Every finding on record at Chaparral House

Based on interview and record review the facility failed to provide proper notice for discharge for four of four sampled residents (Resident 2, 3, 4, and 5) when:Resident 2 received a Notice of Proposed Transfer and Discharge (NPTD, a document given by the facility to the resident indicating an upcoming discharge from the current facility to another location) providing less than 30 days' notice.Resident 5 received a NPTD providing less than 30 days' notice.Resident 3 was not given a 30-day advance written NPTD by the facility.Resident 4 was not given a 30-day advance written NPTD by the facility.These failures could have resulted in Residents 2,5,4 and 3 in not having the opportunities to have an advocate inform them of their right to appeal and could have led to an inappropriate transfer or discharge.1. Review of Resident 2's admission Record (AR) dated 7/23/26, indicated Resident 2 was admitted on [DATE] with diagnosis of cervical disc disorder (wear and tear, bulging, or damage to the soft cushion pads between the bones in the neck).A review of Resident 2's NPTD, the NPTD was dated 4/13/26, and was signed by Resident 2's representative on the same day, with a planned discharge date of 4/16/26 (resident was only given 3 days' notice).2. Review of Resident 5's AR dated 7/23/26, indicated Resident 5 was admitted on [DATE] with diagnosis of rhabdomyolysis (a serious medical condition where damaged muscle tissue breaks down rapidly and leaks its poisonous contents directly into the blood).A review of Resident 5's NPTD, the NPTD was dated 4/28/26, and was signed by Resident 2 on the same day, with a planned discharge date of 5/6/26 (resident was only given 8 days' notice).A review of Resident 5's medical records indicated that Resident 5 was discharged home on 5/6/26.3. Review of Resident 3's AR dated 7/23/26, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of fracture of left femur (broken left thigh bone) and history of falling.A review of Resident 3's medical records indicated that Resident 3 was discharged home on 4/2/264. Review of Resident 4's AR dated 7/23/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of fracture of left femur and history of falling.A review of Resident 4's medical records indicated that Resident 4 was discharged home on 3/11/26.During a concurrent record review and interview on 7/22/26, at 2:49 p.m. with the SSD, Resident 3 and 4's medical records were reviewed. SSD stated that Resident 3 and Resident 4 were not given the NPTD during their facility stay. Furthermore, Resident 2 and Resident 5's medical records were also reviewed. SSD stated that Residents 2,3,4 and 5 should have been given the NPTD 30 days prior to their discharge to allow adequate time for the residents' safe relocation planning and give families time to find an appropriate new home.During an interview on 7/23/26, at 2:52 p.m. with the Director of Nursing (DON), DON stated that Residents 2,3,4 and 5 should have been given the NPTD 30 days prior to their discharge because it was the federal regulation (Federal regulations are official rules issued by government agencies).During a review of the facility's Policy and Procedures (P&P), titled Transfer or Discharge Notice, Revised March 2021, indicated, Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation.3) . the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility.Title 42 of the Code of Federal regulations S483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged .

Based on interview and medical record review, the facility failed to ensure ongoing psychosocial monitoring was provided to Resident 1 after the resident reported a sexual abuse allegation (psychosocial monitoring is the ongoing process of tracking a resident's mental, emotional, and social well-being). This failure had the potential to delay the identification of changes in the resident's emotional or psychosocial well-being.Review of Resident 1's Face sheet (information containing contact details, brief medical history at-a-glance), indicated the resident was admitted to the facility on [DATE] with diagnoses that included depression (persistent feeling of sadness).Review of the nurse progress notes dated 6/24/26 at 5:37 p.m., indicated Resident 1 reported that she was touched inappropriately by a male Certified Nursing Assistant (CNA). Resident 1 did not provide additional details regarding the allegation.Review of Resident 1's Minimum Data Sheet (MDS, an assessment tool), dated 5/30/26, indicated that Resident 1's brief interview for mental status or BIMS score was 15 (a score of 15 means the resident was cognitively intact).During an interview on 7/22/2026 at 2:50 p.m., with the Interim Social Services Director (ISSD), the ISSD stated that after a resident reports an allegation of abuse, the resident is monitored by the social worker for psychosocial distress for at least 72 hours (psychosocial distress means deep mental and emotional suffering, mainly showing up as ongoing sadness, severe worry, or a feeling of hopelessness). Review of Resident 1's Interdisciplinary notes (IDT, a group of individuals representing different departments of the facility) dated 6/25/26 (one day after the alleged abuse incident was reported by Resident 1), indicated an intervention documented by the previous Social Service Director (SSD) of, SSD to continue to follow up with Resident 1 to provide emotional support. On further review, no documentation was found that the SSD revisited Resident 1 again after 6/25/26. During an interview on 7/23/26 at 2:56 p.m., the Director of Nursing (DON), the DON stated following an allegation of abuse, a resident should have a psychosocial monitoring for at least three days. During a review of the facility's Policy and Procedures (P&P) titled Social Services revised September 2021, indicated, The facility provides medically related social services to assure each resident can attain or maintain their highest practicable physical, mental, and psychosocial well-being .

Based on interview and record review, the facility failed to notify Resident 1 of her Medicaid 'share of cost' in a timely manner and did not explain it in a way the resident could easily understand (Medicaid is a government-funded health insurance. Medicaid 'share of cost' is the specific dollar amount the insured resident is required to pay out-of-pocket for medical bills each month before Medicaid kicks in to cover the rest of the charges).This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial issues. A review of Resident 1's Face Sheet (a one-page summary containing a resident's most critical demographic, financial, and medical information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included epilepsy (a brain disorder that causes a person to have repeated, unprovoked seizures), insomnia (sleep disorder), and abnormalities of gait and mobility. During a review of Resident 2's MDS (an assessment tool used to evaluate the health, functional capabilities, and over-all well-being of all residents staying in a Medicare- or Medicaid certified nursing facility) dated 6/5/26, it indicated Resident 1's BIMS ( Brief Interview for Mental Status :provides an objective, replicable measurement of a resident's baseline mental function) score was 15 (a score of 15 means the resident has intact cognitive function and no signs of memory or thinking impairment). During an interview on 6/30/26 at 10:05 a.m., Resident 1 stated receiving a pending discharge date of 7/19/26 from the Social Services Director. Resident 1 also stated the facility told Resident 1 of monies owed to the facility due to several months of unpaid share of cost (a monthly medical deductible for people who make too much money to get free Medi-Cal benefits, but still qualify for the program based on their age, disability, or need for a long term care). Resident 1 stated the facility charges (share of cost) was not fully explained by the business office staff and/or the Social Services Director (SSD). Resident 1 explained to facility staff Resident 1's inability to pay the charges and is now worried because of the pending notice of discharge without any place to be discharged to.During a concurrent interview and record review on 6/30/26 at 1:20 p.m., with the SSD, Resident 1's facility invoice (bill or amount to pay) was reviewed. SSD stated Resident 1 has not paid the share of cost since 7/1/25 and SSD gave the initial eviction notice to Resident 1 on 4/6/26, and the second notice was given on 6/19/26. SSD was unable to provide documentation that the Medicaid share of cost charges was explained to Resident 1 prior to giving the eviction notice 4/6/26. During a review of the facility's P&P titled, (FACILITY- INITIATED TRANSFER/DISCHARGE POLICY), the P&P indicated, The facility shall protect each resident's right to remain in the facility and shall not transfer or discharge (evict) any resident except as permitted under federal and California law.

