure titled, "Decision Regarding Emotional-Psychological-Alcohol and Drug Problems," dated Revised March 2, 2013, showed that when staff are aware of a patient's severe emotional problems the Licensed Clinical Social Worker or (LMFT) would do a mental evaluation and recommendation of treatment. On June 5, 2013 Resident 3's nurses notes showed the following entries: May 2, 2013, Resident c/o (complains of) left side headache "It feels like someone is hitting me with a hammer." ...Rx's (medications) given. May 5, 2013, "No further concerns regarding headaches (MD 1's name) notified and to be informed if it's an ongoing problem." The following physician's orders for Resident 3 were reviewed on June 5, 2013: March 4, 2013, [MEDICATION NAME] (anti-anxiety)15 milligrams (mgs) by mouth every day. March 30, 2012, Trazadone (anti-depressant) 50 milligrams one by mouth every night for depression. Review of Resident 3's Medication Administration Records (MARs) dated March, April, May and June, 2013, revealed that she consistently took her prescribed anti-anxiety and anti-depressant medications, the [MEDICATION NAME] and the Trazadone. Further review of Resident 3's May, 2013, MAR indicated [REDACTED] May 15, 2013 at 4:00 AM ,she received Tylenol 650 mg for "headache and neck pain." May 17, 2013 at 4:30 AM, she received Tylenol 650 mg and at 1:00 PM Tylenol 325 mgs both of which were for "headache." May 24, 2013 at 10:00 PM, she received Tylenol 325 mg for "headache." During a review of the Food and Drug Administration guidelines (FDA), dated September 17, 2012, Trazadone is used to treat depression and other mental illnesses. It showed that while taking Trazadone to pay close attention to any changes, especially sudden changes in mood and behavior, and immediately notify your physician. It further revealed to immediately notify the physician if having any of the following symptoms: Thoughts of suicide or dying New or worse depression New or worse anxiety Agitation or restlessness Panic attacks New or worse irritability Acting aggressive, or being angry or violent Further review of FDA guidelines, dated June 24, 2013, showed that [MEDICATION NAME] is used to treat anxiety. Some commonly observed adverse reactions noted were the following: nausea headaches nervousness lightheadedness excitement The FDA further recommended to immediately notify the physician if any of the symptoms were observed while administering [MEDICATION NAME]. On June 6, 2013, review of Resident 3's "Monthly Pharmacy Drug Review", dated May 22, 2013, showed the following documentation by the Pharmacist: "Mood: Depression-Trazadone, [MEDICATION NAME]: APAP (tylenol), [MEDICATION NAME] on current meds." On June 6, 2013, at approximately 10:30 AM, an interview was conducted with LVN 2, the medication nurse. LVN 2 was asked what possible side effects she typically observed for when she administered Resident 3 her [MEDICATION NAME] and Trazadone medications. She stated that she would observe her for "Continued anxiety and depression." No further medication side effects were mentioned. On June 6, 2013, at approximately 3:20 PM, an interview was conducted with the facility Pharmacist. He stated that he reviewed Resident 3's medications every month, and during his monthly medication review he would "look for any medications inappropriate for the elderly." The Pharmacist stated that he attended Resident 3's Interdisciplinary care plan (IDCP) meetings monthly. He further stated Resident 3 was on the antidepressant medications for depression and to help her sleep. The Pharmacist stated that he "Goes through any issues (regarding medication) raised by the Director of Nursing (DON)." He stated that he did not believe Resident 3's headaches were related to the Trazadone or the [MEDICATION NAME] medications she was currently taking. The Pharmacist stated there had been talk about putting her on something else (medication) and that the best thing for Resident 3 would be, "To get into some sort of psychiatric facility," however, that had not been discussed to his knowledge at her interdisciplinary meetings. On June 7, 2013, at 10:35 AM, an interview was conducted with Resident 3's primary Physician (MD 1). MD 1 stated that he wasn't aware of any acute change in Resident 3, regarding suicidal thoughts expressed by her until June 5, 2013, at which time he sent Resident 3 to the ER. MD 1 stated that he did not know the resident was having headaches nor any complaints of a stiff neck. He stated that he did not order a psychiatric consult for the duration that she had been at the facility, and that they could have sent her to see a psychiatrist in town at (name of facility), however, the physicians there were continually changing and there would be no continuity of care for the resident, so Resident 3 was not referred there. MD 1 was asked about Resident 3's medications, particularly how the psychotherapeutic medications were prescribed and monitored by the facility. MD 1 stated that he prescribed all of Resident 3's medications. He stated that he did not consult with a psychiatrist while Resident 3 had been in the facility since March 14, 2012. MD 1 said that he prescribed the anti-depressant medications based on her mental status, past medications taken, and her medical history. MD 1 said that typically the "new" residents have an adjustment period due to the "seasonal affective (climate) component", of the mountain location of the facility. On June 10, 2013, the Pharmacist's "Job Description", Revised date, June, 2010, provided by the facility, was reviewed. It noted under the section titled, "Responsibilities and Standards", ..."F. Investigate possible adverse drug reactions." 3. For Resident 1 a physician ordered urology consult was not carried out in a timely manner. This had the potential for Resident 1 to experience pain and a decline in her health. During a review of Resident 1's medical record on June 4, 2013, it showed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's minimum data set (MDS, a tool used by long-term care facilities to assess and plan care and treatment for [REDACTED]. On June 3, 2013 during an interview with Resident 1's relative, he stated that he visits his mother daily in the facility, and that "It has been a battle with her urinary infections, since she's been here." He further stated that his mother did have intermittent pain and that they were waiting for a urology (a physician who specializes in diseases of the urinary tract) consult to be done. Review of Resident 1's medical record on June 4, 2013, showed a Physician's Order dated May 22, 2013, which read, "Consult with urologist." On June 4, 2013 at approximately 1:25 PM, Resident 1's medical record was reviewed with the Director of Nursing (DON). Resident 1's lab reports, nurse and physician notes noted the following dates in which Resident 1 had urinary tract infections (UTI's): October 16, 2012, positive UTI March 14, 2013, positive UTI March 24, 2013, positive UTI April 1, 2013, positive UTI April 22, 2013, positive UTI April 29, 2013, positive UTI May 5, 2013, positive UTI During a review of Resident 1's medical record with the DON on June 4, 2013 at approximately 1:25 PM, she confirmed that Resident 1 had continual UTI's while at the facility. The DON stated that she was the person responsible for scheduling the consult appointments. She further stated that she remembered calling and setting up the appointment for Resident 1 with the urologist who was located "down the hill." The DON could not provide an appointment time, documentation that the urology appointment was ever scheduled or that the urology office was contacted by the facility for Resident 1's consult.