Every finding on record at Bishop Care Center

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one (1) of 1 sampled residents (Resident 1) in accordance with the facility's policies and procedures for investigating allegations of abuse when appropriate staff and residents were not interviewed as part of the investigation for an allegation of abuse to Resident 1. This failure resulted in an incomplete investigation and placed Resident 1 and other residents at risk for potential continued or unidentified abuse because the facility could not reliably determine the circumstances surrounding the allegation, identify affected residents, substantiate or refute the allegation, or implement appropriate corrective and protective measures based on complete investigative findings.Findings: During a review of Resident 1's admission Record (contains medical and demographic information), The admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of the right (a break in the right thigh bone), difficulty in walking, dementia (an impairment in memory, thinking and reasoning which can disrupt every day life), and depression. During a review of the facility document titled, Resident Incident Report, dated June 10, 2026, the incident report indicated, .the resident reported the CNA who assisted with her shower on 6/5/26 was 'very rough' and had 'pushed me around.' The resident further stated that when she questioned the CNA about the treatment, the CNA became 'nasty' and made a derogatory remark. During an interview on July 16, 2026, at 1:57 PM, with the Director of Nursing (DON), the DON stated she was the individual who investigated the allegation of abuse reported by Resident 1. The DON stated she interviewed CNA 1 because CNA 1's name was in the SOC 341 report (a document titled Report of Suspected Dependent Adult/Elder Abuse which is used to document and report allegations of abuse to authorities) as the alleged abuser. The DON stated the facility looked at the facility staffing on June 5, 2026, (the day the incident occurred) to help determine that it was CNA 1 that was involved. During a review of the SOC 341 report titled, Report of Suspected Dependent Adult/Elder Abuse, dated June 6, 2026, the report indicated, Resident Reports CNA was 'very rough' and 'pushed me around' during shower on 6/5/26. During a review of CNA 1's written statement dated June 17, 2026, the statement indicated, I am providing this statement regarding my shift on June 6, 2026, during the night shift from 10:30 PM to 7:00 AM.[Name of Resident 1] did not express any concerns, complaints, or requests related to her care during my shift. I did not experience any difficulties while providing care, and all interactions were appropriate and professional. Additionally, I did not provide a bath to resident [room and bed number of Resident 1] during this shift. During a review of the staffing schedule titled, Nursing Staffing Assignment & Sign-in Sheet (document used to show staff worked on a particular shift and which residents they were assigned to), dated June 5, 2026 (date of alleged incident), the document indicated CNA 1 was assigned to Resident 1 from 10:30 PM (June 5, 2026) to 7:00 AM the next day (June 6, 2026). The schedule also indicated CNA 2 was also assigned to Resident 1 and worked a double shift (AM and PM) from 6:30 AM - 11:00 PM on June 5, 2026 (day of alleged incident). During a review of Resident 1's, Shower/Bed Bath Sheet (a document used by staff to record information including which staff showered/bathed the resident), dated June 5, 2026 (date of the alleged incident), the document indicated CNA 2 showered Resident 1 on June 5, 2026. During an interview on July 16, 2026, at 4:10 PM, with the DON, the DON stated for the facility investigation of the incident, only CNA 1 was interviewed because CNA 1 was the staff member indicated on the SOC 341 report and no other staff had been interviewed. The DON acknowledged and stated CNA 2 worked two shifts on June 5, 2026. CNA 2 was assigned to Resident 1 and was the CNA who documented that she assisted the resident with a shower on June 5, 2026. When asked why she did not interview CNA 2, the DON did not have an answer and stated CNA 1 was the only staff interviewed as part of the investigation. Additionally, the DON stated aside from Resident 1, no other residents who received care by CNA 1 or CNA 2 on the date of the alleged incident were interviewed. During a concurrent interview and record review on July 16, 2026, at 4:16 PM, with the DON, the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, was reviewed. The P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.Investigating Allegations.1. All allegations are thoroughly investigated.7. The individual conducting the investigation as a minimum: .h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.j. Interviews other residents to whom the accused employee provides care or services. The DON stated the policy and procedure was not followed.

Based on interview and record review, the facility failed to implement its abuse prevention program when one of one sampled staff members (Certified Nursing Assistant 1 - CNA 1), did not have a completed background check prior to providing direct care to residents in the facility. This failure resulted in the facility allowing CNA 1 to provide care and services to residents for approximately three months without first verifying eligibility for employment through the required criminal background clearance process, placing residents at potential risk for abuse, neglect, exploitation, or employment of an individual prohibited from working in a licensed health care facility.Findings: During an interview on July 16, 2026, at 3:48 PM, with the Director of Nursing (DON), the DON stated Certified Nursing Assistant 1 (CNA 1) was hired January 30, 2026, and was a graduate of the facility's CNA training program (a state-approved nurse aid training program that prepares individuals to provide nursing and nursing-related services to SNF residents safely and competently). The DON further stated CNA 1 began providing direct patient care on March 3, 2026, and graduated from the CNA training program on March 31, 2026. The DON stated after CNA 1 graduated, she worked full time at the facility as a CNA and had been providing direct patient care since then. The DON stated prior to starting the CNA training program and prior to being hired at the facility, all staff were supposed to have background checks completed to ensure they were safe to work with residents. The background check for CNA 1 was requested. During a concurrent interview and record review on July 16, 2026, at 3:52 PM, with the DON, CNA 1's background check was reviewed. The document titled, California Investigative Consumer Report, dated June 16, 2026, indicated the initial background request was June 19, 2026, and was completed July 7, 2026 (More than 4 months after CNA 1 began having direct resident care on March 3, 2026.) The DON stated CNA 1's background check should have been done in January 2026, but it was not done until June, 2026. The DON further stated a previous human resources (HR) employee (who was no longer with the facility) was responsible for ensuring background checks were done but it had been identified by facility management that the previous HR employee was not doing the background checks as required. The DON stated it was important to do background checks to ensure staff have no violent crime history in order to ensure the safety of the residents. During a review of CNA 1's time card report (facility documented records of employee hours worked) titled, Related Calculated Time blocks (undated), the time card report indicated CNA 1 had worked 571.7 hours between March 3, 2026 (date CNA 1 began having direct patient care) and July 7, 2026 (date the background check was completed). During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated August 2006, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents.2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. protocols for conducting employment background checks.

Based on interviews, and record review the facility failed to ensure adequate supervision and safe environment was provided for one (1) of five (5) sampled residents (Resident 1) when the assigned Certified Nursing Assistant (CNA 2) did not verify Resident 1's whereabouts during the shift. This failure led to Resident 1 being found unresponsive in the facility parking lot and subsequently pronounced dead.During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (brain disorder that primarily affects movement) with dyskinesia (uncontrollable, involuntary muscle movements), and difficulty of walking. During a review of Resident 1's Minimum Data Set (MDS-facility assessment tool), dated [DATE], under Section C, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 12. (A BIMS score of 12 indicates moderate cognitive or thinking impairment, meaning the resident can generally understand and participate in conversations, remember most information and may show occasional mild confusion). During a review of [Name] Police Dept [Department] Controlled Document (Police Report), date reported [DATE], the Police Report indicated, on [DATE], at about 4:55 PM, a police officer responded to the radio traffic of [name] dispatch, dispatching [name] Paramedics to an unresponsive male, not breathing, believed to be deceased and was a resident from the facility. Upon arrival, there was a crowd of people standing in the southeast corner of the small concrete/asphalt parking lot, located just east of the facility. This parking lot is property of the facility and is used for employee parking as indicated by signage by the entrance. The elderly male identified by the facility staff as Resident 1 was lying in a shaded area shaded by a tree. During an interview on [DATE], at 2:35 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated, on [DATE], shortly before 5:00 PM, she heard a report via walkie-talkie (a portable, handheld two-way radio) about a resident lying on the sidewalk in the facility's parking lot. When CNA 1 arrived, she found Resident 1 was lying curled up in a fetal position on the asphalt, unresponsive, near the curb in the facility parking area. CNA 1 stated Resident 1 had no pulse (heartbeat), no breathing, stiff, and cold to touch. CNA 1 further stated she called 911, then the nurses from the facility also arrived. During an interview on [DATE], at 2:54 PM, with License Vocational Nurse (LVN 1), LVN 1 stated on [DATE], at about 5:00 PM, she received an alert on her walkie-talkie about a person lying in the parking lot and when she arrived, CNA 1 was already there, Resident 1 was lying in the parking lot. LVN 1 stated she assessed Resident 1 and found him cold, with no pulse, pale, and while his hands were pale, his face was red. LVN 1 further stated she did not perform CPR, because Resident 1 Physician Orders for Life-Sustaining Treatment (POLST) indicated do not attempt resuscitation/DNR (a medical order to withhold CPR). During a telephone interview on [DATE], at 4:03 PM, with CNA 2, CNA 2 stated he was assigned to Resident 1 on [DATE]. CNA 2 indicated he checked on Resident 1 around 2:53 PM, and noticed Resident 1 was not in the room. CNA 2 stated he did not verify Resident 1's actual location and did not check the sign-out form to determine if Resident 1 had left the facility. CNA 2 stated according to the facility policy, staff are required to account for all residents at the beginning of their shift to ensure residents are present in their rooms, but he did not follow this requirement. CNA 2 did not report Resident 1 was missing to anyone because he thought Resident 1 was still in the facility. A follow-up review of Police Report, date reported [DATE], the Police Report indicated, the paramedic arrived on [DATE], at about 5:00 PM (about 2 hours after staff last checked on Resident 1), and Resident 1 was pronounced death at 5:02 PM. The cardiopulmonary resuscitation (CPR-a lifesaving procedure performed when someone's breathing or heartbeat has stopped) was not initiated as it was apparent the male had been here for a while (indicating decease). During an interview on [DATE], at 4:20 PM, with the Director of Staff Development (DSD 1), and the Director of Nursing (DON), in the DSD office, the DSD stated that it is the responsibility of CNAs to ensure that residents are accounted for at the beginning and during their shifts, but CNA 2 did not meet these expectations. This indicates CNA 2 was not in compliance with the policy. The DON responded by saying, I agree with what DSD stated. The DON further stated that Resident 1 did not sign the sign-out sheet that day because he remained within the facility premises. Residents are not obligated to sign out on the form if they do not exit the facility. During a concurrent telephone interview and record review on [DATE], at 11:38 AM, with the DON, the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated [DATE], and the CNA job description, dated February 2024, were reviewed. The P&P indicated, . 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . The CNA job description indicated, . Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes . Immediately notify the Nurse Supervisor/Charge Nurse of any resident leaving/missing from the facility . The DON confirmed that both the policy and job description belong to them. The DON also noted that in this situation, CNA 2 did not follow the job description. During a review of facility's Unusual Occurrence Summary Report - Resident Death, dated [DATE], it indicated . At approximately 1650 [4:50 PM] hours, the facility received a phone call from a passerby reporting that an individual was lying in the parking area. Nursing staff checked their own Residents and found [name of Resident 1] was not located within the facility and immediately responded and located the resident [Resident 1] in the second parking area. He [Resident 1] was found lying on his left side in a semi-fetal position with his arms clenched and crossed over his chest. Initial assessment revealed the resident [Resident 1] to be unresponsive, without respirations or palpable [felt by touch] pulse. Visible skin was intact with no obvious discoloration, external injuries, or signs of trauma. There was no immediate evidence to suggest a fall or other traumatic event. Compressions were not deemed appropriate at the time of nursing assessment due to Residents desired POLST Code Status of Do Not Resuscitate although Emergency Medical Services (911) were activated. [Paramedics] assessed the resident and pronounced him deceased at the scene. The official time of death was 1702 [5:02 PM] hours.

Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration was provided in accordance with the physician's orders and facility policies and procedures (P&P) for one of three sampled residents (Resident 1) when Resident 1's oxygen humidifier bottle (a water-filled bottle attached to the oxygen tubing and add moisture and prevent drying and irritation inside the nose) was empty while oxygen was flowing. This failure had the potential for Resident 1 to have nasal (nose) dryness, nosebleeds, and sore throat while on oxygen therapy.During a review of Resident 1's admission Record (contains demographic and medical information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with the admitted diagnoses which included chronic obstructive pulmonary disease (COPD - a long - term lung disease that make it difficult to breathe and may require oxygen therapy), acute respiratory failure (a condition in which the lungs are not getting enough oxygen into the blood, requiring oxygen treatment to maintain adequate oxygen levels), and acute on chronic systolic congestive heart failure (a heart condition in which the hear does not pump blood effectively, which can cause fluid buildup in the lungs). During an interview on June 29, 2026, at 3:01 PM, with Resident 1, Resident 1 stated that during the previous week he had trouble breathing and felt he was not receiving enough oxygen through his nasal cannula (a small tube with two prongs place in the nostrils that delivers oxygen to help the person breathe). During a concurrent interview and record review on June 29, 2029, at 3:04 PM, with the Registered Nurse (RN 1), Resident 1's Physician Orders, dated November 25, 2025, was reviewed. The Physician Orders indicated, Resident 1 had an order for continuous oxygen @ [at] 2 [two] Liters/min [liters per minute-delivery unit flow of oxygen] via nasal cannula to keep Spo 2 ( peripheral oxygen saturation - a measurement of the percentage of oxygen-carrying hemoglobin in the blood) > (more than) 90%; (keeping enough oxygen in the blood so body can work properly) Medical Dx (diagnosis) Chronic pulmonary disease. RN 1 verified and confirmed the oxygen order was for Resident 1. During a further record review of Resident 1's Physician Orders, dated December 11, 2025, the Physician Orders indicated, Oxygen Change Nasal Canula, Humidifier and clean filter every week and also PRN (as needed). During a review of Resident 1's care plan (a written plan that explains a person's health needs, goals, and the care and services staff must provide to meet those needs), dated April 7, 2026, the care plan indicated, Resident 1 has a high risk for altered respiratory status/difficulty breathing r/t [related to] chronic respiratory infection due to chronic decreased mobility. goal, the resident will have no complications related to SOB [shortness of breath] through the review date. Interventions. monitor for s/s [sign and symptoms] of respiratory distress [difficulty of breathing] and report to MD (medical doctor) PRN . During a concurrent observation an interview on June 29, 2026, at 3:38 PM, with Licensed Vocational Nurse (LVN 1) and RN 1, inside Resident 1's room, Resident 1 was lying in bed with head of the bed elevated, eyes open and agreed to be interviewed. Resident 1 was receiving continuous oxygen via nasal cannula, at the end of the tubing an oxygen humidifier bottle dated June 23, 2026, was attached. The oxygen humidifier bottle was empty with no water inside and no visible bubbling while oxygen was flowing, a clear tape was observed wrapped around the connection between the humidifier bottle and oxygen tubing. RN 1 stated the humidifier bottles should be check at the beginning of each shift, replaced when empty, and damaged oxygen tubbing should be replaced rather than to be repaired with tape. RN 1 stated she did not know why the tape was placed on the oxygen tubing. LVN 1 acknowledged the humidifier bottle was empty and stated it must be replaced. During a review of the facility's P&P title, Oxygen Administration, dated October 2010, the P&P indicated, . 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.14. Periodically re-check water level in humidifying jar.

Based on observation, interview, and record review, the facility failed to ensure that a change in a resident's condition was promptly reported to the licensed nurse for one (1) of one (1) resident (Resident 1) reviewed, when a Certificate Nurse Assistant (CNA 1) observed discoloration under Resident 1's right eye on the upper cheekbone area, but did not report the finding to the licensed nurse, on May 13, 2026. This failure had the potential to delay Resident 1's timely assessment, treatment, and notification of the physician and or responsible party regarding a potentially significant change in the resident's condition.During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included lack of coordination (the brain and the body are struggling to communicate, resulting in movements that feel clumsy, jerky, or unsteady) and paraplegia (the loss of movement and feeling in the lower half of the body, including both legs). During a review of Resident 1's SOC 341 - Report of Suspected Dependent Adult/Elder Abuse (A mandated report form used to document and report suspected abuse), dated May 15, 2026, Section C (Reporter's observations, beliefs, and statement) indicated, on May 15, 2026, at approximately 6:30 AM, a Certificated Nurse Assistant (CNA) reported that Resident 1 had a Bruise on his eye . During an interview on June 1, 2026, at 1:53 PM, with CNA 1, CNA 1 reported that she was assigned to care for Resident 1 on May 13, 2026. CNA 1 explained that although she worked 12 hours-shift, she was assigned to Resident 1 for only the first 8 hours. CAN 1 further stated that near the end of her shift, she noticed a blue discoloration under Resident 1's right eye on the upper cheek area. CNA 1 stated she did not report the change in Resident 1 condition to the licensed nurse because she believed she was no longer responsible, for Resident 1. CNA 1 further stated she was aware that facility policy requires CNAs to promptly report any changes in a resident's condition to the licensed nurse. During a review of Resident 1 nurses' notes, dated May 12, 2026, through May 15, 2026, there was no documented evidence of a bruise under Resident 1's right eye on May 13, 2026. In addition, no nursing notes were recorded on May 14, 2026. During an interview on June 1, 2026, at 2:41 PM, with the Director of Staff Development (DSD 1), the DSD 1 stated that all staff are required to report any changes in a resident's condition while on duty, even if the resident is not assigned to them. The DSD 1 emphasized that any staff member who observes a change in a resident's condition is responsible for reporting it to the licensed nurse. During a concurrent interview and record review on June 1, 2026, at 3:17 PM, with the Director of Nursing (DON) and DSD, the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, dated March 2018, was reviewed. The P&P indicated, . 3. Direct care staff, including nursing assistants, will be trained to recognize subtle yet significant changes in the resident (for instance, a reduction in food intake, heightened agitation, alterations in skin color or condition) and how to effectively communicate these changes to the Nurse. The DON indicated that CNA 1 was not following the policy in this case.

Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 11 and 80) to be free from physical restraints when: 1. For Resident 11, the resident was unable to freely access an exit the bed from both sides as intended, and documentation supporting the need, safety or authorization of the intervention was not provided 2. For Resident 80, the resident's bed was positioned directly against the wall, thereby limiting Resident 80 ability to move freely and restricting safe access. These failures had the potential to contribute to Resident 11 and 80 decline in physical functioning, and increasing the risk of accidents. Findings: 1. During a review of Resident 11's admission Record (contains demographic and clinical information) the admission Record indicated Resident 11 was admitted to the facility on [DATE], with the diagnosis of paraplegia (partial or complete paralysis affecting the lower part of the body, resulting in impaired mobility and increased dependence on staff assistance for movement and transfers), cognitive communication deficit (difficulty understanding, processing, or expressing information which may affect the residents ability to communicate needs, report concerns or request assistance) and anoxic brain damage (brain injury caused by a lack of oxygen to the brain, which may affect memory, judgement, safety awareness, thinking abilities, and the ability to recognize or respond to unsafe situations). During an observation May 18, 2026 at 4:05 PM, Resident 11 was observed lying in bed with eyes closed. Further observation revelated Resident 11's bed was positioned against the wall on the left side with a floor mat located on the right side of the bed. During an observation on May 19, 2026 at 8:56 AM, Resident 11's bed was observed positioned against the wall on the left side of the bed. Further observation revealed the bed frame and mattress were directly adjacent to the wall with no visible space between the bed and the wall. There was a floor mat located to the right side of the bed. During an interview on May 19, 2026 at 11:08 AM with the Director of Nurses (DON), DON confirmed Resident 11's bed was positioned against the wall as a nursing intervention. During a review of Resident 11's MDS (Minimum Data Set – a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive (involving consciousness intellectual activity Patterns), dated April 2, 2026, indicated Resident 11 had a BIMS (brief Interview for Mental Status – tool used to screen how a resident is functioning cognitively) score of 5 ( a BIMS score 0-7: suggests residents is severe impairment). During a review of Resident 11's MDS (Minimum Data Set – Section GG (functional abilities dated April 2, 2026, indicated, A. Roll left and right: ability to roll from lying on back to left side, and return to lying on back on the bed. Coded 03. Partial / moderate assistance, helper does less than half the effort. Helper lifts hold, or supports truck or limbs, but provides less than half the effort. B. Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed. Coded 02. Substantial/maximal assistance, helper does more than half the effort. Helper lift or hold trunk or limbs and provided more than half the effort. During a review of Resident 11's Physician Orders dated January 1, 2024, the physician orders indicated, Resident 11 to have 1/2 (half) side rails up to both sides of bed for safety and repositioning. Further review indicated, Fall Mat at bedside when in bed every shift for safety Bilaterally on both sides of bed to reduce risk of injury from attempts to crawl out of bed. Dated, October 6, 2022. There was no documented evidence a physician order was identified authorizing placement of the resident's bed against the wall in a manner that restricted exit from one side of the bed. During a concurrent interview and record review on May 21, 2026 at 11:08 AM with DON, the facility's policy and procedure (P&P) titled, Use of Restrains, dated Revised April 2017, was reviewed. The P&P indicated, 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and not permitted, included d. Placing a resident who uses a wheelchair so close to the wall prevents the resident from rising., 9. Restrains shall only be used upon the written order of a physician and after obtaining consent from the resident and/ or representative (sponsor) the order shall include the following: a. The specific reason for the restrain ( as it relates to the resident's medical symptom); b. how the restraint will be used to benefit the resident's medical symptom; and c. the type of restraint, and period of time for the use of the restraint. The DON acknowledge Resident 11's bed was positioned directly against the wall and could affect the Resident 11 ability to exit the bed from the side. 2. During areview of Resident 80's admission Record (contains demographic and clinical information), the admission Record indicated Resident 80 was admitted to the facility on [DATE], with diagnoses which included altered mental status (sudden, noticeable change in a person's thinking, awareness, or behavior), recurrent major depressive disorder (a mental health condition where a person experiences multiple, distinct episodes of severe depression throughout their life, separated by periods of normal mood), hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (one-sided physical impairments caused by a stroke) and dementia (decline in mental abilities—such as memory, thinking, and reasoning—that is severe enough to interfere with daily life). During an observation on May 19, 2026, at 9:02 AM, Resident 80 was observed lying in bed, awake and covered with a blanket. A fall mat was on the floor on the left side of the bed. The right side of the bed was flushed against the wall. During an interview with Certified Nursing Assistant 1 (CNA 1) in the resident's room on May 19, 2026, at 9:10 AM, CNA 1 confirmed Resident 80's bed has been positioned directly against the wall to reduce the likelihood of the resident falling out of bed and sustaining injuries. CNA 1 further acknowledged that positioning the bed against the wall restricts the resident's freedom of movement, effectively blocking access to one side of the bed and limiting the resident's ability to exit the bed independently from that side. During an interview with Infection Preventionist (IP) in the resident's room on May 19, 2026, at 9:15 AM, IP confirmed Resident 80's bed is positioned directly against the wall. The IP further explained that placing the bed against the wall is a fall precaution utilized by the facility specifically for residents identified as having a high risk of falls, such as Resident 80. The IP acknowledged that positioning Resident 80's bed against the wall restricts the resident's free movement, as it prevents the resident from exiting the bed on the right side and is considered a form of restraint due to the obstruction of the resident's ability to freely access and leave the bed from both sides. During an interview with Licensed Vocational Nurse 1 (LVN1) in resident's room on May 19, 2026, at 9:23 AM, LVN 1 confirmed that Resident 80's bed is against the wall and stated that the bed is placed against the wall because staff need more room between the beds for the Hoyer lift and other medical equipment. LVN1 acknowledged that placing the bed flushed against the wall restricts Resident 80's ability to move freely, as it prevents him from exiting the bed from both sides. During a concurrent interview and record review on May 19, 2026, at 11:00 AM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Use of Restraints, revised on April 2017, the P&P was reviewed. The P&P stated, Policy Statement - Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bed rails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; b. Tucking sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the resident from rising, and d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising . 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms . 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. 10. Orders for restraints will not be enforced for longer than twelve (12) hours, unless the residents' condition requires continued treatment . 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problem that may be causing the symptom(s). The Director of Nursing (DON) confirmed Resident 80's bed was positioned against the wall with the intent to reduce the risk of the resident exiting the bed and potentially falling. The DON stated she was not aware that placing the resident's bed against the wall could be considered a form of restraint limiting the resident's mobility and free mobility. The DON acknowledged the P&P was not followed.

Based on interview, and record review, the facility to ensure 1 of 5 sampled Certified Nursing Assistant 5 (CNA 5) received required in-service training of no less than 12 hours per year. This failure had the potential to diminish CNA 5 continuing competence and reduce the CNA 5 ability to provide safe, appropriate care, including dementia management and resident abuse prevention.Findings: During a review of the facility's required in-services log book with the Director of Staff Development (DSD), on May 21, 2026, the following in-services were signed by CNA 5: 1. Fall prevention dated May 22, 2025 from 6:30 AM to 7:30 AM2. Choking Prevention dated May 29, 2025 from 6:30 AM to 7:30 AM and 2:30 PM to 3:30 PM.3. Abuse: Recognizing, Intervening, & Reporting dated May 29, 2025 from 2:30 PM to 3:30 PM.4. Oral Care dated July 22, 2025 from 2:30 PM to 3:30 PM.5. Standard, Enhanced, Droplet, Airborne Precautions dated November 11, 2025 with no time listed.6. Importance of Oral Hygiene dated November 18, 2025 with no time listed.7. Emergency Response Procedures dated February 5, 2026 from 6:30 AM to 7:30 AM and 2:30 PM to 3:30 PM8. Safe Repositioning Techniques dated February 5, 2026 from 6:30 AM to 7:30 AM and 2:30 PM to 3:30 PM During an interview with the DSD, on May 21, 2026 at 11:02 AM, the DSD stated CNA 5 did not meet the minimum required in-services.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention control program for three of three sample residents (Residents 32, 12, and 13) when: 1.For Resident 32, the resident's nebulizer machine was observed with a brown crusted substance at the port site where the tubing connected to the nebulizer and nebulizer tubing not in use was observed hanging from a shelf in the resident's room and not stored in a protective plastic bag. 2.For Resident 12, the resident's wheelchair was observed with dried brown crusted substance on the wheelchair cushion, wheel areas and bilateral side panels. 3.For Resident 13, the resident's oxygen tubing / cannula (a flexible plastic tube to deliver Oxygen from the oxygen concentrator to the resident) was observed hanging underneath the bed and touching the floor. These failures had the potential to place Residents 32, 12, and 13 at risk for infection and harm. Findings: 1. During a review of 32's admission Record (clinical record with demographic information), the admission Record indicated, Resident 32 was admitted to the facility on [DATE], with diagnoses which included, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure( the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from it) and dementia (a progressive state of decline in mental abilities). During an observation and interview on May 18, 2026, at 2:15 PM, in Resident 32's room, Resident 32's nebulizer machine was observed with brown crusted substance at the port site where the tubing connected to the nebulizer machine. Further observation revealed nebulizer tubing was not in use and hanging from a shelf in Resident 32's room. The nebulizer tubing was not stored in a protective plastic bag. Resident 32's stated, resident just finished treatment with the nebulizer machine. During a current observation and interview on May 18, 2026, at 2:34 PM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 32's room, LVN 1 acknowledged the nebulizer equipment was not clean and the tubing should have been stored in a clean protective bag when not in use to prevent contamination. 2. During a review of 12's admission Record (clinical record with demographic information), the admission Record indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses which included, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hypertension (HTN-high blood pressure), behavior disturbances (persistent pattern of actions, emotions, or reactions that disrupt a person's ability to function normally in daily life) and dementia (a progressive state of decline in mental abilities). During an observation on May 18, 2026, at 4:30 PM, in the lobby next to nursing station 3, observed Resident 12's wheelchair with a dry brown crusted substance present on the wheelchair cushion, wheel area and on the both sides panels of the wheelchair. The wheelchair is visibly soiled and was in use by the resident 12. During a current observation and interview on May 18, 2026, at 4:38 PM, with Licensed Vocational Nurse 6 (LVN 6), in the lobby next to nursing station three, LVN 6 acknowledged the wheelchair was visibly soiled and stated the wheelchair should be maintained in a clean and sanitary condition to prevent infection risk to the resident. During a concurrent interview and record review on May 20, 2026, at 1:52 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting of Resident Care Items and Equipment, dated 2001, was reviewed. The P&P indicated, . Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the CDC recommendations for disinfection and the OSHA bloodborne pathogen standards. The DON confirmed the P&P was not followed for Residents 32 and 12. During a concurrent interview and record review on May 20, 2026, at 2:00 PM, with the Director of Nursing (DON), the facility's (P&P) titled, Prevention of Infection Respiratory Equipment, dated November 2011, was reviewed. The P&P indicated, . Purpose: the purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment among residents and staff.Infection Control Considerations Related to Oxygen Administration. 5. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol.2. Take care not to contaminate internal nebulizer tubes.3. Store the circuit in plastic bag, marked with date and resident's name and replace tubing and plastic bag once a week. The DON confirmed the P&P was not followed for Residents 32. 3. During a review of Resident 13's admission Record (Contains demographic and medical information) it indicated Resident 13 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD), (a long-term lung disease that makes it difficult to breath and limits air flow in the lungs. Acute respiratory failure with hypoxia (a serious condition where the lungs cannot provide enough oxygen to the body) and Centrilobular emphysema (a type of lung damage, usually related to smoking, that destroys air sacs in the lungs and causes shortness of breath). During a review of Resident 13's Physician Orders, dated December 11, 2025, it indicated, continuous oxygen @ (at) 2 (two) Liters / Min (liters per minute) via nasal cannula .,medical Dx (diagnosis): acute respiratory failure., Start date: December 11, 2025. During a concurrent observation and interview on May 18, 2026 at 3:15 PM, with the Registered Nurse, (RN 1), in Resident 13's room, further observation revealed the oxygen tubing was loosely coiled and lying directly on the floor next to the resident's bed while remaining connected to the oxygen concentrator powered on at 1.5 L per minute. A clear bag intended for storage of breathing supplies (oxygen tubing) was hanging from the oxygen concentrator. The nasal cannula prongs and portions of the oxygen tubing remained in direct contact with the floor. The RN 1, confirmed the oxygen tubing was touching the floor and stated once the oxygen tubing should be stored in the plastic stored bag for infection control. During a concurrent interview and record review on May 21, 2026 at 10:45 PM with the Director of Nursing the facility's policy and procedure (P&P) titled, Prevention of Infection Respiratory Equipment dated Revised November 2011 was reviewed. The P&P indicated, The purpose of this procedure is to guide prevention of infection associated with associated with respiratory therapy tasks and equipment among residents and staff.5. Keep the oxygen cannula and tubing used PRN (as necessary) in plastic bag when not in use. The DON confirmed the policy was not followed by staff.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when: Insulin (injectable drug to manage blood sugar) was not administered at the prescribed time for three of three sampled residents (Resident 7, Resident 35, and Resident 46) on May 20, 2026, when License Vocational Nurse (LVN 2) administered physician-ordered insulin glargine (brand name Lantus) approximately 2 hours and 21 minutes to 2 hours and 29 minutes prior to the ordered administration time of 6:00 AM.LVN 5 administered Resident 82 chewable aspirin 81 mg (low dose blood thinner) instead of the physician ordered enteric coated aspiring 81 mg (a low dose blood thinner with a special coating designed to help protect the stomach from irritation). This failure resulted in the potential for adverse outcomes including hypoglycemia (low blood sugar), altered blood glucose control, diaphoresis (excessive sweating), dizziness, changes in level of consciousness, falls, and other complications associated with the early administration of insulin, a high-alert medication (a medication that bears an increased risk of causing significant resident harm when used in error). Findings:1a. During a review of Resident 7's admission Record, (contains demographic and clinical information), the document indicated Resident 7 was admitted to the facility on [DATE], with the diagnosis of type 2 diabetes mellitus with diabetic neuropathy (a chronic condition in which the body does not properly control blood sugar level with nerve damage), Chronic Kidney Disease Stage 3 (moderate decrease in kidney function that may affect medication processing and elimination), and vascular dementia with behavioral disturbance (a decline in memory and thinking abilities caused by reduced blood flow to the brain, accompanied by confusion, agitation, or poor safety awareness).During an interview on May 20, 2026, at 5:29 AM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated they had already completed the blood sugar check and administered insulin glargine 5 units (a unit of measurement for dose) to Resident 7 prior to surveyor observation.During a concurrent interview and record review on May 20, 2026, at 5:29 AM, with LVN 2, the physician orders for Resident 7 dated January 9, 2026, were reviewed. The physician orders indicated to administer Lantus subcutaneous solution 100 Unit/ML (insulin glargine) with instructions to inject 5 units subcutaneously two times a day at 6:00 AM and 8:00 PM, for blood sugar management related to Type 2 diabetes mellitus with hyperglycemia. LVN 2 confirmed that insulin glargine was administered to Resident 7 at 3:31 AM that morning. LVN 2 further stated the insulin was administered approximately 2 hours and 29 minutes earlier than the physician ordered time and acknowledged insulin is considered a high alert medication. 1b. During a review of Resident 35's admission Record, the document indicated Resident 35 was admitted to the facility on [DATE], with the diagnosis of type 2 diabetes mellitus with diabetic neuropathy, heart failure (a condition in which the heart is unable to pump blood effectively, increasing the resident's vulnerability to complications associated with blood glucose fluctuations and medication errors), and difficulty walking (impaired ability to walk safely).During an interview on May 20, 2026, at 5:31 AM, with LVN 2, LVN 2 stated they had already completed blood sugar check and administered insulin glargine 26 units to Resident 35 prior to surveyor observation.During a concurrent interview and record review on May 20, 2026, at 5:31 AM, with LVN 2, the physician orders dated February 11, 2026, were reviewed. The physician orders indicated to administer Lantus subcutaneous Solution 100 unit/mL (insulin Glargine) inject 26 units subcutaneously in the morning at 6:00 AM related to type 2 mellitus. LVN 2 confirmed that insulin glargine was administered to Resident 35 at 3:31 AM that morning. LVN 2 confirmed the insulin was administered approximately 2 hours and 29 minutes before the physician ordered administration time of 6:00 AM time and acknowledged insulin is considered a high alert medication. 2. During a review of Resident 46's admission Record, the document indicated Resident 46 was admitted to the facility on [DATE], with diagnosis of type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension (elevated blood pressure), and difficulty walking. During an interview on May 20, 2026, at 5:33 AM, with LVN 2, LVN 2 stated they had already completed blood sugar check and administered insulin glargine 32 units to Resident 46 prior to surveyor observation. During a concurrent interview and record review on May 20, 2026, at 5:33 AM, with LVN 2, the physician orders dated December 29, 2025, were reviewed. The physician orders indicated, to administer Insulin Glargine solution 100 Unit/ML inject 32 units subcutaneously in the morning at 6:00 AM related type 2 diabetes mellitus with diabetic neuropathy. LVN 2 confirmed that insulin glargine was administered to Resident 46 at 3:39 AM that morning. LVN 2 further stated the insulin was administered approximately 2 hours and 21 minutes earlier than the physician ordered time and acknowledged insulin is considered a high alert medication. During a concurrent interview and record review on May 20, 2026, with the LVN 2, the facility's P&P titled, Administering Medications, revised April 2019 was reviewed. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within (1) hour of their prescribe time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering the medication check the labeled THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.23 As required or indicated, for a medication the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered. LVN 2 confirmed that the policy was not followed because the insulin was administered too early and it have may cause hypoglycemia reaction. During a concurrent interview and record review on May 21, 2026, with the Director of Nursing (DON), the facility's P&P titled Administering Medications, revised April 2019 was reviewed. The P&P indicated, Medications are administered in a safety and timely manner, as prescribed. The DON stated it is important for nursing staff to follow physician orders and administer medications within the facility's approved medication administration time frame. During a review of Resident 32's admission Record (contains demographic and clinical information), the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with foot ulcer ( a chronic condition here the body does not properly use insulin, causing high blood sugar levels and wounds on the feet that heal slowly), Peripheral autonomic neuropathy (nerve damage caused by diabetes that can affect body functions such as blood pressure, heart rate, and blood sugar regulation), and acute respiratory failure with hypoxia ( a serious condition where the lungs cannot provide enough oxygen to the body, increasing the resident's risk for complications). During a review of resident 32's Care Plan Report dated April 26, 2023, the care plan indicated, Focus Diabetes care plan, resident with altered blood glucose AEB (as evidence by) fluctuating blood sugars. At risk for ill effects as: Hypoglycemia (tremors, confusion., Hyperglycemia (blurred vision, acetone odor breath) related to DM (diabetes mellitus), Goal Resident will not have any complications of diabetes through next review.Interventions.Obtain blood glucose levels as ordered, document and notify MD (doctor) as needed. During a review of Resident 32's physician's