Based on observation, interview, and record review, the facility failed to ensure timely reporting and thorough investigation of an allegation of misappropriation of resident property for one out of three sampled residents (Resident 1). Specifically, the facility did not notify law enforcement as required and document or maintain required lost-and-found logs.This failure resulted in the facility's inability to investigate the reported loss of $5,000, placing Resident 1 at risk for unreported financial exploitation.During a record review of facility's document titled, admission Record, printed 6/2/26, Resident 1 was initially admitted to the facility on [DATE] with multiple diagnoses including hyperlipidemia (high cholesterol in blood), and acute on chronic diastolic heart failure (a condition where the heart does not pump enough blood to meet the needs of the body).During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status), dated 3/6/26, the MDS assessment showed Resident 1 was able to understand others and make herself understood. Resident 1 was assessed with a Brief Interview for Mental Status (BIMS, an assessment for mental status) with a score of 15 out of 15, indicating no impaired cognition (mental status).During an interview on 6/2/26 at 1:20 p.m. with Resident 1, Resident 1 stated she had informed the Social Services Director (SSD) several weeks ago that $5,000 was stolen from her room. Resident 1 also stated SSD told her he would file a police report. Resident 1 stated she asked SSD for a copy of the report and never received one. Resident 1 stated a police officer never spoke with her about the missing money.During an interview on 6/2/26 at 1:41 p.m. with SSD, SSD stated Resident 1 reported losing $5,000 and he filed a police report but was unable to provide the name of the officer or a case number. SSD also stated he could not provide proof that law enforcement was notified.During a concurrent interview and record review on 6/2/26 at 1:41 p.m. with SSD, facility's document titled, Resident Theft and Loss Record, undated, was reviewed. SSD stated the current Resident Theft and Loss Record does not include the 5 thousand dollars that Resident 1 reported as missing. SSD also stated the Resident Theft and Loss Record was blank and SSD was unable to provide any Resident Theft and Loss Records that were filled out in the past year.During a record review, facility's document titled, Resident Theft and Loss Record, undated, was reviewed. The Resident Theft and Loss Record indicated, .the proper law enforcement agency must be notified within 36 hours when the current value of the stolen property is $100 or more. The Resident Theft and Loss Record also indicated the facility was required to document resident's lost or stolen personal property with a value of $25.00 or more within 72 hours of the theft/loss discovery. During a concurrent interview and record review on 6/2/26 at 1:51 p.m. with SSD, facility's document titled, Interdisciplinary Progress Note, dated 5/4/26, for Resident 1 was reviewed. SSD stated he wrote the Interdisciplinary Progress Note on 5/4/26 and the note stated SSD is currently investigating the resident's claim of missing money. SSD stated this was the only documentation in Resident 1's electronic medical record about the missing money.During a concurrent interview and record review on 6/2/26 at 1:53 p.m. with SSD, facility's document titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/4/26, for Resident 1 was reviewed. SSD stated the form indicated the ombudsman (an advocate for residents in skilled nursing facilities) was informed about the missing money. SSD also stated the box on the form indicating that law enforcement was informed was not checked. SSD stated for a large amount of money being reported as lost, the ombudsman should be notified because they are advocates for the residents and due to the amount of money, the police should be also notified. During an interview on 6/2/26 at 2:00 p.m., with Administrator (ADM), ADM stated the Resident Theft and Loss Record should have been filled out for a report of lost money and it was not completed. ADM stated the reason the Resident Theft and Loss Record should be completed is for investigations and tracking.During an interview on 6/2/26 at 1:48 p.m. with the Director of Nursing (DON), DON stated she was not informed that Resident 1 alleged she had lost five thousand dollars in the past month.During a review of [NAME] Police Department's website, titled Report a Crime, retrieved from https://berkeleyca.gov/safety-health/police/report-crime on 6/4/26, the website indicated that when crimes were reported, the person reporting the crime would receive a tracking number.During a review of the facility's policy titled Lost and Found, dated 2001, the policy indicated, .Resident or family complaints of missing items must be reported to the Director of Nursing Services. Lost and found records will be maintained for one (1) year.

Based on observation, interview, record review, the facility failed to maintain a safe, comfortable and homelike environment when Resident 1's bedside table had scratched marks on top and had chipped edges. This failure resulted in Resident 1 feeling angry. On 12/26/25 at 10:40 a.m., an unannounced visit was made at the facility to investigate a complaint allegation. During a phone interview on 12/26/25 at 2:03 p.m., Resident 1 stated when she was living at the facility, her bedside table had scratch marks on top and peeled edges. Further stated she felt angry about this. During a review of Resident 1's Facesheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included depression (a mental health disorder characterized by persistently sad mood or loss of interest in activities, causing significant impairment in daily life) and was discharged from the facility on 9/9/25. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 8/11/25 indicated a BIMS (Basic Interview of Mental status) score of 15 (meaning Resident 1 was cognitively intact). During a concurrent observation and interview on12/26/25 at 2:15 p.m., with the Director of Nursing (DON) in the room where Resident 1 used to reside, the bedside table was observed to have scratch marks on top and had chipped edges. The DON described the bedside table as an old furniture. Also, the wall facing the bathroom was observed to have areas of chipped paint. During a concurrent observation and interview on 12/26/25 at 2:33 p.m., with the Maintenance Assistant (MA) in Resident 1's former room, MA described the wall's paint as chipping and stated that the wall with chipped paint had been in that condition for a few months. MA acknowledged that the condition of the room's wall was not homelike. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment .1. Staff provides person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include: .c. inviting colors and decor .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 received the medication Percocet instead of Norco (Percocet is the brand name for oxycodone/acetaminophen and Norco is the brand name for hydrocodone/acetaminophen for pain. Both medications are for pain but have different opioid ingredients. Opioids are very powerful type of drugs used for pain relief). This failure exposed Resident 1 to the risk of adverse medication effects and discomfort. During a review of Resident 1's Face Sheet, it indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included right femur fracture (broken bone in right thigh bone). A review of Physician's orders dated 8/5/25, indicated an order of Norco or Hydrocodone-Acetaminophen oral tablet 10-325 milligrams (mg., a form of measurement), give one tablet by mouth every four hours as needed for severe pain. During an interview on 12/26/25 at 12:46 p.m. with the Director of Nursing (DON), DON stated that on 8/6/25, two doses of Percocet 10/ 325 mg. (two doses totaled to two tablets) were taken from the E-kit and were given to Resident 1 for pain instead of the ordered Norco 10/325 mg. DON acknowledged this was a medication error and stated the adverse effects for the resident receiving Percocet could have been respiratory distress due to an allergic reaction (an Emergency Kit or E-kit is a small, pre-stocked supply of medications kept in the facility to quickly treat common, sudden symptoms like pain, nausea, or anxiety). A review of Incident of Emergency Kit Non-Compliance, dated 9/5/25, it indicated: Percocet 10/325 mg. tablets (#2 tabs taken on 8/06/25) - Nurse mistakenly took the wrong medication out of the E-kit. (Incident of Emergency Kit Non-Compliance was a document sent by the pharmacist which referred to the facility's failure to follow the rules for using the emergency medication supplies in the E-kit). During a review of the facility's Post Event Review dated 9/8/25, it read: Nurse mistakenly removed Percocet 10/325 mg. from E-kit instead of intended medication. the nurses acknowledged the error. (a post-event review is a comprehensive analysis meeting conducted by the facility after an event to identify areas for improvement, inform future planning or evaluate its success). During an interview on 12/30/25 at 1:00 p.m. with Pharmacist Consultant (PC), PC stated the nurses made medication errors and should have given the correct medication of Norco 10/325 tablet instead of Percocet 10/325 tablets from the E-kit. Further stated the risks of giving Percocet was the possibility for Resident 1 to experience adverse side effects like sedation, nausea and hallucinations. During a review of the facility's policy and procedure (P&P) titled, Administering Medications revised April 2019, the P&P indicated, . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method(route) of administration before giving the medication .

Based on observation, interview and record review, the facility failed to treat three of three sampled residents (Resident 21, 22, and 29) with dignity and respect when Residents 21, 22, and 29, who needed full assistance with meals, were not offered or fed their bread rolls during lunch. This failure had the potential to affect Residents 21, 22 and 29's psychosocial well-being and nutritional needs. Findings: During a dining observation on 9/23/24 at 12:53 p.m., in the dining room, Residents 21, 22, and 29 were being assisted by staff during lunch. Registered Nurse (RN) 3 asked Resident 29 if she wanted her bread roll to which Resident 29 replied, yes. RN 3 did not have gloves available to feed the bread roll and RN 3 offered water to Resident 29 instead. Residents 21, 22, and 29 did not receive their bread rolls from the staff who assisted them during feeding. During an interview on 9/25/24 at 3:07 p.m. with Director of Staff Development (DSD), DSD stated RN 3 should have accommodated and assisted Resident 29 when Resident 29 wanted to eat the bread roll. DSD further stated Residents 21, 22, and 29 were not able to feed themselves and needed a helper to pick up the food for them so they can eat. During a record review of the facility's policy and procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that can affect the mind, emotions, and behavior) for three of 38 sampled residents (Residents 8,7 and 10) when: 1. Resident 8 did not have the appropriate indications for the use of Seroquel (Seroquel is an antipsychotic medication; Antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts), 2. Resident 7 had no rationale for continued use of PRN Ativan beyond 14 days (PRN is short for pro re nata [a Latin phrase], meaning as needed, or as necessary; Ativan is a psychotropic medication used to treat anxiety; psychotropic medications are used to treat mental health disorders), and 3. Resident 10 was administered Trazadone (an antidepressant medication to treat major depressive disorder, some anxiety disorders and chronic pain conditions) for insomnia (difficulty falling and staying asleep) and facility did not monitor hours of sleep for Resident 10. These failures had the potential to not promote or maintain Residents 8, 7 and 10's highest practicable mental, physical, and psychosocial well-being. (Cross Reference F645) Findings: 1. During a review of Resident 8's Admission Record, dated 9/25/24, the record indicated Resident 8 had diagnosis of brief psychotic disorder (mental disorder that can cause abnormal thinking and perception). During a review of Resident 8's Physician's Orders(PO), dated 8/22/23, the PO indicated an order of Seroquel 12.5 milligrams (mg., a form of measurement), by mouth two times a day. The PO indicated the symptoms to be managed by Seroquel were, agitation/restlessness/anxiety, manifested by repetitive questioning of things, events. Easily gets frustrated despite reassurance and with aggressive response. Review of Resident 8's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/20/24, the MDS indicated Resident 8's cognition was severely impaired. The MDS indicated Resident 8 had no verbal and physical behavioral symptoms directed toward others (verbal- threatening others, screaming at others, cursing at others; physical - hitting, kicking, pushing, scratching .). During an interview on 9/27/24 at 9:28 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 8 did not get agitated whenever she took care of him. CNA 4 stated Resident 8 would get confused at times but would calm down when CNA 4 reoriented Resident 8. During an interview on 9/26/24 at 2:18 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 8 was not physically aggressive. RN 2 further stated Resident 8 was not a danger to himself and to others. During a concurrent interview and record review on 9/26/24 at 1:50 p.m. with the Director of Nursing (DON), Resident 8's Electronic Health Record (EHR) for physician orders dated 9/25/24 was reviewed. The DON stated the use of Seroquel for Resident 8 was not appropriate because the resident was not aggressive and was not a danger to himself, other residents, and the staff. 2. During a review of Resident 7's clinical record indicated a diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities) and anxiety (a type of mental health condition). During a review of Resident 7's physician order dated 9/25/24, the order indicated the physician prescribed Ativan 0.5 mg by mouth every 6 hours PRN for anxiety with a start date of 3/28/24. The order did not indicate a stop date for the PRN Ativan. During a concurrent interview and record review on 9/25/24 at 12:45 p.m., with the Director of Nursing (DON), Resident 7's Physician's Order, dated September 2024 was reviewed. The DON stated Resident 7's PRN Ativan did not have a stop date and should have a duration of 14 days per the facility policy. DON also acknowledged there was no physician documentation found which indicated Ativan PRN should be extended. During an interview on 9/26/24 at 12:39 p.m. with the Medical Doctor (MD), the MD stated Resident 7's PRN Ativan should have had a stop date of 14 days. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, . PRN orders for psychotropic medications are limited to 14 days . If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale (reason) for extending the use and include the duration for the PRN order . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated July 2022, the P&P indicated, . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others AND: (1.) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity) . 36593 3. During a review of Resident 10's Admission Minimum Data Set, dated dated [DATE], the MDS indicated Resident 10 had daily mood symptom of feeling down, depressed or hopeless. The MDS indicated Resident 10's diagnoses included Major Depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and insomnia (persistent problems falling and staying asleep). During a review of Resident 10's physician Orders, dated 8/23/24, the physician order indicated Resident 10 was prescribed Trazadone HCL oral tablet 100 mg by mouth at bedtime related to insomnia. During a review of the Medication Administration Record (MAR), dated 9/1/24 to 9/30/24, the MAR indicated Resident 10 was administered Trazadone 100 mg tablet by mouth at bedtime. The MAR indicated Resident 10's hours of sleep was not monitored from 9/7/24 to 9/23/24. During a concurrent interview and record review on 9/25/24 at 9:17 a.m., with the (DON), Resident 10's physician orders and MARs were reviewed. The DON stated there was no hour of sleep monitored for use of trazadone. The DON stated monitoring sleep provides information on the effectiveness of medication. The DON stated if Resident 10 did not sleep, the physician will be notified to reevaluate the use of Trazadone. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, Psychotropic medication management includes: a. indication for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences.

Based on observation, interview, and record review, the facility failed to follow the menu for the soft and bite-sized (foods that are soft, moist, and easy to swallow) and easy to chew diet (soft, tender foods that are easy to chew) for 12 out of 12 residents (Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22) when Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 did not receive two ounces of gravy for lunch with their chicken on 9/23/24. This failure had the potential for Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 to have problems chewing and swallowing the food when the established menu was not followed accordingly and had the potential for poor nutrition and to further compromise the medical status of the residents. Findings: During the tray line (an assembly line preparation of meal trays in the kitchen to be delivered to residents) observation on 9/23/24, at 12:17 p.m., in the kitchen, the Dietary Services Supervisor (DSS) did not serve gravy to residents who were on the soft and bite-sized and easy to chew diet. During a record review of a facility document titled Therapeutic Spreadsheet Menu Week 1, dated 9/23/24, the document indicated both the soft and bite-sized diet and easy to chew diet's baked chicken were to be served with two ounces of gravy. During an interview on 9/25/24 at 1:21 p.m., with DSS, the DSS stated she had prepared the gravy but forgot to serve it to the residents. The DSS further stated the weekly menu should have been followed, and the gravy should have been served to residents who were on soft and bite-sized and easy to chew diet. During a record review of the facility's policy and procedure (P&P), titled, Menus, dated 2018, the P&P indicated Menus are planned to meet guidelines as established by the most current federal/state regulations .All menus will provide adequate nutrients to meet the special needs of the residents, including dietary modifications.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. Can opener had red discoloration on the blade that pierced the can, 2. Under the stove and steam tray line, the floors had a build-up of food crumbs, trash, dust, and grime, 3. The oven had build-up of black grime inside, 4. Dry storage floors had build-up of food crumbs, trash, and dead ants, and 5. Diet Aide 1 (DA 1) did not wear a bear net during meal preparation and service. These failures had the potential to expose 38 medically compromised residents who received food from the kitchen to foodborne illness due to cross-contaminations (the transfer for harmful substances or disease-causing microorganisms to food). Findings: 1. During an initial tour observation of the kitchen and interview on 9/23/24 at 9:32 a.m. with Dietary Service Supervisor (DSS), the can opener had red discoloration on the blade. DSS stated the can opener should have been cleaned. During a phone interview on 9/25/24 at 1:10 p.m. with the Registered Dietician 1 (RD 1), RD stated the can opener should have been kept clean and should have been washed after each use. 2. During an observation and interview on 9/23/24 at 9:46 a.m. with DSS, the kitchen floors under the two stoves and steam table tray line counter had build-up of food crumbs, dust, trash, and black grime. DSS stated they have not done a deep cleaning in the kitchen recently because the person who was assigned to do the task had retired. 3. During an observation and interview on 9/23/24 at 9:47 a.m., the oven had a build-up of black grime under the racks. DSS stated the black grime was from food residue. During a phone interview on 9/25/24 at 1:10 p.m. with RD 1, RD 1 stated the oven should have been wiped down after each use and should have been cleaned based on the cleaning schedule. 4. During an observation on 9/23/24 at 9:52 a.m., inside the dry storage, the floors had build-up of dead ants, food crumbs, and trash under the shelves. During a phone interview on 9/25/24 at 1:10 p.m. with RD 1, RD 1 stated the kitchen should have been kept cleaned and floors should have been free from food crumbs, dust, trash, and grime. RD 1 stated the dead ants should have been cleaned right away in the dry storage area. 5. During a tray line (an assembly line preparation of meal trays in the kitchen to be delivered to residents) observation on 9/23/24 at 12:24 p.m., DA 1 with facial hair did not have a beard net on while assisting DSS in plating the residents' foods. During an interview on 9/25/24 at 1:15 p.m. with DSS, DSS stated DA 1 should have worn a beard net or shaved his facial hair when directly in contact with food. During a record review of the facility's policy and procedure (P&P), titled, Sanitation and Infection Control (Cleaning Schedule), dated 2018, the P&P indicated The Dining Services Director will develop comprehensive cleaning schedules that staff will follow in order to maintain a sanitary department, prevent cross-contamination, and meet state/federal requirements. During a review of the facility's P&P, titled, Sanitation and Infection Control (Personal Hygiene), dated 2018, the P&P indicated, The Director of food and Nutrition services will instruct Department of Food and Nutrition Services employees regarding the relationship between personal hygiene and food safety, including the association of hand contact personal habits and behaviors and food employees' health to food borne illness .Beards and/or mustaches should be covered during meal preparation and service. During a record review of the Food and Drug Administration (FDA) Federal Food Code 2022, .Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests.