Based on interview and record review, the facility failed to provide sufficient number of staff when 22 out of 31 sampled days had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility).This failure had the potential to result in unmet needs, such as psychosocial and physical needs, and safety concerns for 97 residents who reside in the facility.Findings: During a concurrent interview and record review on May 20, 2026, at 9:56 AM, with the Director of Staff Development (DSD), the Director of Nursing (DON), and the Administrator (ADMIN) the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD- the number that results from dividing the actual nursing hours perform by direct caregivers per patient day and the number of residents in the facility), for April 18, 2026, to May 18, 2026, was reviewed. The DHPPD indicated the following: 1. The Actual DHPPD was 2.91 (facility was short of 0.59) on April 18, 2026.2. The Actual DHPPD was 3.24 (facility was short of 0.26) on April 19, 2026.3. The Actual DHPPD was 3.36 (facility was short of 0.14) on April 23, 2026.4. The Actual DHPPD was 3.23 (facility was short of 0.27) on April 24, 2026.5. The Actual DHPPD was 2.82 (facility was short of 0.68) on April 25, 2026.6. The Actual DHPPD was 2.71 (facility was short of 0.79) on April 26, 2026.7. The Actual DHPPD was 2.87 (facility was short of 0.63) on April 27, 2026.8. The Actual DHPPD was 3.10 (facility was short of 0.4) on April 28, 2026.9. The Actual DHPPD was 3.10 (facility was short of 0.4) on April 29, 2026.10. The Actual DHPPD was 3.22 (facility was short of 0.28) on April 30, 2026.11. The Actual DHPPD was 2.60 (facility was short of 0.9) on May 1, 2026.12. The Actual DHPPD was 2.87 (facility was short of 0.63) on May 2, 2026.13. The Actual DHPPD was 3.29 (facility was short of 0.21) on May 3, 2026.14. The Actual DHPPD was 2.78 (facility was short of 0.72) on May 9, 2026.15. The Actual DHPPD was 3.38 (facility was short of 0.12) on May 10, 2026,16. The Actual DHPPD was 3.09 (facility was short of 0.41) on May 11, 2026.17. The Actual DHPPD was 3.37 (facility was short of 0.13) on May 12, 2026.18. The Actual DHPPD was 3.14 (facility was short of 0.36) on May 13, 2026.19. The Actual DHPPD was 3.36 (facility was short of 0.14) on May 14, 2026.20. The Actual DHPPD was 2.64 (facility was short of 0.86) on May 16, 2026.21. The Actual DHPPD was 2.42 (facility was short of 1.08) on May 17, 2026.22. The Actual DHPPD was 2.59 (facility was short of 0.91) on May 18, 2026. The DSD stated the Actual DHPPD was accurate. The DON and the ADMIN acknowledged the facility did not meet the DHPPD required for those dates.During a record review on May 20, 2026, at 11:25 AM, the facility's staffing waiver for certified nursing assistants (CNAs), with a valid date of July 1, 2025, to June 30, 2026, indicated, .2. The facility shall provide no less than 3.5 direct care service hours per patient day.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 11) had access to a functioning resident's call light in the bathroom. This failure had the potential for Resident 11 to experience delayed assistance and increased the risk for unmet care needs, falls, injury, and inability to request help during an emergency. Findings: During a review of Resident 11's admission Record (contains demographic and clinical information), the admission Record indicated Resident 11 was admitted to the facility on [DATE] with the diagnosis of paraplegia (partial or complete paralysis affecting the lower part of the body, resulting in impaired mobility and increased dependence on staff assistance for movement and transfers), cognitive communication deficit (difficulty understanding, processing, or expressing information which may affect the residents ability to communicate needs, report concerns or request assistance) and anoxic brain damage (brain injury caused by a lack of oxygen to the brain, which may affect memory, judgement, safety awareness, thinking abilities, and the ability to recognize or respond to unsafe situations). During observation on May 20, 2026 at 12:27 PM, in Resident 11's room, Resident 11 was sitting upright in a wheelchair. The resident was awake, alert and oriented to name, place and situation. The resident stated he wanted to use the restroom and reported he was waiting for staff assistance. During an observation on May 20, 2026 at 12:28 PM in Resident 11's bathroom, surveyor attempted to activate the bathroom emergency call light system by pulling the emergency call cord and pressing the call light button located inside the bathroom. There was no No alarm, signal, or notification was activated. The bathroom call light system was not functioning. During a concurrent observation and interview on May 20, 2026, at 12:39 PM, with the Director of Nurses (DON) and Administrator, they were requested to come to Resident 11's room to verify the functionality of the call light located inside the resident's restroom. Further observation revealed the restroom emergency call light was inoperable. The DON stated she was unaware the call light was not functioning and indicated maintenance would need to evaluate the system. The DON and Administrator confirmed the emergency call light located in Resident 11's restroom was not functioning. The DON and Administrator acknowledged that a functioning call light system was important for residents to request assistance and notify staff during emergencies. During an interview on May 20, 2026 at 12:43 PM with the Maintenance Director, (MDR), MDR stated Resident 11 frequently pulled on and damaged the call light equipment, requiring repairs on multiple occasions. The MDR confirmed the restroom call light located in Resident 11's bathroom was not functioning. During a review of Resident 11's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive (involving consciousness intellectual activity Patterns), dated April 2, 2026, indicated Resident 11 had a BIMS (brief Interview for Mental Status - tool used to screen how a resident is functioning cognitively) score of 5 ( a BIMS score 0-7: suggests residents is severe impairment). During a review of Resident 11's MDS (Minimum Data Set) , Section GG (functional Abilities and Goals), dated April 2, 2026, indicated, Section GG0130 C. (toileting hygiene), was coded 01 Dependent - helper does all of the effort. Resident does none of the effort to complete the activity. Or , the assistance of 2 or more helpers is required for the resident to complete the activity. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light dated October 2010, the P&P indicated, 3. Ask the resident to return the demonstration so that you will be sure that the resident can operate the system (Note: Explain to the resident that a call system is also located in his / her bathroom. Demonstrate how it works.), 4. Be sure that the call light is always plugged in.,7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the resident's call light as soon as possible. During an interview on May 21, 2026 at 11:10 AM with DON, the DON reviewed the P&P, and acknowledged the restroom emergency call light for Resident 11 was expected to be function and available for the resident to request staff assistance.

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse with an injury of unknown origin was reported to the State Survey Agency within the required time frame for one of one sample resident (Resident 11). This failure had the potential to put at risk the health and safety of Resident 11. Findings: During a review of Resident 11's admission Record (contains demographic and clinical information) the admission Record indicated Resident 11 was admitted to the facility on [DATE], with the diagnosis of paraplegia (partial or complete paralysis affecting the lower part of the body, resulting in impaired mobility and increased dependence on staff assistance for movement and transfers), cognitive communication deficit (difficulty understanding, processing, or expressing information which may affect the residents ability to communicate needs, report concerns or request assistance) and anoxic brain damage (brain injury caused by a lack of oxygen to the brain, which may affect memory, judgement, safety awareness, thinking abilities, and the ability to recognize or respond to unsafe situations). During a review of Resident 11's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive (involving consciousness intellectual activity Patterns), dated April 2, 2026, indicated Resident 11 had a BIMS (brief Interview for Mental Status - tool used to screen how a resident is functioning cognitively) score of 5 ( a BIMS score 0-7: suggests residents is severe impairment). During a review of Resident 11's MDS (Minimum Data Set - Section GG (functional abilities dated April 2, 2026) indicated Resident 11 needs maximal assistance. During a review of Resident 11's Physician Orders dated January 1, 2024, the physician orders indicated, Resident 11 to have 1/2 (half) side rails up to both sides of bed for safety and repositioning. Further review indicated, Fall mat at bedside when in bed every shift for safety bilaterally on sides of bed to reduce risk of injury from attempts to crawl out of bed dated October 6, 2022. During an observation May 18, 2026 at 4:05 PM, Resident 11 was observed lying in bed with eyes closed. Observation revelated the resident's bed was positioned against the wall on the left side with a floor mat located on the right side of the bed. Further observation revelated approximately circular area of yellow - green discoloration surrounding the resident's right eye. The discoloration appeared faded in appearance. During a telephone interview on May 19, 2026 at 10:38 AM with Family Member (FM 1), FM 1 stated she visited Resident 11 on May 14, 2026 and observed a large black bruise underneath the resident's right eye while seated in the dining room. The FM1 stated she asked Resident 11 what happened; however, Resident 11 shrugged his shoulders and was unable to explain the cause of the injury. FM 1 stated a staff member assisting Resident 11 with his meals, was unable to explain how the injury occurred. FM 1 stated the facility did not contact her regarding the injury until May 15, 2026 when a licensed nurse informed her staff had observed the injury. FM 1 stated she informed the nurse she had already observed the bruise during her visit on May 14, 2026. FM 1 stated she was informed the facility would investigate the injury; however, as of the date of the interview, she had not received any follow up regarding the cause of the injury or the outcome of the investigation. FM 1 stated she did not know how the injury occurred. During an interview on May 20, 2026 at 1:08 PM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 11 had a long history of behaviors including removing clothing, throwing himself onto the floor and crawling and often requiring assistance from two to three staff members to return him to bed. CNA 3 further stated that on May 13, 2026, she assisted other staff members with showering Resident 11. CNA 3 observed discoloration around the resident's right eye and believed that nursing staff had already identified and reported the injury. CNA 3 further stated staff are expected to immediately report observations to the nurse who would then notify management. CNA 3 acknowledged that despite observing the discoloration around the resident's right eye, she did not report it. During an interview with the Director of Nurses (DON) on May 21, 2026 at 11:09 AM, the DON stated staff are expected to immediately report new bruising, injuries of unknown origin, or allegations of abuse to the nurses for assessment and notification to management. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated, Revised April 2021, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state a federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.3. Immediately is define as a. within two hours of an allegation involving abuse or resulting in serious bodily injury ; b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. During a review of facility's Reported Incident (FRI) , the allegation was reported to the state survey agency on May 15, 2026, 48 hours after the first observation of possible abuse to Resident 11.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows a resident to communicate with nursing staff when a resident needs assistance) was within resident reach for one of six sampled residents (Resident 49 ) when Resident 49's call light was hanging off the side of the bed and out of the reach. This failure had the potential to place Resident 49 at risk for safety and well-being.Findings:A review of Resident 49's admission Record (contains demographic and medical information), indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia ( the lungs are suddenly unable to adequately transfer oxygen into your bloodstream), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), osteoarthritis( a degenerative joint disease where the protective cartilage covering the ends of your bones gradually wears away). During a concurrent observation and interview on May 18, 2026, at 4:04 PM, with Resident 49 in Resident 49's room, observed Resident 49 lying in bed and looking around in the bed. Resident 49 stated I can't find my call light and this happens all the time. Further observation, noted the call light hanging off the side of the bed and out of reach. Resident 49 was unable to independently notify staff for assistance and to report need for care.During a concurrent observation and interview on May 18, 20, 2026, at 4:15 PM, with Certificated Nursing Assistant 4 (CNA 4), in Resident 49's room, CNA 4 validated Resident 49's call light was hanging off the side of bed and out of reach of resident. CNA 4 stated the call lights should be within resident's reach and it's important for the residents to be able to request care. During a concurrent interview and record review on May 20, 2026, at 1:43 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010 was reviewed. The P&P indicated, The purpose of this procedure is to respond to the resident's requests and needs.5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The Director of Nurses (DON) stated the expectation is for call lights to remain within residents' reach at all times and acknowledged the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure a written response was provided timely and in accordance with the facility's policy when the Family Council (also known as Resident Council; an organized group of relatives and friends of residents who meet regularly to discuss and address concerns about quality of care in the nursing home) submitted a grievance on November 9, 2025, and have not received any response until December 29, 2025. This failure has the potential to impact on the facility's ability to ensure grievances were promptly addressed and resolved, which could negatively affect 99 highly vulnerable residents residing in the facility. Findings:During a review of the facility's document titled Resident Council Town Hall Minutes, dated November 20, 2025, it indicated the meeting was held at 1:59 PM. Further review indicated there were new concerns discussed in the meeting which included residents waiting two hours for a incontinence pad change, and residents not being checked every two hours by the staff.During an interview on December 29, 2026, at 2:00 PM, with the Director of Nursing (DON), the DON verified that the Long-Term Care Ombudsman (trained advocate for residents in nursing homes, assisted living, and other long-term care facilities; assists with residents in with issues related to day-to-day care, health, safety, and personal preferences) submitted the October 17, 2025, Family Council minutes to the Former Administrator on November 9, 2025, and the facility was unable to provide any written response addressing that. She further stated that during that time, they had a change of Administrator. She stated the facility should have provided a written response within 14 days as per their policy, but because there was a change in administrators, they were not able to do so.During a review of the facility's undated policy and procedure titled Family Council, the policy and procedure, indicated, The facility will respond in writing to written requests, concerns, or recommendations of the family council, within 14 calendar days.

F 725: Sufficient Staffing - [NAME] Care Center S/S D [NAME] S483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e). S483.35(a) Sufficient Staff. S483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Intent:To assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. F 725: Sufficient Staffing - [NAME] Care Center S/S D [NAME] Based on interview and record review, the facility failed to provide sufficient numbers of staff when six (6) out of 6 sampled days had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility).This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 95 residents.Findings:An unannounced complaint investigation was conducted related to quality of care.During an interview with the Director of Nursing (DON) on August 11. 2025, at 4:00 PM, DON stated, We are short staffed mostly on night shift. The DON further stated three (3) Certified Nursing Assistants (CNA) recently quit and they are currently using travelers with the shortage.During a concurrent interview and record review on August 11 , 2025, at 4:15 PM, with the DON, the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD- the number that results from dividing the actual nursing hours perform by direct caregivers per patient day and the number of residents in the facility), for dates: July 24, 2025 through July 29, 2025, were reviewed. The Census and Direct Care Service Hours Per Patient Day document indicated the following dates when the required 3.5 DHPPD hours was not met:a. July 24, 2025- 3.21 DHPPD (facility was short of 0.29)b. July 25, 2025 - 3.37 DHPPD (facility was short of 0.13)c. July 26, 2025- 2.33 DHPPD (facility was short of 1.17)d. July 27, 2025- 2.22 DHPPD (facility was short of 1.28)e. July 28, 2025- 3.48 DHPPD (facility was short of 0.2) A reference to a document titled All Facilities Letter (AFL) 18-12 [an official notice issued by the California Department of Public Health (CDPH) to licensed healthcare facilities to provides updates on regulations, policies, procedures, or urgent public health information that facilities must follow]. The AFL 18-12 indicated Skilled Nursing Facilities are required to provide a minimum of 3.5 direct care service hours per patient day, with a minimum of 2.4 performed by certified nurse assistants.During a review of the facility's policy titled, Staffing, Sufficient and Competent Nursing revised August 2022, was reviewed. The P&P indicated, Our facility provides sufficient numbers of staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The DON acknowledged that the policy was not followed and acknowledged they were aware of having fewer DHPPD hours than required on the specified dates.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff when the 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility) staffing requirement was not met. This failure had the potential to result in unmet resident's needs, such as psychosocial, physical needs, and safety concerns for 95 vulnerable residents. Findings: An unannounced visit was conducted on June 9, 2025, to investigate a complaint with allegations that included quality of care and staffing concern. During a telephone interview on June 9, 2025, at 4:08 PM, with the License Vocational Nurse (LVN 1), LVN 1 reported that on May 18, 2025, she observed the call light was activated for 40 minutes without the Certified Nursing Assistant (CNA) present to respond to it. During a concurrent telephone interview and record review on June 11, 2025, at 3:30 PM, with the Director of Staff Development (DSD), the facility's staffing waiver for Certified Nursing Assistant (CNA), issued by the California Department of Public Health was examined. The staffing waiver document indicated approval for 2.4 [hours] DHPPD for CNA, valid from July 1, 2024 to June 30, 2025, under the following conditions: .2. The facility shall provide a minimum of no less than 3.5 direct care service hours per patient day . Additionally, the facility staffing assignments from May 18, 2025 through June 10, 2025, were reviewed with the DSD. The staffing assignment indicated the waiver condition to provide 3.5 direct care service hours per patient day was not met on the following dates: a. May 18, 2025 - actual DHPPD was 2.50 hours (short by 1) b. June 6, 2025 - actual DHPPD was 3.07 hours (short by 0.43) c. June 7, 2025 - actual DHPPD was 2.81 hours (short by 0.69) d. June 8, 2025 - actual DHPPD was 2.72 hours (short by 0.78) e. June 9, 2025 - actual DHPPD was 2.97 hours (short by 0.53) The DSD acknowledged the facility did not meet the staffing requirements on the above dates and emphasized the necessity of adequate staffing for patient safety. During a telephone interview on June 11, 2025, at 3:42 PM, with the Director of Nursing (DON), the DON acknowledged, the facility failed to meet the required staffing requirements on May 18, 2025, June 6, 2025, through June 9, 2025. Furthermore, the DON indicated inadequate staffing can adversely affects the quality of care, skin care, and all facets of resident care and safety.