Based on interview and record review, the facility failed to ensure Resident 8's Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting; and 3) receive the services they need in those settings.) completed when Resident 8 had diagnosis of brief psychotic disorder (mental disorder that can cause abnormal thinking and perception). This failure resulted in Resident 8 not being properly evaluated if he was receiving appropriate mental health services. (Cross Reference F758) Findings: During a review of Resident 8's Admission Record, dated 9/25/24, the record indicated Resident 8 had diagnosis of brief psychotic disorder. During a review of Resident 8's Physician's Orders, dated 8/22/23, the order indicated an order of Seroquel 12.5 milligrams (mg., a form of measurement), by mouth two times a day (Seroquel is an antipsychotic medication. Antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts). During a concurrent interview and record review on 9/26/24 at 10:36 a.m., with the Medical Record Director (MRD), MRD stated she was not able to find any PASARR evaluation in Resident 8's medical records. During an interview on 9/26/24 at 10:04 a.m., with the Administrator (Adm), the Adm acknowledged it was the facility's mistake for not having a PASARR evaluation for Resident 8. During a review of the facility's policy and procedure (P&P) titled, Admission Criteria, dated March 2019, the P&P indicated, . All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) .

Based on observation, interview, and record review, for two (Resident 10 and Resident 11) of thirteen sampled residents, the facility failed to implement its Care Plan, Comprehensive Person Centered policy and procedure when: 1. Facility did not develop care plan to address Resident 10's medical diagnoses of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ) and Insomnia (persistent problems falling and staying asleep), and there was no care plan to address Resident 10's use of Amitriptyline and Trazadone (antidepressant medications, antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions), and 2. Facility did not identify and address Resident 11's hairy mole on chin with a care plan and appropriate interventions. (Hairy moles are skin lesions that have both hair and pigmentation. They are usually present at birth. Hairy moles can appear anywhere on the body, but are often found on the face, trunk, or limbs). These failures had the potential to result in Resident 10 and Resident 11 not receiving appropriate care and treatment. Findings: 1. During a review of Resident 10's Admission Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 8/30/24. The MDS indicated Resident 10 had diagnoses of major depressive disorder and insomnia. During a review of Resident 10's physician orders, dated 8/23/24, the order indicated Resident 10 was prescribed: a. Amitriptyline HCL tablet 50 mg (milligram, unit of measurement) by mouth daily related to major depressive disorder, and b. Trazadone HCL oral tablet 100 mg by mouth at bedtime related to insomnia. During a concurrent interview and record review on 9/25/24 at 9:17 a.m., with the Director of Nursing (DON), Resident 10's MDS and care plans were reviewed. DON could not show Resident 10 had care plans that addressed the use of Amitriptyline and Trazadone for depression. DON could not provide documentation that Resident 10's diagnosis of major depression was care planned. DON stated care plan was not initiated for Resident 10 major depression and use of antidepressant. 2. During a review of Resident 11's Admission record, dated 5/5/22, indicated Resident 11 was admitted to the facility with multiple diagnoses that included seborrhea (abnormally increased secretion and discharge of sebum) and rash and other nonspecific skin eruption. During a review of Resident 11's Minimum Data Set, dated dated [DATE], the MDS indicated Resident 11's Basic Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 12 and indicated moderate impaired mental status. The MDS indicated Resident 11 was able to recall the correct year, month, and day of the week. MDS indicated Resident 11 had clear speech, able to express her ideas and wants, and understood what others said to her. During a concurrent observation and interview on 9/23/24 at 10:00 a.m., Resident 11 laid in bed in her room, awake, alert and verbally responsive. Resident 11 was observed with hairy mole on her chin. Resident 11 stated she had hairy mole on chin for some time and would like the hair removed. Resident 11 stated nurses had not addressed the presence of hairy mole on her face. Resident 11 stated she would like to have facial hair removed. During a concurrent observation and interview on 9/23/24 at 10:21 a.m., with Certified Nursing Assistant/Restorative Nursing Assistant (CNA) 1 in Resident 11's room, Resident 11 had hairy mole on chin. CNA1 stated she was aware Resident 11 had a mole with facial hair on her chin. can 1 stated because of the presence of mole with facial hair and informed a licensed nurse. During a concurrent interview and record review on 9/26/24 at 8:49 a.m., with the DON, Resident 11's weekly summaries, care plans and MDS were reviewed. DON could not provide documentation that Resident 11 care plans identified and addressed hairy mole on Resident 11's chin. DON stated nursing staff did not identify or care plan Resident 11's hairy mole presence on the chin. During an interview on 9/26/24 at 1:31p.m., with the DON, the DON stated the expectation was for CNAs to observe residents' skin daily, during shower and notify licensed nurses who will notify physician with changes in skin condition and care plan. The DON stated there was no documentation that Resident 11's hairy mole on chin was identified or care planned. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident 14) long toenails received podiatry (foot care) treatment services as ordered by the physician. This failure had the potential to place Resident 14 at risk for injury and infection. Findings: During an observation on 9/23/24 at 1:45 p.m., Resident 14 laid in bed in her room. Resident 14 had contracted (tightened and may cause deformity) feet with long toenails. During a review of Resident 14's Minimum Data Set (MDS, Resident Assessment tool used to guide care), dated 9/12/24, the MDS indicated Resident 14 had short- and long-term memory problem. The MDS indicated Resident 14 was dependent on staff and required two or more helpers for putting on and taking off socks and shoes or other footwear and personal hygiene. The MDS indicated Resident 14's diagnoses included Peripheral Artery Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and Non-Alzheimer's Dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). During a concurrent observation and interview on 9/24/24 at 11:00 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 14's room, LVN 1 stated Resident 14's long toenails needed podiatry care since Resident 14 had other comorbidity (presence of two or more diseases). During a concurrent interview and record review on 9/24/24 at 11:24 a.m., with Social Services Director (SSD), Resident 14's Progress Notes, dated 3/4/24 was reviewed. The progress notes by the podiatrist indicated Resident 14 had elongated toenail with plan to trim toenails every 2 to 3 months for foot care. SSD stated Resident 14's foot care was missed and was not seen by the podiatrist. SSD stated he coordinated with the podiatrist in making sure residents' schedule for podiatry care was kept. During a review of Resident 14's order summary report dated 8/19/2017, the order indicated the physician ordered Resident 14 to receive podiatry care as needed. During a review of the facility's policy and procedure (P&P) titled, Foot Care, revised October 2022, the P&P indicated, Residents with foot disorders or medical conditions associated with foot complication are referred to qualified professionals. Foot disorders that require treatment include corns, neuromas, calluses, hallux valgus, digit flexus, heel spurs and nail disorders.

Based on observation, interview, and record review, the facility failed to ensure one (Resident 9) of two sampled residents received treatment services to address limitation in range of motion to right upper extremity when Resident 9 had contracture (a condition of shortening and hardening of muscles often leading to deformity and rigidity of joints) of right upper extremity and a resting splint (a device that supports and protects a broken bone or injured tissue) was not applied to right hand as ordered by the physician. This failure had the potential to cause Resident 9's decline in range of motion and risk of decreased muscle strength. Findings: During an observation on 9/24/24 at 10:53 a.m., Resident 9 laid in bed in her room. Resident 9 had right hand contracture. Resident 9's right hand upper extremity had no splint. During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/19/24. The MDS indicated, Resident 9 had short- and long-term memory problem. The MDS indicated Resident 9's had diagnosis of Non-Alzheimer's Dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). During a review of Resident 9's care plan revised on 6/19/2017, the care plan indicated Resident 9 had an ADL (activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) self-care performance deficit related to limited mobility, interventions included nursing rehab/restorative splint/brace program. During a review of Resident 9's order summary report dated 9/3/21, the order indicated physician prescribed Resident 9 to receive RNA [restorative nurse assistant] program: RNA/can [certified nursing assistant] to do PROM [passive range of motion, the person performing the movement does not use any of their own muscles] to all joints to patient tolerance 3x/week flexible days. Goal: maintain res [resident] current joint ROM in all extremities and reduce risk of contracture development . During an interview on 9/25/24 at 8:55 a.m., with Certified Nursing Assistant/Restorative Nursing Assistant (CNA) 1, CNA 1 stated Resident 9 used to have splint applied to right upper hand contracture. CNA 1 stated Resident 9 was no longer on RNA program for a while and had not used a splint for some time. CNA 1 stated Resident 9 had contracture to right hand upper extremity. During a concurrent observation and interview on 9/25/24 at 11:03 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 9's room, Resident 9 sat up in wheelchair, right upper extremity had no resting splint. LVN 1 stated she was the charge nurse for Resident 9, cared for Resident 9 four days a week. LVN 1 stated she had not seen Resident 9 with splint application to right hand. During a concurrent observation and interview on 9/25/24 at 11:16 a.m., with CNA 2, CNA 2 stated she was Resident 9's caregiver. CNA 2 stated Resident 9 used to have a splint on the right hand but no longer for a while now. CNA 2 stated she did not know the reason for not having splint in place. CNA 2 stated that RNA was responsible for splint application. During an interview on 9/25/24 at 10:20 a.m., with Occupational Therapist (OT), OT stated facility will reevaluate Resident 9. OT stated there was no treatment record for Resident 9's right hand limitation in range of motion. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting revised March 2018, the P&P indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.

Based on interview and record review, the facility failed to have a written contract/agreement with Resident 189's outpatient dialysis provider (dialysis is the process of removing toxins from the kidneys and blood through a machine. The contract/agreement should include all aspects of how Resident 189's dialysis care and needs were to be managed by the dialysis provider outside of the facility). This failure had the potential to result in Resident 189's poor dialysis care management. Findings: During a review of Resident 189's Admission Record, dated 9/26/24, the record indicated Resident 189 had diagnosis of acute kidney failure (a condition where the kidneys stopped working properly). Review of Resident 189's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 9/20/24, the MDS indicated Resident 189's cognition was intact. During a review of Resident 189's Physician's Orders dated 9/14/24, the order indicated Resident 189 had outpatient hemodialysis (a medical procedure that filters a person's blood when their kidneys are not functioning properly) appointments on Mondays and Fridays from 10:00 a.m. to 1:00 p.m. During an interview on 9/23/24 at 2:41 p.m., with Resident 189, Resident 189 stated she just returned from having dialysis from the dialysis provider. During an interview on 9/25/24, at 10:21 a.m., with the Administrator (Adm), the Adm stated there was no contract in place between the facility and dialysis provider of Resident 189. The Adm further stated the facility also did not have a contract with the transportation company that transported Resident 189 to the dialysis provider. The Adm stated he knew it was a regulation to have a contract but acknowledged that he had not done it yet.

Based on observation, interview and record review, the facility failed to ensure two (Residents 15 and 21) of 38 sampled residents' call lights were within easy reach. This failure had the potential for the Resident 15 and Resident 21 to not to be able to use the call light when needing assistance. Findings: During an initial tour of the facility on 9/23/24 at 10:43 a.m., in Resident 15's room, Resident 15 was observed lying in bed, alert and was able to answer questions. The call button wire was observed to be hanging in right middle side of Resident 15's bed and the call button was almost touching the floor. Resident 15 attempted to reach for the call button but had a difficult time and failed. Resident 15 stated she could not reach her call button and further stated she needed the call light to call for help. During a concurrent observation and interview on 9/25/24 at 12:09 p.m., with Certified Nursing Assistant (CNA) 3 in Resident 15's room, CNA 3 confirmed that Resident 15 was not able to reach her call light. CNA 3 stated the call light should be within the resident's reach at all times. CNA 3 acknowledged that the risk for the resident in not being able to reach the call light was that the resident could not call for her needs. During an initial tour of the facility on 9/23/24 10:49 a.m., in Resident 21's room, Resident 21 was observed lying in bed, alert and was able to answer questions. The call light was observed to be on the floor in the upper right side of Resident 21. Licensed Vocational Nurse (LVN) 3 confirmed Resident 21's call light should not be on the floor. LVN 3 stated the call light should be always within the resident's reach so that the resident could call for her needs. During an interview with the Director of Nursing (DON) on 9/25/24 at 12:09 p.m., the DON stated the residents should be able to reach the call lights all the time, especially when they were in bed. The DON further stated, the risk for the residents on not being able to reach their call lights were unmet needs. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated September 2022, the P&P indicated, .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .

Based on interviews and record reviews, the facility failed to ensure four (Residents 4, 28, 41 and 43) of five sampled residents were free from unnecessary drugs when; - Resident 4 was administered two antipsychotic medications, Risperdal and Zyprexa, without adequate clinical indication for use and monitoring for adverse side effects. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. - Resident 28 was administered Clozapine an antipsychotic and Sertraline an antidepressant without adequate monitoring for target behavior and adverse side effects. Antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions - Resident 41 was administered Mirtazepine (anti-depressant) for sleep without adequate monitoring the hours of sleep. to determine effectiveness. -For Resident 43,the indication for use of Seroquel an antipsychotic was not monitored. These failures had the potential for residents to receive unnecessary drugs and adverse medication side effects. Findings: According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidal not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.drugs.com/pro/risperdal]. 1. Review of Resident 4's significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 1/4/23, indicated Resident 4 had unclear speech with slurred or mumbled word, rarely/never understood. Resident 4 had short and long term memory problems. Resident 4 had no behavioral symptoms and diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the physician orders indicated Resident 4 was prescribed the following medications : - Risperdal tablet 1 mg (milligram) by mouth daily for anoxic (oxygen deprived) brain damage manifested by poor impulsive control to leave out of exit doors unattended. - Zyprexa tablet 10 mg, give 1 tablet by mouth two times a day for poor impulse control manifested by poor judgement, no safety awareness, limited self awareness. Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 4 was administered Risperdal tablet 1 mg by mouth daily for poor impulsive control to leave out of exit doors unattended and Zyprexa tablet 10 mg give 1 tablet by mouth two times a day for poor impulse control manifested by poor judgement, no safety awareness, limited self awareness. Further review of Resident 4's MARs, dated February, March and April 2023, indicated adverse side effects for Risperdal and Zyprexa use were not monitored. During an interview on 4/18/23 at 11:23 a.m., the Certified Nursing Assistant (CNA 1) stated Resident 4 had no behavior, no agitation and sleeps most of the time. During an interview on 4/19/23 at 10:31 a.m., the Consultant Pharmacist (CP) stated he identified the inadequate clinical justification and discussed Resident 4's use of Risperdal for poor impulse control to leave out of exit door unattended with the facility's interdisciplinary team. CP could not provide a Medication Regimen Review (MRR) documentation that addressed his concern for Resident 4's use of Risperdal and Zyprexa. 2. Review of Resident 28's Minimum Data Set, Resident Assessment and Care Screening, dated 3/14/23, indicated Resident 28 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 28 had short and long term memory problems. Resident 28 had no behavioral symptoms and had trouble falling asleep and little energy. Resident 28 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), depression and anxiety. Review of the Physician Orders indicated Resident 28 was prescribed the following medications : - Clozapine tablet 25 mg give 2.5 tablet by mouth in the evening for major depression and generalized anxiety disorder severe psychotic features. - Sertraline HCL tablet mg give 3 tablet by mouth one time a day for depression. Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 28 was administered Clozapine tablet 25 mg give 2.5 tablet by mouth in the evening for major depressive and generalized anxiety disorder with severe psychotic features and Sertraline HCL (hydrochloride) tablet 50 mg give 3 tablet by mouth one time a day for depression. Further review of Resident 28's MARs, dated February, March and April 2023, indicated target behaviors and adverse medication side effects were not monitored for usage of Clozapine and Sertraline. During an interview on 4/19/23 at 10:07 a.m., Registered Nurse (RN 1) stated Resident 28's behavior manifestation included scratching CNAs during brief changes. RN 1 stated side effects of Clozapine and Sertraline are monitored in the electronic medical records. RN 1 could not provide documentation that Resident 28 target behaviors manifestation and adverse side effects were monitored. 3. Review of Resident 41's Significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 3/3/23, indicated Resident 41 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 41 had short and long term memory problem. Resident 41 had no behavioral symptoms. Resident 41 trouble falling asleep and little energy. Resident 41 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language) and depression. Review of the Physician Orders indicated Resident 41 was prescribed Mirtazapine 15 mg tablet, give 2 tablet by mouth at bedtime for sleep related to major depression Review of the Medication Administration Record (MAR), dated February, March and April 2023, indicated Resident 41 was administered Mirtazapine 15 mg at bedtime for sleep Further review of Resident 41's MARs, dated February, March and April 2023, indicated hours of sleep before and after the administration of Mirtazepine for sleep and adverse medication side effects were not monitored. During an interview on 4/19/23 at 10:07 a.m., Registered Nurse (RN 1) stated Resident 28's target behaviors and side effects of Resident 28 and 41's use of psychotropic medications are monitored in the electronic medical records. RN 1 could not provide documentation that Residents 4, 28 and 41's target behaviors and adverse side effects were monitored. During an interview on 4/19/23 at 10:31 a.m., the Consultant Pharmacist (CP) stated he did not identify Residents 4, 28 and 41's behavior manifestation and adverse side effects were monitored for use of psychotropic medications during the monthly MRR. During an interview on 4/20/23 at 8:42 a.m., Director of Nursing (DON) stated facility used the 24 hour report hurdle to monitor residents target behaviors for psychotropic medication use. DON could not provide documentation that behaviors and adverse side effect are monitored for Resident 4, 28 and 41 use of psychotropic medications. The facility's policy and procedure, titled, Medication Regimen Reviews (MRR), revised May 2019 indicated; The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medication ordered in excessive doses or without clinical indication; b. medication regimens that appear inconsistent with resident's stated preferences; c. duplicate therapies or omissions of ordered medications; d. inadequate monitoring for adverse consequences. The facility's policy and procedure, titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019 indicated; When medications are prescribed for behavioral, documentation will include; rationale for use, potential underlying causes of behavior, other approaches and interventions tried prior to the use of antipsychotic medication, specific target behaviors and expected outcomes and monitoring for efficacy and adverse consequences. 32717 4. Review of Resident 43's Admission Record indicated Resident 43 has been known to the facility since 4/30/22 with diagnoses that included dementia (loss of mental functions severe enough to affect daily life) and hallucinations. Review of Resident 43's Order Summary Report as of 4/20/23 indicated for Resident 43 to receive quetiapine fumarate tablet (Seroquel, treats psychosis, a mental illness that cause abnormal thinking and perceptions) 50 milligrams by mouth at bedtime for other hallucinations. [Reference:https://medical-dictionary.com/]. Review of Resident 43's hallucination care plan dated 4/17/23 indicated the goal was for Resident 43 to have fewer episodes of hallucinations by review date 9/3/23. Interventions included for staff to administer Seroquel as ordered and monitor effectiveness and monitor hours of sleep during night shift. During an interview and concurrent review of Resident 43's clinical record with DON, on 4/20/23 at 12:11 p.m., DON stated Resident 43's MAR for April 2023 did not indicate monitoring for medication effectiveness. DON stated the MAR did not identify what type of hallucinations the staff were monitoring for. DON also stated the MAR did not indicate monitoring for hours of sleep at night. Review of the Social Services assessment dated [DATE] indicated, The resident mentions the hallucinations are not distressing to her. Review of Interdisciplinary Team (IDT, group composed of individuals representing different departments in the facility) Progress Notes dated 11/23/33 indicated .no mood indicators at this time. Another IDT Progress Note dated 3/30/23 indicated Resident 43 had improvement with mood and activities of daily living. Both IDT Notes did not indicate monitoring for hallucinations and hours of sleep.

Based on observation, interviews, and record review, the facility failed to ensure storage of food under sanitary conditions when: - Dietary staff's lunch bag was kept in the kitchen refrigerator. - One container of low-fat cottage cheese was opened and not labeled or dated - One bottle of chili garlic sauce open date 2/28/23 - One bottle salad cream opened 8/3/22 - One bottle spicy sauce opened 2/28/23 - 1/2 sliced apple in cup not labeled or dated - Two bottles of jam opened 3/6/23 These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 4/17/23 at 9:19 a.m., and accompanied by the Director of Food and Nutrition Services (DFNS), one staff lunch bag was stored in the refrigerator, One container of low fat cottage cheese opened not labeled or dated, one bottle of chili Garlic sauce opened 2/28/23, one bottle salad cream opened 8/3/22, one bottle spicy sauce opened 2/28/23, half sliced apple in cup not labeled or dated, two bottles of jam opened 3/6/23. During an interview on 4/18/23 at 9:36 a.m., Cook (CK) stated the dietician gave him training every so often about dating and labeling food items when opened and placed in the refrigerator. During an an interview on 4/18/23 at 9:51 a.m., DFNS stated the lunch bag was her bag. The facility's policy and procedure, titled, Cover, Label and Date items for storage, undated, indicated, All employees of Food and Nutritional Services (FSN) are responsible for covering, labeling and dating all food stored in the kitchen. All food not used by the appropriate date must be discarded.