Based on interview and record review, the facility failed to report for one of 3 sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged abuse/ injury of unknown cause. This failure has the potential to put (Resident 1) health, safety and well-being at risk. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: Alzheimer's (disease destroys memory and mental functions), osteoarthritis (bones wear down), benign prostatic hyperplasia (enlargement gland causing urination difficulty), lack of coordination. During a review concurrent interview and record review of Resident 1's Medical Record reviewed are as follows: 1. March 01,2025, at 0612 Nurse Note: 1cm redness noted to resident Right side of face above eyebrow. No s/s of trauma, no bleeding, no drainage noted at this time. Will endorse to AM nurse. 2. March 01, 2025, at 1324 Social Service Note: Resident Power Of Attorney (POA) came to this writer with concerns regarding marks on resident face. Per notes from night nurse resident had small scratch above eyes. POA is concerns with discolorations of nose, and that resident has more than scratch above his left eye. She is requesting investigation to find out what happened with the resident. Director of Nursing (DON) and administrator notified. 3. March 06, 2025, SOC341, submitted to state agency. (facility could not provide 5 Day investigation). During an interview on April 01, 2025, with the Certified Nursing Assistant (CNA1), the CNA1 stated, I worked with Resident 1 on February 28,2025, he was good, nothing on his face. My shift ended CAN 2 took over for me, Saturday morning 6:30AM I came back and then that when supervisor told me he had bruises on his face, cheek area. I was confused because that's not how we left him. We used pillows on bed rales for him not to hit self. The Director of Staff Development (DSD) assistant interviewed me, then on Monday (DSD) interviewed me. They proceeded with Resident 1 sister; she was here Saturday they had meeting with her. On Saturday, his left side of face redness some bruising and nose scratches. If I would have seen this, I would report to the nurse. During an interview on April 01, 2025, with the Certified Nursing Assistant (CNA2), the CNA2 stated, I work 11PM-7AM shift, when I first arrived on shift February 28, 2025, I didn't notice anything to Resident 1 face, he is usually up during the night, he calmed around down 1:00AM, that's when I do my rounds. When I checked on his, I didn't notice his face, at 3:00AM I noticed redness to left side to face, I explained to the License Vocational Nurse (LVN) it's the first time I seen it. She told me she was going to chart it. At 6:30AM I got him up and the redness was still there I notified the LVN that it looked the same from 3:00AM. It looked like red like when you are laying too long, not a bruise no open wound, no blood. I didn't get a clean view of his face with light on until 3AM. During an interview on April 01, 2025, with the License Vocational Nurse (LVN), the LVN stated, The CAN did mention a small abrasion to side of his face, prior to endorsement his nails were jagged, but his sister or mom (I don't know who it is) cuts his nails and does not let staff doing it. The redness, it did not look open, he was not bleeding. I cannot say it was 100% how he got it, it was that night or the day before. I wrote a note on this, I let the next nurse and DON know about this. I did not think it needed to be reported, or investigated, I personally felt it didn't look intentional. It didn't seem anything more than or intentional. I did leave a voicemail to family sister, that was my last day working with him after that I don't know what happened. The DON said she would look into it and notify the doctor and wound care. For unknown injuries we document and endorse to next nurse and notify the DON. During an interview on April 01, 2025, with the Director of Staff Development (DSD), the DSD stated, I spoke with Resident 1 sister, she called me regarding the scratches to his face. I got statements from the staff, they were not able to identify where they came from, he did have long nails at the time when scratches occurred. They place padding on bedrails to prevent him grazing against bed rails. We did not know where the scratches came from. I was notified approx. March 03 or 04 2025, I spoke with Administrator and DON, the DON did the investigation and gathered statements I got from the CNAs. We are only speculating we don't know they came from. I think it occurred on NOC shift. I'm assuming it was reported, the sister spoke with the DON and administrator. We do a SOC341 form, it would have been DON to report. I think this was reportable, no intent to cause harm. It should have been reported. The sister told me, the CNAs did report to the nurses. There should have been a progress note. The sister wanted this investigated. A few days after the ombudsman talked to me and she interviewed the CNAs. I can agree, this should have been reported sooner. During an interview on April 01, 2025, with the Administrator (Admin), the Admin stated, On March 01, 2025 I heard about it this, the sister noticed the markings, we interviewed and got statements from CNAs, we had them write the statements. The sister asked us what happened, she wanted an investigation. After reviewing the SOC341 (a report of suspected abuse form), this was sent March 06, 2025, to the state agency. I don't know about the 5-day investigation, I gave it to DON to do. (facility could not provide 5Day investigation report). During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022, the policy and procedure indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative .3.Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; orb. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to provide sufficient numbers of staff when 52 sampled days from October ' 2024 till March ' 2025 had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 97 residents. Findings: During an interview with Certified Nurse Assistant 1 (CNA 1) on April 1. 2025, at 3:10 PM. CNA 1 stated we are unable to provide 1:1 care to one of our residents who wander off to other resident ' s room due to not having enough staff. We also have 2 CNA ' s that recently quit, and they have not found any replacement. CNA 1 also stated We recently had a meeting, and we were told by management that we are not using registry anymore. We have not had any registry in the facility. During an interview with Certified Nurse Assistant 2 (CNA 2) on April 1,2025 at 3:20 PM, CNA2 stated We are short staff on PM and NOC, especially when there ' s sick calls. We are short staff lately due to Travelers not working anymore and we also have 2 CNA that recently quit with no replacement at this time. During a concurrent interview and record review on April 1, 2025, at 3:45 PM, with the Acting Director of Nursing (DON), DON stated that we are still having issues with not enough staffing especially whenever we get sick calls. I ' m the MDS nurse, RN and now the acting DON because our current DON just resigned yesterday. When acting DON asked about the DHPPD hours below the minimum required hours. Acting DON stated that Director of Staff Developer (DSD), previous DON and Administrator (ADM) are aware. During record review on April 1, 2025, at 4:00 PM, with the Acting Director of Nursing (DON), the facility ' s policy and procedure (P&P), titled, Staffing, revised in April 2007, was reviewed. The P&P indicated, Our facility provides adequate staffing to meet needed care and services for our resident population. The acting DON stated the policy was not followed. During a phone interview with DSD on April 1,2025 at 4:15 PM, DSD stated We are aware that our DHPPD hours are less that 3.5 hours especially on those days when staff calls off. We are in a Rural area and it ' s difficult to get staff. When DSD asked if the facility admitting residents with low staffing, and she stated that it is the ADM ' s decision. During record review of DHPPD hours on April 1,2025, at 4:30 PM, it indicated, the Actual DHPPD was less than 3.5 hours on the following dates, October 5,2024- 3.0, October 6, 2024- 3.39, October 12, 2024- 3.09 , October 13, 2024,-3.13, October 19, 2024- 3.17, October 20, 2024,-3.21, October 26, 202- 2.77, October 27, 2024- 2.82, November 02, 2024- 3.25, November 03, 2024- 3.33, November 9, 2024- 3.36, November 10, 2024- 2.61, November 16,2024- 3.00, November 17, 2024- 2.69, November 23, 2024- 3.23, November 24, 2024- 2.99, November 30, 2024- 3.05, December 07, 2024- 2.83, December 08,2024- 3.10, December 14,2024- 2.45, December 15,2024- 3.06, December 21,2024- 3.42, December 22,2024- 3.36, December 28,2024- 2.91, December 29,2024- 2.90, January 05,2024 - 3.00, January 18,2025- 3.16, January 25,2025- 3.06, January 26/2025- 2.91, February 01,2025- 3.22, February 09/2025- 3.23, February 15, 2025- 2.92, February 22,2025 2.90, February 23,2025- 3.19, March 01,2025 - 3.22, March 02,2025 - 2.67, March 08,2025- 3.09, March 09,2025 - 3.09, March 13,2025 - 3.27, March 15,2025 - 2.16, March 16,2025 - 2.25, March 17,2025 - 3.02, March 18, 2025 - 3.25, March 19, 2025 2.85, March 20,2025 - 2.86, March 22,22025 - 2.47, March 23, 2025 - 2.41, March 25,2024 - 3.09, March 27/2025 - 2.86, March 28, 2025 - 2.48, March 29, 2025 - 2.23, March 30, 2025 - 2.95. During interview and record review of the document titled, Census and Direct Care Service Hours Per Patient Day with ADM on April 1,2025, at 6:00 PM, ADM acknowledged the facility did not meet the DHPPD required. ADM stated Yes, I ' m aware we are below the 3.5 minimum required hours. Since the beginning of 2025, we hired 6 RN ' s, 1 LVN ' s and 2 CNAs. We currently have 7 CNA ' s that are still doing their classes and Training. We are actively hiring to alleviate our staffing issues. During phone interview on April 14, 2025, at 10:32 AM, with the ADM, the facility ' s staffing waiver with a valid date of July 1, 2024, to June 30, 2025, which indicated, .2. The facility shall provide a minimum no less than 3.5 direct care service hours per patient day. 4. The facility shall employ, and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all applicable state and federal staffing requirements . The ADM acknowledged the waiver was not followed during some days from October ' 2024 through March ' 2025 due to the DHPPD being below 3.5 . ADM stated we are working diligently in hiring Full Time staff so patient care is not affected and for the staff working to have enough help.

Based on interview, record review, and facility document and policy review, the facility failed to ensure there was registered nurse (RN) coverage eight consecutive hours, seven days a week for 6 days (10/23/2024, 11/17/2024, 11/24/2024, 12/01/2024, 12/08/2024, and 12/22/2024) during Fiscal Year (FY) 2025, Quarter 1 (October 2024, November 2024, and December 2024) and 3 days (02/23/2025, 03/01/2024, and 03/02/2025) during the timeframe from 02/11/2025 through 03/11/2025. Findings included: A facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/2022, specified, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy indicated, 3. A registered nurse [RN] provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A PBJ [Payroll-based Journal] Staffing Data Report CASPER [Certification and Survey Provider Enhanced Reports] Report 1705D FY Quarter 1 2025 (October 1 - December 31), with a run date of 03/05/2025, revealed the facility triggered for No RN Hours on the following Sundays: 10/13/2024, 11/17/2024, 11/24/2024, 12/01/2024, 12/08/2024, and 12/22/2024. Cross-reference of a facility schedule dated 10/13/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility on 10/13/2024. Cross-reference of a facility schedule dated 11/17/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 11/17/2024, revealed the Director of Nursing (DON) was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 11/24/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 11/24/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 12/01/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/01/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 12/08/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/08/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 12/22/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/22/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. A facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled for 02/23/2025 and 03/02/2025. Additionally, the schedule revealed there was an RN scheduled for only four hours on 03/01/2025. During an interview on 03/12/2025 at 9:20 AM, RN #3 stated there had been times when there was no RN scheduled to work in the facility. RN #3 stated that RNs were needed in the facility to administer treatments that licensed vocational nurses (LVNs) were not trained to do. During an interview on 03/12/2025 at 9:31 AM, the DON stated that an RN needed to be in the building seven days a week for eight consecutive hours each day. She stated she was on-call for some of the weekends that had no RN coverage in the facility. She clarified that being on-call was different from being in the facility, adding that on-call did not mean she was physically present in the facility. The DON stated the facility was not meeting the regulatory requirement and said the facility's schedule needed to be rearranged. During an interview on 03/12/2025 at 9:57 AM, Acting Administrator #1 and Acting Administrator #2 confirmed there needed to be an RN in the building eight consecutive hours a day, seven days a week. They both stated not having RN coverage in the building could be avoided with some reorganization of the schedule.

Based on interview and record review, the facility failed to provide sufficient numbers of staff when 3 out of 5 sampled days (January 9, 2025-January 13, 2025) had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 93 residents. Findings: During interview with the Administrator (Admin) on January 22. 2025, Informed issues of staffing, (Admin) states, It's up to me to admit residents, I rely on my staff also, we have said no to admitting residents due to staffing. I listen to the staff; I never want the quality of care to go down. I'm not halting any hiring; we are hiring and have registry. During a concurrent interview and record review on January 22,2025 at 9:20 AM, with Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Staffing, revised October 2017, was reviewed. The P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . The DON stated the policy was not followed. During a concurrent phone interview and record review on February 11 , 2025, at 11:15 AM, with DON, the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD- the number that results from dividing the actual nursing hours perform by direct caregivers per patient day and the number of residents in the facility), for dates: January 9, 2025 thru January 13, 2025, were reviewed. The DHPPD indicated, the Actual DHPPD was 3.33 (facility was short of 0.17) on January 9, 2025, Actual DHPPD was 3.31 (facility was short of 0.19) on January 11, 2025, and Actual DHPPD was 3.15 (facility was short of 0.35) on January 12, 2025. The DON acknowledged the facility did not meet the DHPPD required for those dates. During a concurrent phone interview and record review on February 11, 2025, at 11:25 PM, with the DON, the facility's staffing waiver for certified nursing assistant (CNA), with a valid date of July 1, 2024, to June 30, 2025, which indicated, .2. The facility shall provide a minimum no less than 3.5 direct care service hours per patient day. 4. The facility shall employ, and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all applicable state and federal staffing requirements . The DON acknowledged the waiver was not followed on January 9, 2025, January 11, 2025, and January 12, 2025, due to the DHPPD being below 3.5 and stated it was important to have enough staff so patient care is not affected and for the staff working to have enough help.

Based on observation, interview, and record review, the facility failed to ensure an emergency call light in the bathroom was able to be reached for one of three sampled residents (Resident A). This failure resulted in Resident A to experience a fall on March 18, 2017 and sustain a laceration (deep wound) of the forehead requiring sutures (stitches). Finding: An unannounced visit was made to the facility on [DATE] at 4:45 PM, to investigate a complaint regarding quality of care. During an observation on March 23, 2017 at 9:35 AM, in resident's room, Resident A was lying in bed with bandages on top of his head. During an interview with Resident A, on March 23, 2017 at 9:45 AM, he stated, I fell .I couldn't reach the call light. I got dizzy. The toilet bowel was spinning and I fell down on the floor of the bathroom. There was a lot of blood. The door was shut. My roommate shouted and shouted and finally someone came. During an observation on March 23, 2017 at 10 AM, in Resident A's bathroom in room 109, the call light string was observed to be tied in knots, shortening the length of the cord. During an interview with a Licensed Vocational Nurse (LVN 3), on March 23, 2017 at 10:15 AM, she stated, The call light string is short. I don't know how long that has been like that. I would make it a little longer. He (Resident A) would have to reach for it which would throw him of balance. She confirmed the call light string was tied in knots shortening the length of the cord and stated, It should not be like that. During an interview with the Director of Nurses (DON) on March 23, 2017 at 10:45 AM, she confirmed the call light string was tied in a knot. The emergency call light string was measured. It measured 2 feet when tied in a knot and 2 feet 11 inches when untied. She stated, It should not be like that. Let me unknot it and make it longer. During a review of the clinical record for Resident A, the licensed nurse's progress notes dated March 18, 2017 at 8:17 PM, indicated, Resident found on floor of bathroom. Staff was alerted to resident fall by his calling out. Resident stated that he was attempting to reach call string and then became dizzy. Was sent out to hospital at 7:35 PM. A review of the Fall Risk assessment dated [DATE], indicated Resident A's fall risk score was 15, and Resident A was considered at risk for falls. A review of Resident's A's Fall care plan dated May 29, 2015 indicated the resident was at risk for falls. The intervention listed included call light within reach. During a review of the policy and procedure titled, Answering call light dated October 2010, indicated under Policy, the purpose of this procedure is to respond to the resident's requests and needs. In the same policy under General Guidelines . 2. Demonstrate the use of the call light. 3. Ask the resident to return the demonstration .explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works.

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent a fall for one of three sampled residents (Resident A) when a certified nursing assistant (CNA 1) left Resident A unattended in the bathroom. This failure resulted in Resident A to experience a fall on March 18, 2017 and sustain a laceration (deep wound) of the forehead requiring sutures (stitches). Finding: An unannounced visit was made to the facility on [DATE] at 4:45 PM, to investigate a complaint regarding quality of care. During an observation on March 23, 2017 at 9:35 AM, in Resident's room, Resident A was lying in bed with bandages on top of his head. During an interview with Resident A, on March 23, 2017 at 9:45 AM, he stated, I fell .I couldn't reach the call light. I got dizzy. The toilet bowel was spinning and I fell down on the floor of the bathroom. There was a lot of blood. The door was shut. My roommate shouted and shouted and finally someone came. During an observation on March 23, 2017 at 10 AM, in Resident A's bathroom in room 109, the call light string was observed to be tied in knots, shortening the length of the cord. A review of Resident A's clinical records, reflected Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's history and physical, completed on May 27, 2014, indicated Resident A does have the capacity to understand and make his own decisions. A review of the Fall Risk assessment dated [DATE], indicated Resident A's fall risk score was 15, and Resident A was considered at risk for falls. A review of the Resident Assessment Instrument (RAI-a computerized assessment tool) section G, dated March 7, 2017, indicated Resident A required extensive assistance in toileting. During a review of the clinical record for Resident A, the licensed nurse's progress notes dated March 18, 2017 at 8:17 PM, indicated, Resident found on floor of bathroom. Staff was alerted to resident fall by his calling out. Resident stated that he was attempting to reach call string and then became dizzy. Was sent out to hospital at 7:35 PM. During an interview with the certified nursing assistant (CNA 1), on April 14, 2017 at 4:35 PM, she stated, I got him out of bed, and took him to the bathroom. I transferred him to the toilet. I left the room to provide privacy. I went next door. The next thing I knew, he had fallen. She confirmed she left Resident A unattended in the bathroom and stated, Now I know that I should have not left him alone. During an interview with a Licensed Vocational Nurse (LVN 1), on April 19, 2017 at 3:55 PM, he stated he was the charge nurse on duty when Resident A fell on [DATE]. He stated Resident A was left alone in the bathroom. Resident A was found by CNA 2 who happened to go to the room and find Resident A on the ground. CNA 2 was not available for interview. A review of Resident A's care plan dated November 25, 2016, indicated the resident was on a scheduled toileting plan related to a history of falls from attempting to use the bathroom unassisted. The intervention listed included provide physical staff assistance for toileting. During a review of the policy and procedure titled, Assisting a Resident to walk to the bathroom dated October 2010, indicated under the section titled Steps in Procedures .13. Tell the resident to call or signal for you. Wait outside the door, if permitted. 14. When the resident has signaled or called you, return to the bathroom.