Based on interview and record review, the facility failed to develop and implement written policy and procedures to prevent abuse, neglect and exploitation of residents and misappropriation of resident property when: 1. Resident 31's statement that a nurse was Tearing [Resident 31] to pieces was not investigated and not reported. This failure had the potential to result in abuse by the same staff who continued to provide care to Resident 31. 2. Facility did not perform background checks for five of five employees. This failure had the potential for allowing potential employees who have been convicted of abuse, neglect and exploitation and misappropriation of resident property to care for the residents. Findings: 1. During review of the Resident Council Suggestion/Issue/Question/Concern dated 4/13/23 with Activity Director (AD), on 4/18/23 at 11:10 a.m., the record indicated Resident 31 claimed on 4/13/23 that a nurse was tearing me to pieces during a bath and while being changed. AD stated the information was passed on (shared) with the Nursing Department but could not identify which staff member received the information. AD stated there was no response from the Nursing Department as of yet because it would usually take up to a week to hear back. AD also stated, at the time, AD did not think of the concern as an abuse allegation that should be reported to the Administrator (ADM) who was the facility's abuse coordinator. AD stated she should have reported it right away. During a follow-up interview with AD on 4/19/23 at 10:13 a.m., AD stated, she shared Resident 31's concern on 4/18/23 with ADM, who responded by having Social Service Designee (SSD) conduct an interview with Resident 31. During an interview with SSD on 4/19/23 at 11:10 a.m., SSD stated having received a copy of Resident 31's concern on 4/18/23. SSD stated he went to talk to Resident 31 to ask about preferences with how staff should provide care. SSD stated he did not ask Resident 31 about the incident and staff who was tearing her to pieces which he stated he should have. SSD also stated, such statements coming from any resident should have been investigated with the thought that it could very well be an abuse incident. Review of Resident 31's Admission Record indicated Resident 31 was admitted to the facility with diagnoses that included age-related osteoporosis (bones become brittle and fragile that they are more likely to break (fracture) and pain in right ankle and joints of the right foot. Review of Resident 31's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/9/23 indicated Resident 31 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 12. BIMS score range is from 0-15, with zero as the most impaired. During an interview with Resident 31 on 4/19/23 at 11:39 a.m., Resident 31 stated not being able to accurately recall details about the incident of a staff tearing me to pieces because of a failing memory. Resident 31 stated, it would have been better if questions were asked the same day Resident 31 made the statement. Resident 31 also stated no one from the facility had asked questions about Resident 31's statement. During an interview with ADM on 4/20/23 at 12:49 p.m., ADM stated, statements from residents such as, nurse is tearing me to pieces should be investigated right away to make sure this was not an abuse case. Review of the facility's policy and procedure titled Abuse Prevention and Reporting last revised April 2021 indicated When a resident or someone in behalf of a resident reports a grievance or makes a complaint .thorough investigations are commenced immediately upon presentation of complaint/grievance/event. 2. During an interview and concurrent review of the employee files with the Director of Nursing (DON) on 4/20/23 at 11:05 a.m., files for the following staff were reviewed; a. Certified Nursing Assistant (CNA) 2. b. Restorative Nursing Assistant (RNA). c. Activity Assistant (AA). d. Licensed Vocational Nurse (LVN) 1. e. Activities Director (AD). DON stated, background checks with the Department of Justice (DOJ) were not done for all five employees. DON also stated, for licensed nurses like LVNs and Registered Nurses and CNAs,the facility relied on the background checks being done by respective licensing and certification agencies for both professions. DON stated, for CNA 2, hired on 3/30/22, the facility did not have a copy of their certification on file. There was no documentation that background checks with the DOJ or State Registry were performed for all five employees reviewed. During an interview with ADM on 4/20/23 at 12:49 p.m., ADM stated the facility has not done background checks for all employees, and, for licensed staff, the facility relied on the background checks performed by the respective licensing board or certification agencies. For the unlicensed staff (i.e., activities, kitchen, housekeeping), the facility did reference checks because most were known to be long-time employees of the facility. ADM also stated the facility utilizes information based on Megan's law (penal code that mandates the state DOJ to notify the public about sex offender registrants who pose a risk to public safety). ADM, however, stated that doing reference checks did not give information if the prospective employees were convicted of crimes other than sexual in nature. Review of the facility's policy and procedure titled, Abuse Prevention and Reporting last revised April 2021, indicated all applicants for employment have references checked prior to hiring. The policy also indicated three different ways the facility checks for criminal background as follows; - If a license or certification of a staff is deemed active by the licensing or certification agency, the prospective employee is deemed to have had a criminal background check. - Persons who have had a finding entered into the State Registry concerning abuse, neglect, mistreatment and misappropriation of property shall not be hired. - Megan's Law website is checked prior to job offer and after references are checked.