Based on observation, interview, and record review, the facility failed to ensure: 1. Two of 16 sampled residents (Residents 4 and 11) received adequate supervision and assistance to prevent falls/accidents as evidenced by: a. For Resident 4, the Interdisciplinary Team (IDT- includes the licensed nurse (Registered Nurse {RN}/ Licensed Vocational {LVN}), RN minimum data set/care plan coordinator/Director of Staff Development (MDS/DSD), Occupational Therapist (OT), Physical Therapy (PT), Social Services Designee (SSD), Dietician, the resident and/or responsible party, and the Physician) failed to identify, evaluate and analyze the residents' risks for falls such as pain and discomfort, including supervision in order to reduce the risk of an accident or fall. This failure resulted in multiple incidents of falls including complaint of pain and injury. b. For Resident 11, the IDT failed to identify, evaluate and analyze the residents' risks for falls such as the need for a scheduled toileting program including supervision in order to reduce the risk of an accident or fall. This failure resulted in multiple incidents of falls. 2. The facility failed to ensure the residents environment remained as free of possible accidental hazards as possible when a Licensed Vocational Nurse (LVN 7) was observed carrying a portable oxygen cylinder tank under her arm. This failure had the potential to result in accidents or injuries in a universe of 78. Findings: 1. a. On January 28, 2015, Resident 4 was observed in his room lying on a recliner next to the bed, awake, alert and able to answer simple questions during a conversation. The resident's bed (left side of the bed) was positioned against the wall and the right side of the bed had a bolster device (a soft triangular shaped device that lined up one side (right side) of the bed from head of the bed to foot of the bed). A soft floor mat was observed on the floor next to the bed. Resident 4 stated he could only walk with assistance and had to use a wheelchair to move around. When asked about pain, Resident 4 stated he still had occasional pain on his back (wound area) at a scale of 6-7 of 10 (Facility Pain scale included: 1-2= least pain; 3-4= mild pain; 5-6= moderate pain; 7-8= severe pain; 9-10= worst pain). A review of Resident 4's medical record on January 28, 2015, indicated Resident 4 was [AGE] years of age and had [DIAGNOSES REDACTED]. The current Minimum Data Sets (MDS- a comprehensive resident assessment) dated November 22, 2014, reflected Resident 4 had 2 or more falls since admission to the facility, had complained of occasional pain with an intensity of 4-6 (mild to moderate) of 10 on scale, needed extensive assistance with transfers, walking and toileting, and was frequently incontinent of urine and bowel. A review of the nurses observation report including fall assessments and weekly progress notes from August to December 2014, showed Resident 4 had 14 incidents of falls which included unwitnessed falls and injury to the resident. The nurses observation reports included the following: August 20, 2014- "Slid from bed; no injury" (No documentation of whether the resident complained of pain). There was no documentation in the resident's medical record that a fall assessment had been conducted to identify and evaluate the cause of the fall. September 15, 2014- "Unwitnessed fall" (No documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall. October 12, 2014- "Unwitnessed fall." The clinical observation and assessment by an LVN staff indicated, "Resident gets up from his chair (wheelchair) or his bed and attempts to transfer self (without assistance). Has a Foley catheter, wants to go to bathroom to void. Possible UTI ..." The assessment did not include other possible underlying causes of the fall such as pain and discomfort (including the pressure ulcer on mid back area). October 21, 2014 at 4:40 PM- "Resident fell from recliner chair. Resident complained of pain on the left hip and skin tear on elbow" (record did not specify which elbow). There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible cause of the fall. October 27, 2014 at 7:12 AM- "Unwitnessed fall, unassisted transfer from bed" (to outside of bed). (No documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible cause of the fall. November 2, 2014 at 12:39 AM- "Resident found on floor" (no documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible cause of the fall. November 6, 2014 at 4:54 AM- "Fall" (no documentation of whether the resident sustained [REDACTED]. The weekly progress notes dated November 10, 2014, indicated Resident 4's pain was controlled, and "often rolls to back when in bed despite frequent verbal reminders from staff " and to continue care plan. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall. November 19, 2014 at 4:14 AM- "Unwitnessed fall." (no documentation of whether the resident sustained [REDACTED]. The weekly nurses progress notes dated November 17, 2014, indicated Resident 4's pressure ulcer treatment included a [DEVICE] (a medical device consisting of rubberized/plastic vacuum/tubings) applied on the pressure ulcer wound on the mid back area, and the resident needed physical assistance with bed mobility, transfers and toileting. There was no documentation in the resident's medical record that a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall. November 20, 2014 at 10:04 PM- "Fall" (no documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record that a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall, until after 5 days (on November 25, 2014). November 21, 2014- "Fall" (no documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall, until after 4 days (on November 25, 2014). November 24, 2014- "Unwitnessed fall" (no documentation of whether the resident sustained [REDACTED]. The "Fall Risk Assessment", conducted by a licensed nurse (LVN 5), dated November 25, 2014, indicated the contributing factors of the fall included joint pain/arthritis, dementia, decline in cognitive (mental ability) skills and functional status (such as walking, during transfers, toileting), heart problem, and bowel/bladder incontinence. There was no documentation indicating the IDT conducted an analysis of the fall assessment to determine the possible underlying cause of the fall (such as determining if the [DEVICE] and pressure ulcer on the mid back area was creating pain/discomfort when in bed or on recliner, or the resident needed scheduled toileting on a regular basis to prevent from getting out of bed/recliner to go to the restroom unassisted). The plan was to continue current care plan. December 1, 2014- "Fall" (no documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record that a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall. December 2, 2014 at 4:32 AM- "Resident found on knees on floor mat." (No documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall. December 5, 2014 at 7:24 AM- "Resident found on the floor mat." (No documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to show a fall assessment had been conducted to identify and evaluate the possible underlying cause of the fall such as if the resident had been having pain or discomfort when in bed. The weekly progress notes dated December 22 and 29, 2014, indicated to continue current plan of care. The Fall Protocol and policy and procedure provided by the facility, dated April 2007, indicated when a resident had a fall, staff (such as the IDT) would attempt to define possible causes within 24 hours of the fall which included factors associated with or that directly resulted in a fall (such as if the resident fell in the restroom, a toileting/bowel and bladder assessment would be conducted, a toileting plan developed and implemented). The fall guideline indicated that after more than one fall, the staff and physician would identify pertinent, various relevant interventions based on the (fall) assessment to prevent subsequent falls and until incidents of falls stopped. A review of the resident's "Fall Care Plan" dated August 15- December 5, 2014, indicated the following interventions and updates to prevent falls: August 15 and 20, 2014- care plan approaches/interventions included, to keep call light within reach; clip alarms (in bed/chair); verbal reminders to ask for assistance as needed; bowel and bladder (toileting assistance) as needed (PRN); pain medication regimen; bed against the wall; low bed; floor mat; and Rehab (PT/OT) fall screening (fall assessment). The care plan did not include new interventions based on the fall assessment after the fall incident on August 20, 2014. October 12 and 21, 2014- an added care plan intervention after the fall incident on October 12, 2014, included to place and observe Resident 4 in a supervised area when out of bed. The same interventions to keep call light within reach; clip alarms (in bed/chair); verbal reminders to ask for assistance as needed; bed against the wall; low bed; floor mat next to bed were noted. There were no new interventions developed based on a fall assessment result after the fall incident on October 21, 2014. November 2- December 5, 2014- care plan interventions included to analyze the resident's fall trend/pattern and to continue the same plan of care. There was no documentation in the medical record to show the IDT had conducted fall assessments and analyzed the resident's successive fall incidents on November 2, 6, 19, 20, 21, and December 1, 2 and 5, 2014. In an interview with the RN MDS/DSD on January 28, 2015 at 2 PM, regarding the facility's policy when a resident had multiple incident of falls, the RN MDS/DSD stated a fall assessment (an assessment used to identify the risks and cause of fall) would be conducted after each fall by the rehabilitation (Rehab) staff (such as the PT and/or the PT), then an interdisciplinary team (IDT) meeting would be conducted to analyze the cause of fall, and the care plan would be updated. When asked how could Resident 4 have 14 incidents of falls in 4 months, the RN MDS/Care Plan coordinator stated, "We have done every preventive measures, precautions and devices (from August to December 2014), but I think we failed to assess the resident's (Resident 4) pain and discomfort caused by the [DEVICE] on his back. " The RN MDS/DSD stated since the [DEVICE] was discontinued on December 2014, Resident 4 had not attempted to get up by himself from the bed or recliner chair. The RN MDS/DSD acknowledged there was no documentation in Resident 4's medical record to indicate that fall assessments were not consistently conducted and that the IDT properly analyzed and failed to identify the cause of the resident's multiple fall incidents. The RN MDS/DSD acknowledged the plan of care to prevent further falls was not updated based on fall assessment analysis results such as putting the resident on scheduled toileting plan, and ensuring the [DEVICE] and the resident's pressure ulcer on the mid back area did not create pain and discomfort when lying in bed or on recliner chair. 1 b. During an observation of Resident 11 on January 29, 2015 at 10:15 AM, the resident was up in a wheelchair propelling self around her bed. Resident 11 was alert and oriented to name and place, and was able to answer simple questions with slurred speech. The resident was able to follow simple commands such as moving her arms and legs. Resident 11 stated with slurred speech and by motioning with her slinged right arm that she could not move her right arm and leg, and was unable to walk by herself without assistance. A review of Resident 11's medical record on January 29, 2015 indicated the resident was [AGE] years of age, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current Minimum Data Sets (MDS- a comprehensive resident assessment) dated December 25, 2014, reflected Resident 11 had 2 or more falls since admission to the facility, was frequently incontinent of bowel and bladder, and required extensive assistance with bed mobility, transfers and toileting. The assessment further indicated Resident 11's communication status were "usually understands" and "sometimes understood." A review of the post fall assessments conducted by the Occupational Therapist (OT 1) from December 2014 to January 2015, showed Resident 11 had 8 repeated incidents of falls which included 3 unwitnessed falls. The post fall assessments indicated the following: Unwitnessed fall in the resident's room on December 20, 2014- The "Rehab status [REDACTED]. The OT 1 recommendation was to continue with the use of clip alarm/bed sensor and landing pads (floor mat) on both sides of the bed. The care plan interventions further included concave mattress; call lights within reach; medication regimen review; and verbal reminders to ask for assistance if needed. There was no documentation in the resident's medical record to show an evaluation and analysis of the fall assessment had been conducted by the IDT in order to identify other possible causes of the fall. December 24, 2014- "Witnessed fall in resident's room." The OT 1's post fall assessment on December 24, 2014, recommended a "continuation of sensor alarms in wheelchair/bed, landing pads (floor mats), and bed in lowest position." There was no documentation to indicate that an evaluation and analysis of the fall assessment had been conducted by the IDT in order to identify other possible causes of the fall. December 30, 2014- "Witnessed fall in the bathroom." The OT 1's post fall assessment on December 31, 2014, with recommendation to continue safety precautions and fall prevention protocol (Fall protocol included defining possible causes within 24 hours of the fall such as factors associated with or that directly resulted in a fall, and to identify pertinent, various relevant interventions based on the (fall) assessment to prevent subsequent falls and until incidents of falls stopped). There was no documentation to show an evaluation and analysis of the fall assessment had been conducted by the IDT in order to identify other possible causes of the fall. December 31, 2014- "Unwitnessed fall. Resident was found on the floor next to toilet." (No documentation whether the resident sustained [REDACTED]. The Physical Therapist's (PT 2) post fall assessment dated [DATE] indicated Resident 11 refuses gait training, therapeutic exercises, and the use of clip sensor alarms. PT 2's recommendation was to continue safety precautions for fall prevention. There was no documentation to show an evaluation and analysis of the fall assessment had been conducted by the IDT in order to identify other possible causes of the fall. January 3, 2015- "Unwitnessed fall incident at bedside." The post fall assessment conducted by PT 1 on January 4, 2015, did not include a recommendation for fall prevention interventions. There was no documentation to show an evaluation and analysis of the fall assessment had been conducted by the IDT in order to identify other possible causes of the fall. January 5, 2015- "Witnessed fall in the bathroom." The post fall assessment conducted by PT 1 on January 5, 2015, indicated "at this time, Resident 11 had a one to one (1:1) sitter in order to prevent self-transfer (from bed to chair and vice versa or from chair to toilet and vice versa). PT 1's recommendation was to "continue monitoring Resident 11, and follow IDT protocol and recommendations." There was no documentation indicating the IDT had conducted evaluation and analysis of the fall assessment and developed new/additional care plan interventions based on post fall assessment results. January 17, 2015- "Witnessed fall in the resident's room." The post fall assessment conducted by OT 1 on January 19, 2015 (2 days after the fall incident) reflected the IDT recommended continued use of sensor alarms/clip alarms in wheelchair and in bed along with educating the resident in safety strategies. There was no documentation in the resident's medical record to indicate the IDT had conducted an evaluation and analysis of the fall assessment and developed new/additional care plan interventions based on post fall assessment results. January 18, 2015- "Witnessed fall while the resident was self transferring in room." (There was no documentation of whether the resident sustained [REDACTED]. There was no documentation in the resident's medical record to indicate the IDT had conducted an evaluation and analysis of the fall assessment and developed new/additional care plan interventions based on post fall assessment results. A review of the "Fall Protocol" and policy and procedure provided by the facility, dated April 2007, indicated when a resident had a fall, staff (such as the IDT) would attempt to define possible causes within 24 hours of the fall which included factors associated with or that directly resulted in a fall (such as if the resident fell in the restroom, a toileting/bowel and bladder assessment would be conducted, a toileting plan developed and implemented). The fall guideline indicated that after more than one fall, the staff and physician would identify pertinent, various relevant interventions based on the (fall) assessment to prevent subsequent falls and until incidents of falls stopped. A review of Resident 11's "Fall Care Plan" dated December 20, 2014 - January 18, 2015, indicated the following interventions and updates to prevent falls: December 20 and 21, 2014- care plan approaches/interventions after 2 incidents of fall on December 20 and 21, 2014 included, to "analyze falls to determine patterns and trends; to keep call light within reach; use of sensor/clip alarms (in bed/chair); verbal reminders to use call light to ask for assistance as needed; place the resident in a supervised area; use concave mattress in bed and floor mats on both sides of the bed; bed in lowest position; medication regimen review (by the pharmacist)." December 24, 2014- fall prevention interventions were to continue current interventions such as the use of floor mats, sensor alarms in bed/chair, and to remind the resident to ask for assistance for transfers. There was no new care plan intervention developed by the IDT based on the post fall assessment after the fall incident on December 24, 2014 2014. December 31, 2014- fall prevention interventions were to continue current interventions such as the use sensor alarms in bed/chair, place the resident in a supervised area, and monitor and remind the resident to ask for assistance for transfers. There was no new care plan intervention developed based on post fall assessments after the fall incidents on December 30 and 31, 2014. January 17, 2015- fall prevention interventions were to continue current interventions such as to encourage the resident to use the call light, verbal reminders to ask for assistance, and close monitoring the resident. There was no new intervention developed based on the post fall assessment after the fall incident on January 17, 2015. January 18, 2015- After multiple incidents of falls, a new care plan intervention was added, to provide toileting every two hours (scheduled toileting) and as needed. There was no written documentation in the resident ' s medical record including the certified nursing assistant (CNA) notes that Resident 11 had been offered and toileted every two hours and as needed. In an interview with CNA 4 on January 29, 2014 at 8:50 AM, she was asked whether Resident 11 had been on a scheduled toileting program such as offering and assisting the resident to the restroom every two hours. CNA 4 stated she had been taking care of Resident 11 and the resident needed extensive assistance with "one person assist" during toileting. CNA 4 stated Resident 11 was not on a scheduled toileting (every 2 hours) and was being taken to the restroom "randomly" (no specific scheduled time). During an interview with the RN MDS/DSD on January 28, 2015 at 2 PM, regarding the facility's policy when a resident had multiple incident of falls, the RN MDS/DSD stated a fall assessment (an assessment used to identify the risks and cause of fall) would be conducted after each fall by the rehabilitation (Rehab) staff (such as the PT and/or the PT), then an interdisciplinary team (IDT) meeting would be conducted to analyze the cause of fall, and the care plan would be updated. The RN MDS/DSD acknowledged the plan of care to prevent further falls was not updated based on fall assessment analysis results such as putting the resident on a scheduled toileting plan and ensuring the plans were being implemented and evaluated for effectiveness. 2. On January 27, 2015 at 6:40 AM, LVN 7 was observed walking out of the Oxygen Storage Room, near Station 3 in the hallway, carrying a portable oxygen cylinder tank under her left arm. LVN 7 was observed entering Room 217. On January 27, 2015 at 6:45 AM, LVN 7 was observed walking out of Room 217, carrying a portable oxygen cylinder tank under her left arm. LVN 7 was observed walking towards the Oxygen Storage Room. During an interview with LVN 7 on January 27, 2015 at 7 AM, when asked how a portable oxygen cylinder tank should be transported safely, LVN 7 stated the way she was to keep the tank upright and to grasp the tank fully with both hands. LVN 7 stated, "They (the facility) didn't have anything to wheel it on." During an interview with the Director of Nurses (DON) and a concurrent review of the facility policy and procedure on January 27, 2015 at 9 AM, the DON stated the standard of practice was the portable oxygen cylinder tank should be "strapped" and wheeled as illustrated in a copy of a printout titled, "Oxygen E Cylinder Storage: Correct vs. Incorrect." DON stated that they have "carts" to wheel the tanks on available in the oxygen storage room. The facility policy and procedure titled, "Oxygen Administration" (Revised October 2010), revealed under Equipment and Supplies, "The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand);..."

Based on observation, interview, and record review, the facility failed to ensure that one of 16 sampled residents (Resident 10), who was admitted to the facility without a pressure ulcer (bedsore-a damage to the skin or tissues caused by prolonged pressure), received timely identification, assessment, and necessary treatment and services, to prevent new sores from developing and worsening. This failure resulted in Resident 10 to develop a Stage 3 (full thickness of the skin is lost) pressure ulcer on the coccyx (tailbone). Findings: A review of the clinical record indicated Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical examination [REDACTED]. A review of the progress notes, dated May 14, 2015 at 3:09 PM, revealed, "Stage III pressure ulcer on coccyx (tailbone) discovered during brief change. Measures 1.0 x 0.5 cm (centimeters), slough (dead tissue) noted in wound bed. Res (resident) is immobile (cannot move by herself) and total dependence (to staff members) of ADLS (activities of daily living), incontinent (loss of bowel or bladder control)..." A review of the "ADMISSION NURSING ASSESSMENT" form, dated October 1, 2009, revealed absence of any pressure sore at the time of the admission. During an interview with the Licensed Vocational Nurse (LVN 1) and a concurrent review of the clinical record on January 29, 2015 at 3:10 PM, LVN 1 confirmed the Stage 3 pressure ulcer on Resident 10's coccyx was not identified until May 14, 2014. During a concurrent review of the Certified Nurse Assistant (CNA's) daily skin assessment forms of Resident 10, from March 2014 to May 2014, LVN 1 confirmed the assessments revealed presence of skin problems on Resident 10's bilateral buttocks and coccyx areas (as encircled) as follows: On March 10, 2014, "Redness." On March 15, 2014, "Redness." On March 19, 2014, "Red." On March 20, 2014, "Redness." On March 26, 2014, "Redness." On March 26, 2014, "red sore on butt." On March 29, 2014, "Redness." On April 2, 2014, "Redness." On April 7, 2014, "Redness." On April 11, 2014, "red bottom applied cream." On April 12, 2014, "Red areas." On April 12, 2014, "Red bottom, I put cream." On April 13, 2014, "Red." On April 16, 2014, "Red." On April 17, 2014, "Sore bottom I applied cream" On April 24, 2014, "red bottom applied cream." On April 24, 2014, "Redness." On April 28, 2014, "Redness." On May 7, 2014, "Redness." On May 8, 2014, "open sore." On May 9, 2014, "duoderm" (a gel dressing used for wounds) on the bilateral buttocks and coccyx areas. On May 9, 2014, "Has a patch between her buttock." On May 10, 2014, "slightly red" on the coccyx area. On May 11, 2014, "dressing on coccyx area; didn't see the wound." On May 12, 2014, "pink bottom and duoderm." During a concurrent interview with LVN 1, she stated she reviewed the CNA's daily skin assessment forms. LVN 1 explained whenever the CNA would document or report any skin problems on the daily skin assessment form, LVN 1 would assess the resident's skin condition to verify accuracy of the CNA's findings and documentation. When asked to show documented evidence to show she reassessed Resident 10's skin condition on the dates which indicated a presence of skin problems for Resident 10, LVN 1 was unable to do so. LVN 1 confirmed the Stage 3 pressure sore on Resident 10's coccyx area was not identified and addressed until May 14, 2014. During an interview with CNA 3 on January 29, 2015 at 4 PM, and a concurrent review of the CNA's daily skin assessment form dated May 9, 2014 (5 days before LVN 1 identified and addressed the Stage 3 pressure ulcer on Resident 10's coccyx on May 14, 2014), CNA 3 confirmed the presence of a patch between Resident 10's buttocks. She stated she was unable to see the "wound" because there was a patch covering it. A review of the physician orders [REDACTED]. A concurrent review with LVN 1 of the facility's policy and procedure titled, "Pressure Ulcer Risk Assessment" (Revised March 2005), revealed under Assessment, "...3. Monitoring: b. Nurses are to be notified to inspect the skin if changes are identified..4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers..."

Based on interview and record review, the facility failed to ensure one of 22 residents who received oxygen therapy using a portable oxygen tank, (Resident 9), received oxygen therapy as ordered, when Resident 9's portable oxygen tank was found to be empty. This failure resulted in Resident 9's oxygen (O2) saturation level (O2 sat-level of oxygen in the blood) to drop to 75% (the goal was to maintain the O2 sat above 88% according to the physician order), and Resident 9 to be lethargic (sluggish), confused with mild facial weakness, and with a high blood pressure (BP) reading. Findings: A review of the clinical record, revealed Resident 9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the progress notes by the Physical Therapist (PT 1), dated January 19, 2015 at 3:32 PM, revealed, "Patient seated in WC (wheelchair), very confused, agreeable to light PT. O2 (oxygen) monitored, 75% due to O2 tank (portable oxygen tank) empty. O2 replaced, spO2 (oxygen level in the blood measure by use of a pulse oximeter) remained mid 80's, BP 188/74 (BP typically 120/80 mmHg - millimeters of mercury; a unit used to measure blood pressure), HR (heart rate per minute) 70, patient lethargic and confused with mild facial weakness noted (noted) on L (left). CN (Charge Nurse) unavailable, therefore alternative nurse assisted with patient assessment. Increased O2 with SPO2 88/89 (88% to 89%) 2 L continuous. Smile equal B (bilateral)...Nursing aware, and CNA's advised to observe patient closely." A review of the physician orders, dated December 3, 2014, revealed an order for [REDACTED]. During an interview with the Registered Nurse (RN)/Director of Staff Development (DSD)/Minimum Data Set (MDS - an assessment tool) Coordinator on January 30, 2015 at 7:05 AM, and a concurrent review of the clinical record, RN/DSD/MDS Coordinator confirmed the facility had no system in place on how to monitor, maintain, and ensure availability of the oxygen delivered to residents through the use of portable oxygen tanks. The RN/DSD/MDS Coordinator stated, "We missed it." During an interview with PT 1 on January 30, 2015 at 8:35 AM, and a concurrent review of the progress notes, PT 1 stated on January 19, 2015 at 3:32 PM, she observed Resident 9 by the south hallway on the wheelchair with the O2 nasal cannula off and the portable oxygen tank was empty. Resident 9's oxygen O2 saturation level was noted to be 75%. Resident 9 was also noted to be lethargic, confused, with mild facial weakness, and with a BP reading. PT 1 stated that Resident 9's charge nurse LVN 3 was with another resident and was unavailable at that time, so she got LVN 4 to assist her. PT 1 took Resident 9 to Station 3 and replaced the portable oxygen tank. There was no specific policy that addressed how the facility should monitor, maintain, and ensure availability of the oxygen to residents who use portable oxygen tanks.

Based on observation, interview, and record review, the facility failed to ensure six of 16 sampled residents (Residents 1, 3, 7, 9, 10 and 13) and one of four unsampled residents (Resident D) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, when: 1. For Resident 10, the facility failed to ensure timely identification, assessment and interventions when Resident 10 was noted to have multiple episodes of of skin redness on the bilateral buttocks and coccyx (tailbone) areas. This failure resulted in Resident 10 developing a Stage 3 (full thickness of the skin is lost) pressure ulcer (skin wound cause by pressure) on the coccyx (tailbone). 2. For Resident 9, there was no documented evidence to show an immediate assessment was conducted by the licensed nurse for one of 22 residents (who received oxygen therapy using a portable oxygen tank) when Resident 9's oxygen saturation level (O2 sat - level of oxygen in the blood), dropped to 75% (the goal was to maintain the O2 sat above 88%), when the portable oxygen tank was found to be empty. This failure had the potential to result in Resident 9 not receiving the appropriate medical interventions and care. 3. For Resident 9, there was no documented evidence of a thorough assessment, monitoring and interventions when Resident 9 verbalized, "I am dying, I want to die." This failure had the potential to result in Resident 9 not receiving the appropriate medical, mental and psychological interventions and care. 4. For Resident 7, the blood glucose testing (a procedure to determine the blood sugars levels) was not performed as ordered. This failure had the potential to negatively affect the Resident 7's health condition. 5. For Resident 13, the [MEDICATION NAME] medication (an anti-anxiety drug used for the management of anxiety) was not administered as ordered. This failure had the potential to negatively affect the Resident 13's health condition. 6. For Resident D, the Alendronate medication (a medication for brittle bones) was not administered as ordered. This failure had the potential to negatively affect the Resident D's health condition. 7. For Resident 1, the facility failed to evaluate and report to the physician the effectiveness of the Resident 1's pain management regimen in a timely manner when the resident continued to express having severe pain and was not getting enough relief from pain despite the administration of prescribed pain medication. This failure resulted in the Resident 1's continued suffering from pain, a decline in the resident's mood, sleep, activities of daily living (ADL- such as eating, grooming and hygiene), and social isolation (such as refusing to participate in facility activities and staying in room most of the time). 8. For Resident 3, facility staff (RN 2) failed to assess and evaluate the resident's pain which resulted in failure to administer prescribed pain medication and appropriate nursing interventions, which placed the Resident 3 at risk for increased intensity of pain and discomfort. Findings: 1. A review of the clinical record indicated Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical examination [REDACTED]. A review of the progress notes, dated May 14, 2015 at 3:09 PM, revealed, "Stage III pressure ulcer on coccyx (tailbone) discovered during brief change. Measures 1.0 x 0.5 cm (centimeters), slough (dead tissue) noted in wound bed. Res (resident) is immobile (cannot move by herself) and total dependence (to staff members) of ADLS (activities of daily living), incontinent (loss of bowel or bladder control)..." A review of the "ADMISSION NURSING ASSESSMENT" form, dated October 1, 2009, revealed absence of any pressure sore at the time of the admission. During an interview with the Licensed Vocational Nurse (LVN 1) and a concurrent review of the clinical record on January 29, 2015 at 3:10 PM, LVN 1 confirmed the Stage 3 pressure ulcer on Resident 10's coccyx was not identified until May 14, 2014. During a concurrent review of the Certified Nurse Assistant (CNA's) daily skin assessment forms of Resident 10, from March 2014 to May 2014, LVN 1 confirmed the assessments revealed presence of skin problems on Resident 10's bilateral buttocks and coccyx areas (as encircled) as follows: On March 10, 2014, "Redness." On March 15, 2014, "Redness." On March 19, 2014, "Red." On March 20, 2014, "Redness." On March 26, 2014, "Redness." On March 26, 2014, "red sore on butt." On March 29, 2014, "Redness." On April 2, 2014, "Redness." On April 7, 2014, "Redness." On April 11, 2014, "red bottom applied cream." On April 12, 2014, "Red areas." On April 12, 2014, "Red bottom, I put cream." On April 13, 2014, "Red." On April 16, 2014, "Red." On April 17, 2014, "Sore bottom I applied cream" On April 24, 2014, "red bottom applied cream." On April 24, 2014, "Redness." On April 28, 2014, "Redness." On May 7, 2014, "Redness." On May 8, 2014, "open sore." On May 9, 2014, "duoderm" (a gel dressing used for wounds) on the bilateral buttocks and coccyx areas. On May 9, 2014, "Has a patch between her buttock." On May 10, 2014, "slightly red" on the coccyx area. On May 11, 2014, "dressing on coccyx area; didn't see the wound." On May 12, 2014, "pink bottom and duoderm." During a concurrent interview with LVN 1, she stated she reviewed the CNA's daily skin assessment forms. LVN 1 explained whenever the CNA would document or report any skin problems on the daily skin assessment form, LVN 1 would assess the resident's skin condition to verify accuracy of the CNA's findings and documentation. When asked to show documented evidence to show she reassessed Resident 10's skin condition on the dates which indicated a presence of skin problems for Resident 10, LVN 1 was unable to do so. LVN 1 confirmed the Stage 3 pressure sore on Resident 10's coccyx area was not identified and addressed until May 14, 2014. During an interview with CNA 3 on January 29, 2015 at 4 PM, and a concurrent review of the CNA's daily skin assessment form dated May 9, 2014 (5 days before LVN 1 identified and addressed the Stage 3 pressure ulcer on Resident 10's coccyx on May 14, 2014), CNA 3 confirmed the presence of a patch between Resident 10's buttocks. She stated she was unable to see the "wound" because there was a patch covering it. A review of the physician orders revealed there was no documented evidence of a physician order for [REDACTED]. A concurrent review with LVN 1 of the facility's policy and procedure titled, "Pressure Ulcer Risk Assessment" (Revised March 2005), revealed under Assessment, "...3. Monitoring: b. Nurses are to be notified to inspect the skin if changes are identified..4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers..." 2. A review of the clinical record revealed Resident 9 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the progress notes by Physical Therapist (PT 1) dated January 19, 2015 at 3:32 PM revealed, "Patient seated in WC (wheelchair), very confused, agreeable to light PT. O2 (oxygen) monitored, 75% due to O2 tank empty. O2 replaced, spO2 (oxygen level in the blood measured by use of a pulse oximeter) remained mid 80's, bp (blood pressure) 188/74 (typically 120/80 mmHg), HR (heart rate per minute) 70, patient lethargic (sluggish) and confused with mild facial weakness ntoed (noted) on L (left). CN (Charge Nurse) unavailable, therefore alternative nurse assisted with patient assessment. Increased O2 with SPO2 88/89 2L continuous. Smile equal B (bilateral)...Nursing aware, and CNA's (Certified Nurse Assistant) advised to observe patient closely." A review of the physician orders, dated December 3, 2014, revealed an order for [REDACTED]. During an interview with the Registered Nurse/Director of Staff Development (DSD)/Minimum Data Set (MDS-an assessment tool) coordinator (RN/DSD/MDS) on January 30, 2015 at 7:05 AM, and a concurrent review of the clinical record, RN/DSD/MDS Coordinator confirmed the facility had no system in place to monitor and ensure delivery of the oxygen to residents who use portable oxygen tanks, in a universe of 22. The RN/DSD/MDS Coordinator stated, "We missed it." During an interview with PT 1 on January 30, 2015 at 8:35 AM, and a concurrent review of the progress notes, PT 1 stated on January 19, 2015 at 3:32 PM, she observed Resident 9 by the south hallway sitting in the wheelchair with the O2 nasal cannula off and the portable oxygen tank was empty. PT 1 stated Resident 9's charge nurse, Licensed Vocational Nurse (LVN 3), was with another resident and was unavailable at that time, so she got LVN 4 to assist her. PT 1 took Resident 9 to Station 3 and replaced the portable oxygen tank. When asked if the physician was notified of the change in Resident 9's condition, PT 1 stated she did not believe the physician should be notified because "she (Resident 9's O2 sat level) came back to 88-89's." PT 1 stated whenever there was a change in the resident's condition, she would notify the nurse who would then call the physician. During an interview with LVN 3 on January 30, 2015 at 11:30 AM, and a concurrent review of the progress notes, dated January 19, 2015 at 3:32 PM, LVN 3 stated he did not know about the change in Resident 9's condition. LVN 3 stated the statement made by PT 1, regarding the charge nurse was "unavailable", was not true because the facility has the "radio" system where they could page/call each other right away. LVN 3 stated if he would have known about it, he would have conducted an assessment, and would have called the physician and made him aware of the change in Resident 9's condition. A review of the facility policy and procedure titled, "Guidelines for Notifying Practitioners of Clinical Problems" (Revised March 2011), revealed, "These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record..." A review of the facility policy and procedure titled, "Pulse Oximetry (Assessing Oxygen Saturation)" (Revised October 2010), revealed under Assessment, "1. Assess the resident for the following signs and symptoms of impaired oxygen saturation: a. altered respirations, difficulty breathing, abnormal breath sounds..." 3. A review of the clinical record, revealed Resident 9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the progress note dated January 13, 2015 at 7:01 PM, revealed, "Extremely groggy, tired, unable to wake up, cannot hold head up, refused breakfast and lunch, also refused morning meds (medications), she took the meds and then spit them onto the floor...No complaint of pain however, she is making bizarre statements, for example, I am dying, I want to die. Will continue to monitor, call light within reach." A review of the care plan, dated January 10, 2014, titled, "Mood State," revealed Resident 9 has alterations in mood/behavior "related to dementia, depression, anxiety... m/b (manifested by) tearfulness, expressions of fear, anger, hopelessness...negative statements, ...verbal/physical aggression..." The "Approach" revealed, "Assess resident's potential for hurting herself and/or suicide PRN (as needed)," by nursing and social service disciplines. During a concurrent interview with the Registered Nurse (RN)/Director of Staff Development (DSD)/Minimum Data Set (MDS-an assessment tool) Coordinator and the Social Service Director (SSD) and a review of the clinical record on January 29, 2015 at 5:15 PM, the RN/DSD/MDS Coordinator stated whenever a resident would verbalize "I am dying, I want to die," the resident would be assessed and monitored. The RN/DSD/MDS Coordinator confirmed there was no documented evidence to show Resident 9 was assessed, reassessed and monitored. During a concurrent interview with the SSD, she stated she never heard Resident 9 verbalize this kind of statement. The SSD stated, "It should have been reported to me." The SSD stated if she would have known about it, she would have assessed Resident 9 for any suicidal thoughts and tendencies. During an interview with the Licensed Vocational Nurse (LVN 2) and a concurrent review of the clinical record on January 29, 2015 at 5:20 PM, she stated Resident 9 had been "consistently tired and groggy" for approximately a month. LVN 2 stated when Resident 9 verbalized, "I am dying, I want to die," the resident (Resident 9) has not verbalized this before; "It's not like she wanted to commit suicide, was my perception." She confirmed there was no documented evidence to show Resident 9 was assessed, reassessed and monitored after verbalizing the statement. A review of the facility policy and procedure titled, "Guidelines for Notifying Practitioners of Clinical Problems" (Revised March 2011), revealed, "These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff is a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record..." 4. A review of the clinical record, revealed Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of Resident 7's physician's order, dated October 14, 2014, indicated "FSBS (finger stick blood sugar) 2 times a week on Monday and Thursday at 6 AM. Notify MD if >200 for diabetes mellitus." During a review of Resident 7's Medication Administration Record [REDACTED]. During an interview with the RN DSD/MDS on January 30, 2015 at 7:30 AM, she confirmed the blood glucose testing for January 1, 2015, January 19, 2015 and January 22, 2015 at 6 AM were not done. She confirmed there is no documentation for the reasons why the blood glucose testing was not done. She stated if the results are not there, It is not done. 5. A review of the clinical record revealed, Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of recapitulation (a summary of the resident's orders) physician order (PO) for January 2015, showed an PO, dated September 3, 2014, for "[MEDICATION NAME] (anti-anxiety medication) 0.5 mg (milligrams) one tablet to be administered three times a day (8 AM, 2 PM, 10 PM) for excessive concerns of going home." A review of Resident 13's Medication Administration Record [REDACTED]. A review of the [MEDICATION NAME] bubble pack (a system that places medication in individual sealed compartments for each dose) with the LVN 9 on January 28, 2015 at 3:30 PM, showed that the dose of [MEDICATION NAME] scheduled for January 9, 2015 at 10 PM was not administered as ordered by the physician. LVN 9 was unable to locate documented evidence to show why the [MEDICATION NAME] was not administered as ordered by the physician. She stated the reason for not administering the medication should have been documented by the licensed nurse. A review of the facility Policy and Procedure titled," Administering Medication," dated April 2010, indicated, "3. Medication must be administered in accordance with the orders, including any required time frame." 6. A review of the clinical record for Resident D indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review physician's orders, dated January 23, 2013, indicated "Alendronate (a medication for treatment of [REDACTED]." A review of Medication Administration Record [REDACTED]. A review of the medication for Resident D was conducted on January 27, 2015 at 9:30 AM, with the Registered Nurse (RN 2) which revealed, a box of 4 doses of the medication Alendronate for the month of January. Three doses were given. There was one dose still available in the box. During a concurrent interview with RN 2 on January 27, 2015 at 9:45 AM, she confirmed one dose of Alendronate medication remained in the medication box and the MAR indicated [REDACTED]. A review of the facility Policy and Procedure titled, "Administering Medication" dated April 2010, indicated, "3. Medication must be administered in accordance with the orders, including any required time frame." 7. On January 27, 2015 at 9 AM, Resident 1 was observed sitting up on a chair receiving oxygen via nasal cannula (N/C- a two pronged plastic tubing that deliver oxygen through the nose). Resident 1 called the attention of the surveyor and wanted to express his concern about not getting enough relief from pain even though he was receiving prescribed pain medication. Resident 1 was alert and oriented to person, time, place and situation (that he was in a nursing home). During an interview with Resident 1 on January 27, 2015 at 9 AM, regarding his pain concern, he stated he continued having severe pain on his neck, back, and legs. He stated, "My pain is terrible, 10 of 10 (10/10- on the pain scale). "Resident 1 stated he had expressed his pain concern with the medication nurses (licensed vocational nurses), and that he still has to wait 1- 2 hours before the next scheduled dose of pain medication, which is every 8 hours, in order to get relief. (Facility Pain scale included: 1-2= least pain; 3-4= mild pain; 5-6= moderate pain; 7-8= severe pain; 9-10= worst pain). On January 27, 2015, a review of Resident 1's medical record indicated the resident was [AGE] years of age, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders for the month of January 2015 included pain medications, such as '[MEDICATION NAME]' (a narcotic (controlled) pain medication) 10-325 milligrams (mg) by mouth (PO) every 8 hours for back pain; [MEDICATION NAME] (a muscle relaxant drug) 10 mg PO twice daily (BID) for left knee pain. The resident's current Minimum Data Set (MDS- a comprehensive resident assessment) dated October 30, 2014 and January 2015, showed Resident 1 had been experiencing frequent pain with a pain intensity level of 6/10 on the pain scale despite being on a pain management regimen (scheduled pain medication). The MDS assessment indicated Resident 1's mood was described as, "feeling down, depressed; trouble falling asleep; and little interest with pleasure on nearly every day." A review of Resident 1's 'Pain Care Plan' dated October 24, 2014, indicated the resident was at risk for pain related to multiple health conditions such as 'Arthritis' (pain and inflammation of the joints); chronic (long standing) pai[DIAGNOSES REDACTED] (combination or group of symptoms); low back disorders; headaches; chronic leg cramps/muscle spasms; [MEDICAL CONDITION] (a disease affecting the nerves); and [MEDICAL CONDITION] (a disease characterized by long standing and widespread pain). Care plan interventions included to observe signs and symptoms of discomfort, evaluate the degree/severity of the resident's pain, and to report changes in pain pattern to the physician as needed. A review of the nurses observation notes and weekly progress notes (WPN) dated January 3- 22, 2015, showed Resident 1 had expressed his concern of not getting enough pain relief. The nurses observation notes included the following: January 3, 2015- Resident had requested ten times (10 x) last week for breakthrough pain. The nurses 'Weekly Progress Notes' dated January 9, 2015 documented, "Has [MEDICATION NAME] BID for left knee pain. Requested '[MEDICATION NAME]' 10 x last week for breakthrough pain with positive effect." There was no documentation to show the resident's pain management regimen had been evaluated for effectiveness when the resident continued to complain of pain despite the administration of scheduled pain medication and for breakthrough pain. January 9, 2015- Resident complained of left knee pain at 10/10 (on pain scale). Resident had requested '[MEDICATION NAME]' 12 times (12 x) last week for breakthrough pain (complain of pain between or prior to scheduled pain medication). The nurses 'Weekly Progress Notes' dated January 9, 2015, indicated Resident 1 was medicated 12 x for breakthrough pain of 6-10/10 (moderate to worst pain). There was no documentation to show the resident's pain management regimen had been evaluated for effectiveness even though the resident had continued having moderate to severe pain. On January 22, 2015- Resident refused (respiratory) assessment. On oxygen (O2) at 2 liters N/C. When (Resident 1) asked about pain, (the resident stated) 'Yes, I'm in pain all the time, 10/10' (worst pain on pain scale). The nurses 'Weekly Progress Notes' dated January 21, 2015, indicated there was no documentation to show Resident 1's pain management regimen had been evaluated for effectiveness even though the resident had expressed he continued to have severe/worst pain. There was no documentation to show staff had discussed significant changes in the resident's mood (including refusing respiratory assessment, social isolation (staying in his room most of the time), pattern and levels of pain/comfort (such as persistent pain) with the attending physician in order that adjustment of treatment and interventions would be considered accordingly. In an interview with the Registered Nurse (RN) Minimum Data Set Coordinator/Director of Staff Development (MDS/DDS) on January 28, 2015 at 10:15 AM, she was asked whether Resident 1's pain management regimen had been evaluated and discussed with the physician when the resident continued to complain of persistent pain. The RN MDS/DDS reviewed Resident 1's medical record and acknowledged Resident 1 continued to complain of persistent pain and had asked the staff RN for medication for breakthrough pain 10- 12 times every week. The RN MDS/DDS was unable to find documentation to show the resident's pain management regimen had been evaluated for its effectiveness and that significant changes in levels of the resident's chronic and persistent pain had been discussed with the physician. A review of the facility's "Pain Clinical Protocol", dated October 2010, indicated the (facility) staff would evaluate and report to the physician how much and how often the resident asked for PRN (as needed) pain medication; reassess the resident's pain and related consequences at least each shift for significant changes in levels of chronic pain; and staff would discuss significant changes in levels of comfort with the attending physician who would consider adjusting interventions accordingly. 8. During a medication pass observation on January 27, 2015 at 12:10 PM, RN 2 prepared the medications for Resident 3, scheduled for 12 noon, then administered the medications by mouth to Resident 3. After administering the medications, RN 2 asked Resident 3 if he had pain and at what level was the pain. Resident 3 stated his pain was 5 of 10 (moderate pain on pain scale). RN 2 immediately returned to the medication cart in the hallway and proceeded to prepare and administer other residents' medications. RN 2 did not conduct an assessment and evaluation of Resident 3's pain, such as asking about how the pain was affecting the resident (including activities of daily living (ADL) and/or the resident's mood), the location of pain, what was causing the pain, and whether the resident needed pain medication. Resident 3's current MDS (a comprehensive resident assessment), dated January 19, 2015, indicated Resident 3 was receiving scheduled and PRN (as needed) pain medication. The assessment indicated Resident 3 had frequent left hip and low back pain with a pain intensity of 7/10 (severe pain). A review of Resident 3's medical record on January 27- 29, 2015, indicated the resident was [AGE] years of age, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders for the month of January 2015 included, '[MEDICATION NAME]' (a narcotic (controlled) drug used to relieve/control moderate to severe pain) 10-325 milligrams (mg) by mouth (PO) every 4 hours as needed (PRN) for left hip pain of 5-10/10 (on pain scale) and Tylenol 325 mg, 2 tablets PO every 4 hours PRN for left hip pain of 1-4/10. The Medication Administration Record [REDACTED]. There was no written documentation in Resident 3's medical record to indicate RN 2 had assessed and evaluated the resident's pain to determine how the pain was affecting the resident and whether the resident needed medication to relieve his pain. In an interview with RN 2 on January 27, 2015 at 1:15 PM, RN 2 was asked why an evaluation of the resident's pain (level of 5/10) was not conducted to determine how the pain was affecting the resident, and whether or not the resident needed medication to relieve his pain. RN 2 did not give an answer. A review of the facility's "Pain Clinical Protocol" dated October 2010, indicated the (facility) staff would evaluate and reassess the resident's pain and related consequences at least each shift. And, depending on the severity and location of the pain, PRN doses of pain medications would be administered.

Based on interview and record review, the facility failed to follow its policy and procedure when there was no documented evidence to show the physician was notified of a change in two of 16 sampled residents (Resident 9 and 10), when: 1. Resident 9's oxygen (O2) saturation level (O2 sat-level of oxygen in the blood) dropped to 75% (the goal was to maintain the O2 sat above 88% according to the physician order), the portable oxygen tank was found to be empty, and Resident 9 experienced life-threatening complications. This failure had the potential to result in Resident 9 not receiving the appropriate medical interventions and care. 2. Resident 9 verbalized, "I am dying, I want to die." This failure had the potential result in Resident 9 not receiving the appropriate medical, mental and psychological interventions and care. 3. Resident 10, was noted to have multiple areas of skin redness on the bilateral buttocks and coccyx (tailbone) areas increased the potential for the development of a Stage 3 (full thickness of the skin is lost) pressure ulcer (skin wound cause by pressure) on the coccyx (tailbone). This failure resulted in a delay in the provision of appropriate care and interventions. Findings: 1. A review of the clinical record, revealed Resident 9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the progress notes by the Physical Therapist (PT 1), dated January 19, 2015 at 3:32 PM, revealed, "Patient seated in WC (wheelchair), very confused, agreeable to light PT. O2 (oxygen) monitored, 75% due to O2 tank empty. O2 replaced, SPO2 remained mid 80's, BP (blood pressure) 188/74 (typically 120/80 mmHg), HR (heart rate per minute) 70, patient lethargic (sluggish) and confused with mild facial weakness noted (noted) on L (left). CN (Charge Nurse) unavailable, therefore alternative nurse assisted with patient assessment. Increased O2 with SPO2 (oxygen level in the blood pressure by use of a pulse oximeter) 88/89 2 L continuous. Smile equal B (bilateral)...Nursing aware, and CNA's advised to observe patient closely." A review of the physician orders, dated December 3, 2014, revealed an order for [REDACTED]. During an interview with PT 1 on January 30, 2015 at 8:35 AM, and a concurrent review of the progress notes, PT 1 stated on January 19, 2015 at 3:32 PM, she observed Resident 9 by the south hallway in the wheelchair with the O2 nasal cannula off and the portable oxygen tank was empty. PT 1 stated Resident 9's charge nurse, Licensed Vocational Nurse (LVN 3), was with another resident and was unavailable at that time, so she got LVN 4 to assist her. PT 1 took Resident 9 to Station 3 and replaced the portable oxygen tank. When asked if the physician was notified of the change in Resident 9's condition, PT 1 stated she did not believe the physician should be notified because Resident 9's "O2 (sat level) came back to 88-89's." PT 1 stated whenever there was a change in the resident's condition, she would notify the nurse who would then call the physician. During an interview with LVN 3 on January 30, 2015 at 11:30 AM, and a concurrent review of the progress notes, dated January 19, 2015 at 3:32 PM, LVN 3 stated he did not know about the change in Resident 9's condition. LVN 3 stated the statement the charge nurse was "unavailable" was not true because the facility had the "radio" system which enabled the staff members to page/call each other right away. LVN 3 stated if he would have known about Resident 9's condition, he would have conducted an assessment, and would have called the physician and made him aware of the change in Resident 9's condition. During a review of the facility policy and procedure titled, "Pulse Oximetry (Assessing Oxygen Saturation)," (Revised October 2010), revealed under general guidelines, "...2. Normally SpO2 is between 90 and 100 percent; SpO2 below 70 percent is life threatening..." Under "Steps in the Procedure," it revealed, "...11. If SpO2 is less that (than) 90%:...b. If Sa O2 is less than acceptable level for resident's condition, notify the physician..." A review of the facility policy and procedure titled, "Change in a Resident's Condition or Status," (Revised April 2007), revealed under policy interpretation and implementation, "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status..." 2. A review of the clinical record revealed, Resident 9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician order, dated December 3, 2015, revealed an order for [REDACTED]. A review of the progress note, dated January 13, 2015 at 7:01 PM, revealed, "Extremely groggy, tired, unable to wake up, cannot hold head up, refused breakfast and lunch, also refused morning meds (medications), she took the meds and then spit them onto the floor...No complaint of pain however, she is making bizarre statements, for example, I am dying, I want to die. Will continue to monitor, call light within reach." There was no documented evidence the physician was notified of the resident's condition. During a concurrent interview with the Registered Nurse (RN)/Director of Staff Development (DSD)/Minimum Data Set (MDS-an assessment tool) Coordinator, and the Social Service Director (SSD) and a concurrent review of the clinical record on January 29, 2015 at 5:15 PM, the RN/DSD/MDS Coordinator stated whenever a resident would verbalize "I am dying, I want to die," the SSD, the physician, and the responsible party would be notified immediately. The resident would be assessed and monitored. The RN/DSD/MDS Coordinator confirmed there was no documented evidence to show the physician was notified of Resident 9's condition. During a concurrent interview with the SSD, she stated she never heard Resident 9 verbalize this kind of statement and that it was never reported to her; "It should have been reported to me." SSD stated if she would have known about it, she would have assessed Resident 9 for any suicidal thoughts and tendencies. During an interview with the Licensed Vocational Nurse (LVN 2) and a concurrent review of the clinical record on January 29, 2015 at 5:20 PM, she stated Resident 9 had been "consistently tired and groggy" for approximately a month. LVN 2 stated when Resident 9 verbalized, "I am dying, I want to die," LVN 2 stated Resident 9 had not verbalized this before; "It's not like she wanted to commit suicide, was my perception." She confirmed she did not notify the physician and the SSD about Resident 9's statements. A review of the facility policy and procedure titled, "Change in a Resident's Condition or Status" (Revised April 2007), revealed under policy interpretation and implementation, "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status..." 3. A review of the clinical record indicated Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical examination [REDACTED]. A review of the progress notes, dated May 14, 2015 at 3:09 PM, revealed, "Stage III pressure ulcer (Stage 3 - full thickness of the skin is lost) on coccyx (tailbone) discovered during brief change. Measures 1.0 x 0.5 cm (centimeters), slough (dead tissue) noted in wound bed. Res (resident) is immobile (cannot move by herself) and total dependence (to staff members) of ADLS (activities of daily living), incontinent (loss of bowel or bladder control)..." A review of the "ADMISSION NURSING ASSESSMENT" form dated October 1, 2009, revealed absence of any pressure sore at the time of the admission. During an interview with the Licensed Vocational Nurse (LVN 1) and a concurrent review of the clinical record on January 29, 2015 at 3:10 PM, LVN 1 confirmed the Stage 3 pressure ulcer on Resident 10's coccyx was not identified until May 14, 2014. During a concurrent review of the Certified Nurse Assistant (CNA's) daily skin assessment forms of Resident 10, from March 2014 to May 2014, LVN 1 confirmed the assessments revealed presence of skin problems on Resident 10's bilateral buttocks and coccyx areas (as encircled) as follows: On March 10, 2014, "Redness." On March 15, 2014, "Redness." On March 19, 2014, "Red." On March 20, 2014, "Redness." On March 26, 2014, "Redness." On March 26, 2014, "red sore on butt." On March 29, 2014, "Redness." On April 2, 2014, "Redness." On April 7, 2014, "Redness." On April 11, 2014, "red bottom applied cream." On April 12, 2014, "Red areas." On April 12, 2014, "Red bottom, I put cream." On April 13, 2014, "Red." On April 16, 2014, "Red." On April 17, 2014, "Sore bottom I applied cream" On April 24, 2014, "red bottom applied cream." On April 24, 2014, "Redness." On April 28, 2014, "Redness." On May 7, 2014, "Redness." On May 8, 2014, "open sore." On May 9, 2014, "duoderm" (a gel dressing used for wounds) on the bilateral buttocks and coccyx areas. On May 9, 2014, "Has a patch between her buttock." On May 10, 2014, "slightly red" on the coccyx area. On May 11, 2014, "dressing on coccyx area; didn't see the wound." On May 12, 2014, "pink bottom and duoderm." During a concurrent interview with LVN 1, she stated she reviewed the CNA's daily skin assessment forms. LVN 1 explained that whenever the CNA would document or report any skin problems on the daily skin assessment form, LVN 1 would assess the resident's skin condition to verify the accuracy of the CNA's findings and documentation. When asked to show documented evidence that she reassessed Resident 10's skin condition on the dates which indicated presence of skin problems on Resident 10, and that the physician was notified, LVN 1 was unable to do so. LVN 1 confirmed the Stage 3 pressure sore on Resident 10's coccyx area was not identified and addressed until May 14, 2014. During an interview with CNA 3 on January 29, 2015 at 4 PM, and a concurrent review of the CNA's daily skin assessment form dated May 9, 2014, which was 5 days before LVN 1 identified and addressed the Stage 3 pressure ulcer on Resident 10's coccyx on May 14, 2014, CNA 3 confirmed the presence of a patch between Resident 10's buttocks. She stated she was unable to see the "wound" because there was a patch covering it. A review of the physician orders revealed there was no documented evidence of a physician order for [REDACTED]. A review of the facility policy and procedure titled, "Change in a Resident's Condition or Status" (Revised April 2007), revealed under policy interpretation and implementation, "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status..."

Based on observation, interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1) an injury of unknown origin was investigated in a timely manner when the resident complained of shoulder pain. This failure resulted in the delay of medical treatment and continued complaints of pain for Resident 1 and had the potential for Resident 1 to develop medical complications [REDACTED]. Findings: During a review of Resident 1's clinical record the face sheet (part of the record that includes identifying resident information) indicated the Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation on October 13, 2014 at 2:30 PM, Resident 1 was observed in bed sleeping with a sling (device used to support and immobilize a body part) to the left shoulder. During review of the nurses progress notes, indicated the following nurse entries: a. September 7, 2014 at 9:50 PM; "Resident reports pain, in left arm and back. Resident is scheduled for pain medication at 12 AM." b. September 8, 2014 at 11:25 PM; "Resident complained of pain in her left shoulder. Shoulder appeared swollen. Resident voiced concern that it may be dislocated. When asked what happened, resident had difficulty remembering. No external redness noted at this time. ROM (range of motion-the extent a joint can move without pain and little effort) severely diminished. MD (medical doctor) notified and a one time order of [MEDICATION NAME] (a drug used to treat moderate to severe pain) 500 mg (milligram) was ordered." c. September 9, 2014 at 7:15 AM; "Left shoulder pain. Resident has pain to left shoulder at this time. Area involved is anterior (front) left shoulder. Area has redness. Can extend (move body part away from body) and flex (move body part closer to body) extremity to only shoulder height. MD notified. No new orders." d. September 9, 2014 at 11:23 AM; "Resident still complains of pain to the left shoulder and rates it at 4/10 (moderate pain per the pain scale). There was no indication the MD was notified. e. September 10, 2014 at 10:58 AM; "Resident found lying in bed. It was noted that resident has extensive bruising to left chest wall, breast, and under arm. Swelling noted above left breast. MD notified, order for X-ray. CNA (certified nurses assistant) reported resident had a fall on September 7, 2014. f. September 10, 2014 at 12:41 PM; "X-ray results reported from ER (emergency room ) that resident has anterior shoulder fracture." During review of the skin assessment sheets (reports completed by CNA's which document condition of resident skin such as bruising, discoloration or skin tears), dated September 6, 2014 through September 10, 2014, indicated there was no documentation in the reports to show the resident had a discolored or bruised left shoulder. During a review of an event report, dated September 11, 2014, the DON (Director of Nursing) documented the following: "It was reported today that this resident had bruising around the left shoulder under her axilla area surrounding the ribs, and a small bruise noted to her right jaw. Resident cannot remember that she fell , however, though the investigation it was reported that she possibly fell on [DATE]." During an interview with Licensed Vocational Nurse (LVN) 1 on October 13, 2014 at 4:05 PM, regarding her documentation dated, September 10, 2014, she stated she was shocked when she saw the bruising to Resident 1's shoulder, breast and underneath the axilla area and stated it was hard to forget a bruise like that because "it was quite extensive." During further interview with LVN 1, she stated she was told by the CNA (CNA 1) who was in Resident 1's room at the time she assessed the injury, that the resident was found on the bathroom floor on Sunday (September 7, 2014). LVN 1 stated that she documented that the resident fell , because that is what she was told by CNA 1. During an interview with CNA 1 on October 14, 2014, at 10:00 AM, CNA 1 stated she had assisted Resident 1 with a shower on September 7, 2014, and noticed the residents left shoulder and chest wall was purple and the resident had complained of pain. During further interview with CNA 1, she stated she didn't report the bruising and discoloration to nursing staff or to anyone, but did tell Resident 1's nurse that the resident had complained of pain to the area. During an interview with the MDS (minimum data set-a comprehensive assessment) nurse on October 14, 2014 at 10:30 AM, she stated the DON is the person responsible for investigating injuries of unknown origin, and the investigation was not complete and there had been no determination of what caused Resident 1's injury. During further interview with the MDS nurse she verified there had been a three day lapse between the time that Resident 1 had first complained of shoulder and back pain and when CNA 1 had observed the residents bruised and discolored left shoulder and chest wall before Resident 1 was sent to the ER and was diagnosed with [REDACTED]. The MDS nurse further stated there had been a change of administrative staff at or around the time Resident 1 had sustained the shoulder injury and confirmed the investigation regarding the injury was not complete and stated, "It should have been and it's unfortunate." During a review of the facility's policy and procedure titled, "investigating Unexplained Injuries," Revised March, 2013, the policy indicated the following: "Investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by the director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has been jeopardized." "Section 1: Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty or designee will record such information into the resident's clinical record." "Section 2: Injury of unknown source is defines as an injury that meets both of the following conditions:" a. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. the injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one particular point in time; or the incidence of injuries." "Section 3: Any description in the medical record shall be objective and sufficiently detailed (e.g., size and location of bruises), and should not speculate about causes." "Section 4: The nursing staff shall discuss the situation with the Attending Physician or Medical Director to consider whether medical conditions or other risk factors could account for the findings. The Medical Director or Attending Physician shall review and verify conclusions about the possibility of a medical or other similar cause of the findings." "Section 5: With the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours."

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was provided the necessary care and services, when the care plan interventions and physician's order were not implemented. This failure delayed medical interventions and treatment for [REDACTED]. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Nurses Progress Notes indicated Resident 1's condition as follows: On [DATE], at 3:01 PM," Resident was having difficulty swallowing AM meds (medications) and all meals. Could benefit from Speech Therapy." Further review of the clinical record showed no communication to the physician regarding the resident had problem swallowing her medication and meals. On [DATE] at 9:38 PM, Resident continues to have difficulty swallowing meds. In the nurse's note, Licensed Vocational Nurse (LVN) 1 documented "Resident 1 coughing this shift with med pass." Further review of the clinical record, showed there was no communication to the physician regarding the resident's episodes of coughing and problem with swallowing her medications. During an interview with Certified Nursing Assistant (CNA) 1, on [DATE] at 9:34 AM, she stated she was in Resident 1's room on [DATE], helping Resident 2 in "B" bed. She stated Licensed Vocational Nurse (LVN) 1 was in the room administering medication to Resident 1. CNA 1 heard LVN 1 shouting at Resident 1, "Swallow it, swallow it, swallow it..." CNA 1 then heard LVN 1 calling out for help. CNA 1 said, "I helped LVN 1 and observed Resident 1 lying flat in bed and choking." CNA 1 stated she helped LVN 1 pull Resident 1 up in bed. CNA 1 stated LVN 2 and Registered Nurse (RN) 1 walked in to Resident 1's room to assist. CNA 1 observed LVN 2 push the button to raise the head of the bed and RN 1 suctioned the resident through the mouth but it was unsuccessful. CNA 1 stated she heard RN 1 say, "I can't get it down." CNA 1 then saw LVN 1 grab the suction tube and "start shoving it down her (Resident 1's) throat." After 5 - 10 minutes, RN 1 told LVN 1 to ("stop suctioning, that's enough"). LVN 1 told us (CNA 1 and CNA 2) to leave the room. RN 1 then told LVN 1 to get the oxygen and to put it on Resident 1. CNA 1 went back to the resident's room to care for Resident 2 and noted Resident 1 "sounded like a lot of fluids were in her lungs." A review of the care plan "Risk for aspiration", dated [DATE], documented interventions which included, "Puree diet...Position upright in bed..." During an interview with LVN 1 and the Director of Nursing (DON) on [DATE] at 5:15 PM, LVN 1 stated, on [DATE] at 3:00 AM, she administered the [MEDICATION NAME] tablet to Resident 1. Resident 1 began to choke, became cyanotic, and was unable to breathe. LVN 1 mentioned CNA 1 helped to reposition Resident 1 to an upright position in the bed. LVN 1 stated "So, I called {name RN 1} to suction, and thick yellow phlegm (a slippery secretion that is coughed up from the lower airways) was observed. LVN 1 noted Resident 1's lung sounds with wheezes, and stated she endorsed to the AM shift licensed staff to hold all medications until Resident 1 was reevaluated by Speech therapy. LVN 1 stated she gave Resident 1, one [MEDICATION NAME] tablet and did not crush the medication. She acknowledged the [MEDICATION NAME] tablet was a large tablet and was very difficult to swallow for a resident with a [DIAGNOSES REDACTED]. The DON stated,"She had swallowing concerns..." A review of the nurse's note dated [DATE] at 3 AM, LVN 1 documented Resident 1's lungs "sounds wheezes...Will endorse to AM shift to hold all meds..." A review of the nurse's note dated [DATE] at 11:52 AM, documented Resident 1 "Having difficulty swallowing meds...AM meds held." A review of the nurse's note dated [DATE] at 1:59 PM, documented Resident 1 "Has had a decline in swallowing. She isn't drinking or eating anything...Lungs bilat (bilateral/both side) have noted ronchi (Ronchi/crackles is a coarse, rattling, respiratory sound somewhat like snoring, usually caused by secretion), temp (temperature) 100 (elevated temp/ fever) and sats (saturation- a measure of how much oxygen the blood ) 82 % (signs of difficulty breathing-Normal blood oxygen levels in humans are considered ,[DATE] percent)..." A review of the nurse's note dated [DATE] at 3:07 PM, documented "Received new order for [MEDICATION NAME] (antibiotic)...for possible aspiration pneumonia (Lung infection)...Sats down to 80's..." A review of the physician's orders dated [DATE], showed the following: "[MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligram) orally every 6 hours for pain management, puree diet (a general term for cooked food, usually vegetables or beans that have been ground, pressed, blended and/ sifted, or thickened with starch to the consistency of a soft creamy paste or thick liquid), and may crush allowable medication and put in apple sauce." During a review of the clinical record on [DATE], there was no documentation to show the physician was notified promptly when Resident 1 had a significant change of condition on [DATE] at 3:00 AM. Review of the clinical record showed the physician was contacted late on [DATE] at 1:59 PM by the DON, 11 hours after the significant change of condition was identified by LVN 1 and RN 1. Resident 1's condition continued to deteriorate and worsen. At 5:30 PM on [DATE], Resident 1 was found pulseless, unresponsive and expired. During a phone interview with LVN 1 on [DATE] at 5:25 PM, she stated Resident 1's swallowing problem had deteriorated prior to the incident on [DATE]. On [DATE] when she observed Resident 1 had an episode of choking while swallowing the medication, experienced difficulty breathing and became cyanotic, she did not notify the physician. She also acknowledged Resident 1 continued experiencing difficulty breathing, unable to swallowing medications/meals and ronchi in the lungs, "It was my mistake for not calling the doctor, the doctor should always be notified as soon as possible when there is a change of condition in the residents." LVN 1 acknowledged Resident 1 required a puree diet. She stated Resident 1 was at risk for aspiration and the [MEDICATION NAME] tablet was "Large tablet, it should have been crushed for safe swallow." A review of the facility policy and procedure, titled, "Administering Medications", dated [DATE], indicated, "Medications shall be administered in a safe ...and as prescribed...Medications must be administered in accordance with the orders..."

Based on interview and record review, the facility failed to notify the physician of a significant change of condition for 1 of 3 sampled residents (Resident 1), when the resident experienced an episode of inability to breathe, became cyanotic (the appearance of a blue or purple discoloration of the skin due to the tissues near the skin surface having low oxygen saturation), and experienced choking that required suctioning while swallowing a large medication tablet (pill) orally. This failure resulted in a delay of medical treatment when the significant change of condition was not reported to the physician promptly which resulted in further complications of the resident's condition and her death. Finding: During an interview with Certified Nursing Assistant (CNA) 1, on August 21, 2014 at 9:34 AM, she stated that she was in the resident's room on May 1, 2014, helping Resident 2 in "B" bed. Licensed Vocational Nurse (LVN) 1 was in the room administering medication to Resident 1. CNA 1 heard LVN 1 shouting at Resident 1 "Swallow it, swallow it, swallow it..." Then CNA 1 heard LVN 1 calling out for help. CNA 1 went in to help LVN 1 and observed Resident 1 laying flat in bed and choking. CNA 1 stated that she helped LVN 1 pull the resident up in bed. Then LVN 2 and Registered Nurse (RN) 1 walked in to the resident's room to assist. CNA 1 observed LVN 2 push the button to raise the head of the bed and RN 1 suctioned the resident through the mouth but it was unsuccessful. CNA 1 stated that she heard RN 1 say, "I can't get it down." Then CNA 1 saw LVN 1 grab the suction tube and "started shoving it down her (Resident 1) throat." After approximately 5 - 10 minutes, RN 1 told LVN 1 to ("stop suctioning, that's enough"). LVN 1 then told us (CNA 1 and CNA 2) to leave the room. RN 1 then told LVN 1 to get the oxygen to put it on the resident. CNA 1 went back to the resident's room to care for Resident 2 and noted that Resident 1 "sounded like a lot of fluids were in her lungs." A review of Resident 1's clinical record indicated that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders showed the following: "[MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligram) orally every 6 hours (9 PM, 3 AM, 9 AM, 3 PM) for pain management, puree diet, and may crush allowable medication and put in apple sauce." During an interview with LVN 1 and the Director of Nursing (DON) on August 18, 2014 at 5:15 PM, LVN 1 stated, on May 1, 2014 at 3:00 AM, she administered the [MEDICATION NAME] tablet to Resident 1. Resident 1 began to choke, became cyanotic and was unable to breathe. LVN 1 stated "So, I called {name RN 1} to suction. She also stated that she gave Resident 1, one whole large tablet and did not crush the medication. She acknowledged that the [MEDICATION NAME] tablet was a large tablet and was very difficult to swallow for a resident with a [DIAGNOSES REDACTED]. In a concurrent interview the DON stated, "She ( Resident 1) would not take her medications crushed. She would only take them whole. She had swallowing concerns." A review of the care plan for "Risk for aspiration", dated April 2, 2014 documented interventions which included "Puree diet...Position upright in bed..." A review of the clinical record on August 19, 2014, reflected there was no documentation to show that the physician was notified promptly when Resident 1 had a significant change of condition on May 1, 2014 at 3:00 AM. Review of the clinical record showed that the physician was contacted late on May 1, 2014 at 1:59 PM by the DON, 11 hours after the significant change of condition episode of choking identified by LVN 1 and RN 1. On May 1, 2013 at 3:07 PM, Resident 1 was treated with antibiotic for possible aspiration pneumonia. Then at 5:30 PM Resident 1 then was found pulseless and unresponsive. During a phone interview with LVN 1 on September 17, 2014 at 5:25 PM, she stated on May 1, 2014 when she observed Resident 1 choking while swallowing the medication, was unable to breathe and became cyanotic, she did not notify the physician. "It was my mistake for not calling the doctor, the doctor should always be notified as soon as possible when there is a change of condition on the residents." A review of the facility policy and procedure for "Change in a Resident's Condition or Status", dated April 2011 indicated "Our facility shall promptly notify ...his or her Attending Physician,...of changes in the resident's medical/...and /or status..."

Based on observation, interview and record review, the facility failed to ensure that 1 of 16 sampled residents (Resident 5) received the necessary treatment and services to promote healing and to prevent a pressure sore (area of skin damage resulting from a lack of blood flow due to pressure) from worsening by not following their policy and procedure for assessing and treating pressure wounds. Resident 5 developed a Stage I (the standard system of measurement, Stage I to Stage IV is used to define the degree and extent of tissue damage of a pressure sore with Stage I being the mildest and Stage IV being the most severe) which deteriorated to a Stage IV. The failure to provide adequate treatment to promote healing, resulted in the pressure sore changing from a mild reddened area of the skin, to a deep tunneling into the tissue layers producing pain to the resident, requiring debridement (the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) and wound treatment involving cleaning and re-dressing the wound, which can be pain-inducing, from 1/30/11 to 5/12/11. Findings: A record review, conducted on 5/09/11, reflected that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the "Nurses' Progress Notes," dated 12/09/10 and 1/20/11, reflected under the "skin condition" sections, "skin: intact " (which means no skin sores or breakdown). A review of a physician's orders [REDACTED]." A review of the nurses' notes from 1/21/11 to 2/16/11 identified that there was only one nurses' note entry that reflected the status of the reddened area to the left hip. A nurses' note, dated 1/23/11 at 2230 identified that, "Resident has silver dollar size reddened area over joint of (L) hip." A review of the "wound/skin healing record" reflected that Resident 5 had a wound assessment done by the treatment nurse, RN 1, dated 1/31/11, which documented a "Stage I" wound on the left hip measuring 3 x 3 centimeters (cm, length and width) and less than 0.1 cm deep. A review of a physician's orders [REDACTED]." The next wound assessment by RN 1 was dated 2/09/11 and documented the wound as Stage I and being 4 x 3 centimeters and less than 0.1 cm deep. The next wound assessment documented by RN 1 was on 2/16/11. RN 1 documented the wound as being Stage IV, measuring 4.5 x 4 cm with an unknown depth. A review of a nurses' note dated 2/16/11 at 1315 documented, "(L) hip new tx (treatment) ordered and (L) hip darkened 2 - 3 cm x 4 cm Stage 4 pressure area." A care plan (a standard form used by health care facilities to diagnose a patient's health problem, set goals to resolve the problem and document approaches and interventions to achieve the goals) dated 1/06/2009 showed, "Potential for skin breakdown" as a problem for Resident 5. The care plan further identified the potential for skin breakdown was "R/T (related to) decreased mobility and incontinence (involuntary leakage of urine)". A written entry, dated "02/11" was added to the care plan, and reflected, "Has Stage I ulcer (pressure) on (L) hip." The intervention that was added to address the stage 1 pressure ulcer identified, "monitor skin breakdown often" . An interview was conducted with treatment nurse, RN 2, on 5/10/11 at approximately 9:15 AM. RN 2 was asked about Resident 5's pressure ulcer. RN 2 stated she was relatively new to her position and was unable to give complete information about the origin of Resident 5's pressure ulcer and how it had progressed from Stage I to Stage IV in such a short period of time. RN 2 stated, "All that happened when the last treatment nurse was here." RN 2 stated that the prior treatment nurse no longer worked at the facility. On 5/10/11 at 10:20 AM, the Director of Nurses (DON) was interviewed in the conference room. The DON stated it was discovered that the previous treatment nurse had not assessed or appropriately treated Resident 5's pressure ulcer. The DON continued to state that the pressure ulcer had been reported by the Certified Nursing Assistant (CNA) and that the treatment nurse had been terminated because of the incident. On 5/10/11 at 11:05 AM, an interview was conducted with the facility administrator and the DON. The DON stated that RN 1 had assessed the wound at Stage I. The DON stated that the treatment nurse then covered the wound with a [MEDICATION NAME] and documented, "observe x 14 days." The DON further stated that the treatment nurse had charted in the medical chart that a pressure relieving cushion had been placed on Resident 5's bed when it had actually not been done. An interview with Resident 5 was conducted on 5/11/11 at 8:50 AM. Resident 5 was asked about the (L) hip wound. The resident stated that, "It was getting better and it did not hurt as much now as it used to." Resident 5 gave permission for observation of the wound dressing change. An interview was conducted with CNA 1 on 5/11/11 at 9:00 AM. CNA 1 stated that it was reported to the treatment nurse when the wound was a pink area and then reported it when it appeared to be reddening and worsening. CNA 1 stated, "It was reported several times." On 5/11/11 at 9:15 AM, the dressing change to Resident 5's (L) hip wound was observed. The wound was approximately 0.8 cm x 0.6 cm by 0.8 cm deep. The tissue inside the wound was pink, the surrounding tissue was brown. On 5/11/11 at 9:30 AM, an interview was conducted with CNA 2. CNA 2 stated when she first observed the wound on Resident 5's (L) hip it was a small pink area. CNA 2 stated that, "It then turned red and was protruding." CNA 2 stated that, "It was reported several times to nurses and to the DON." CNA 2 further stated that," The DON gave an order to turn the patient and to observe the wound." On 5/11/11 at 3:55 PM, a record review of RN 1's employee file was conducted. A State of California Employment Development Department form "1101 C/Z/" in the employee file, signed by the administrator, dated 3/01/11 documented, "Employee documented that an intervention was in place that was not, contributing to a patient's condition to worsen." RN 1 was terminated 2/17/11. A record review of the facility's policy titled, "Management of Skin Impairment", dated 2/10/10, was conducted on 5/11/11. The "Practice Guidelines" of the policy included, "3. Appropriate preventive surfaces will be implemented on those residents identified at risk." The policy further identified that, "Residents identified with skin impairment will have: 2. Appropriate interventions implemented to promote healing. 3. physician's orders [REDACTED]. a. Type of wound b. Wound location and characteristics c. Description of wound appearance d. Type of dressing e. Frequency of dressing change f. Duration of order up to a maximum of 14 days The impairment will be evaluated by the treatment nurse within 72 hours for order clarification and wound classification."