Based on interview and record review, the facility failed to implement their Abuse policy and procedure to investigate and report injuries of unknown origin for one (Resident 4) sampled resident. Resident 4's laceration to the left pinky toe was not investigated for the source of the injury and reported to the required agencies. This failure resulted in Resident 4 being transferred to the emergency room (ER) for sutures and had the potential to place residents at risk for mistreatment, neglect and /or abuse. Findings: Review of Resident 4's Significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 1/4/23, indicated Resident 4 had unclear speech with slurred or mumbled word, rarely/never understood. Resident 4 had short and long term memory problem. Resident 4 had no behavioral symptoms. Resident 4's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the nurses notes dated 2/12/23 indicated Resident 4 laid on his floor mattress, and noted bleeding bright red with deep cut below his left pinky toe. The physician advised staff to send Resident 4 to the ER. During a review of Resident 4's nurses notes and concurrent interview on 4/20/23 at 12:42 p.m., the Director of Nursing (DON) stated Resident 4's laceration to the left pinky toe was an injury of unknown origin. DON stated the facility did not know the cause of the injury. DON further stated it was assumed Resident 4 bumped his leg on the wall or chair. DON said the facility did not investigate Resident 4's left pinky toe laceration or report to the Department. Review of the nurse's note dated 2/13/23, indicated Resident 4 returned from the ER with stitches to the left pinky toe laceration. Review of the facility's policy and procedure titled, Investigating Resident Injuries, revised April 2021, indicated if the nursing and medical assessment determines an injury of unknown source, the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. Review of the facility's policy and procedure, Abuse, revised and approved November 2022, indicated investigations of suspected abuse or suspicious circumstances or injuries/accidents of known or unknown origin require reporting. The Administrator reports, as indicated, to the appropriate agency: i. California Department of Public Health, licensing and Certification (DPHS L&C) - Supervisor.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when CNA 1 and 2 slapped Resident 1 five times in the back of the head, put a towel over her face, and called her a nasty b*#ch and CNA 1 and 2 were not removed from resident care during the facility's investigation of abuse. This failure resulted in Resident 1 crying out stop hitting me in the head and becoming combative when she started to spit. It was determined to constitute an Immediate Jeopardy situation (IJ). The Director of Nursing (DON) was verbally notified of the IJ on 12/1/16 at 2:30 p.m. The facility failed to protect residents from abuse when Students 1 and 2 witnessed the abuse of Resident 1 by CNA 1 and 2. Through interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of correction through in-services of employees regarding abuse prevention, recognition, and reporting. CNA 1 and 2 were placed on administrative leave on 12/1/16. CNA 1 returned to work on 12/8/16 and CNA 2 returned to work on 12/6/16. The IJ was abated on 12/14/16 at 12:02 p.m. when the Administrator said CNA 1 had self-terminated and CNA 2's performance would be monitored by pairing her up with another CNA and also checking for complaints with her assigned residents. Findings: Record review on 12/1/16 of the document titled, Admission Record, showed the facility admitted Resident 1 on 1/3/11 with a [DIAGNOSES REDACTED]. Record review of the document titled Minimum Data Set, Resident Assessment and Care Screening, (MDS), dated [DATE], showed Resident 1 was severely impaired (never or rarely made decisions) for daily activities. Resident 1's MDS also showed she had a short-term and long-term memory problem was sometimes able to understand others, and sometimes able to make herself understood. The MDS also showed Resident 1 had behaviors that included feeling or appearing down, depressed, or hopeless and being short-tempered or easily annoyed. Resident 1's MDS also showed she required the extensive assistance (resident involved in activity, staff provided weight-bearing support) of two staff persons for transfers and was totally dependent (staff performed entire activity) on two staff persons for personal hygiene. Review of Resident 1's undated care plan showed: a. She had an impaired cognitive (reasoning, memory, attention, and language) function and depression. The care plan showed instructions to staff to .provide the resident with necessary cues - stop and return if agitated .introduce yourself and let her know what you are about to do and what you expect her to do .offer opportunities for choice, simplify instruction; be flexible and patient and encourage involvement in daily life b. She .may have difficulty communicating and will say loudly 'go away or go to hell or mind your own business' if she was getting too much stimulation, or too many questions too fast, or was not understanding The care plan showed instructions to staff to .explain to her what you are doing and why c. She had a self-care problem with activities of daily living (ADL - routine activities that people tend do every day without needing assistance such as eating, bathing, dressing, toileting, transferring, and continence). The care plan showed instructions to staff to .segment (break up) the bathing process so it is not overwhelming for her and to explain what you are doing and what you expect her to do In an interview on 12/1/16 at 2 p.m., Student 1 stated that on 11/28/16 at 1:15 p.m. she was working in the facility with CNA 2 to provide hygiene care for Resident 1 in her room. CNA 1 came into Resident 1's room and sat down while CNA 2 began to change Resident 1's wet undergarment. CNA 2 did not tell Resident 1 what she was doing and Resident 1 became combative. CNA 2 grabbed Resident 1's arm and held it down. Student 1 stated that CNA 1 got up, took hold of Resident 1's other arm and then held her down. Resident 1 became increasingly combative and started to spit. Student 1 stated CNA 1 and 2 then rolled Resident 1 over and put a towel over her nose and mouth. Student 1 stated she heard Resident 1 say I can't breathe, and they took the towel off and rolled her to the other side. Student 1 stated, Resident 1 yelled Let go of me you b*#ches, and CNA 1 got mad and called her a Nasty B*#ch. Student 1 stated that CNAs 1 and 2 moved Resident 1 from her bed to the wheelchair, and then CNA 1 hit Resident 1 on the head five times, and Resident 1 said, Stop hitting me in the head, and CNA 2 was laughing. In an interview on 12/9/16 at 3:07 p.m., Student 2 stated that on 11/28/16 she was assigned to work with CNA 2 and their assignment included caring for Resident 1. At approximately 1:00 p.m., (on 11/28/16) CNA 2 began to change Resident 1's undergarment while she was in her bed. Student 2 stated CNA 1 came into Resident 1's room and sat in a chair. Resident 1 became agitated and told CNA 2 she did not want her (CNA 2) to change her undergarment. Student 2 stated CNA 2 continued to try to change the undergarment and Resident 1 then began to spit at her (CNA 2). Student 2 stated CNA 1 then came over to the bed and held Resident 1's arms down while CNA 2 worked on changing the undergarment. Resident 1 then started to spit at both CNA 1 and CNA 2 and she told them to stop (changing her undergarment). Student 2 stated CNA 1 and CNA 2 continued to try and change the undergarment. Student 2 stated Resident 1 was screaming and yelling and said, Don't hit me in the head again. Student 2 stated CNA 1 and CNA 2 then transferred Resident 1 into her wheel chair and both CNA1 and CNA 2 tried to tie a towel around Resident 1's mouth, but it fell off. Student 2 stated CNA 1 then started to hit the top of Resident 1's head with both of her hands and said Nasty b*#ch. Student 2 stated CNA 2 witnessed CNA 1 hitting the top of Resident 1's head and did not say or do anything. In an interview on 12/1/16 at 2:15 p.m., CNA 2 stated, when working with Resident 1 she needed extra help. CNA 2 stated that on 11/28/16 when they changed and dressed Resident 1 she Spit. In an interview on 12/1/16 at 2:40 p.m., CNA 1 stated, on 11/28/16, went into Resident 1's room to help CNA 2 put Resident 1 into the wheelchair. CNA 1 stated Resident 1 fusses, and gets a little Combative. CNA 1 stated Resident 1 spits so, We put a towel on her mouth. In an interview on 12/1/16 at 3:20 p.m., (fifty minutes after being notified of the IJ) the DON stated she needed to ask CNA 1 to leave because she was still in the in the facility. In an interview on 12/13/16 at 9:10 a.m., the Administrator (ADM) stated CNA 1 and CNA 2 had returned to work providing resident care at the facility. The ADM stated she was still working on the facility's investigation. The ADM stated she could not believe CNA 1 or CNA 2 would do this (abuse Resident 1) or lie about it. The ADM stated she had known them forever and would trust them with her life. Review of the facility document titled, Archived Time Card Report, dated 12/2/16 through 12/13/16 showed CNA 1 worked on 12/8/16, 12/9/16, 12/10/16, and 12/11/16 and CNA 2 worked on 12/6/16, 12/7/16, 12/10/16, 12/11/16, 12/12/16, and 12/13/16. Record review of the facility's policy and procedure titled, Abuse Prevention and Reporting, dated 11/2008, specified Policy: (the facility) is dedicated to providing quality care, which enhances quality of life for the frail elderly residents served. (The facility) strives to maintain compliance with applicable Federal State and Local laws, regulations and requirements. Additionally, (the facility) places value on best practices among community standards for care. Abuse, in all forms, including, physical, emotional / mental, and fiduciary is strictly prohibited. The IJ was removed on 12/14/16 at 12:02 p.m. after the ADM stated CNA 1 self-terminated. The ADM also stated all staff (including CNA 2) would be in-serviced again, through lecture and question and answer, on (recognizing) abuse and their responsibilities as mandated reporters. The ADM stated the facility would closely monitor CNA 2's performance by pairing her up with another CNA and also checking for complaints with her assigned residents.

Based on interview and record review, for one of three sampled residents (Resident1), the facility failed to implement their abuse prevention and reporting policy and procedure when: Two student Certified Nursing Assistants (Student 1 and 2) witnessed CNA 1 and 2 slapped Resident 1 five times in the back of the head, put a towel over her face, and called her a nasty b*#ch. Student 1 and Student 2 reported the witnessed abuse to their instructor Licensed Vocational Nurse (LVN 1), an employee of a contracted CNA training program, who did not report it to the facility. This failure had the potential to result in continued abuse by CNA 1 and CNA 2 when they were allowed to continue providing resident care. It was determined to constitute an Immediate Jeopardy situation (IJ). The Director of Nursing (DON) was verbally notified of the IJ on 12/1/16 at 2:30 p.m. The facility failed to implement their abuse prevention and reporting policy and procedure when Students 1 and 2 witnessed the abuse of Resident 1 by CNA 1 and 2 and LVN 1 did not report the alleged abuse to the facility. Through interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of correction through in-services of employees regarding abuse prevention, recognition, and reporting. CNA 1 and 2 were placed on administrative leave on 12/1/16 at 3:20 p.m. (50 minutes after the facility was notified of the IJ). The IJ was abated on 12/14/16 at 12:02 p.m. Findings: In an interview on 12/1/16 at 12:30 p.m., Registered Nurse (RN 1) stated Students 1 and 2 were in a training program not affiliated with the facility, but did their clinical practice training at the facility. RN 1 stated that while the students are at the facility, they were supervised by a Licensed Vocational Nurse (LVN 1) who worked for a Certified Nurse Aid training program that had a contract with the facility to use its facilities for clinical rotation/training of its Certified Nursing Assistant and Home Health Aide Students. In an interview on 12/1/16 at 2 p.m., Student 1 stated that on 11/28/16 at 1:15 p.m. she was working in the facility with CNA 2 to provide hygiene care for Resident 1 in her room. CNA 1 came into Resident 1's room and sat down while CNA 2 began to change Resident 1's wet undergarment. CNA 2 did not tell Resident 1 what she was doing and Resident 1 became combative. CNA 2 grabbed Resident 1's arm and held it down. Student 1 stated that CNA 1 got up, took hold of Resident 1's other arm and then held her down. Resident 1 became increasingly combative and started to spit. Student 1 stated CNA 1 and 2 then rolled Resident 1 over and put a towel over her nose and mouth. Student 1 stated she heard Resident 1 say I can't breathe, and they took the towel off and rolled her to the other side. Student 1 stated, Resident 1 yelled Let go of me you b*#ches, and CNA 1 got mad and called her a Nasty B*#ch. Student 1 stated that CNAs 1 and 2 moved Resident 1 from her bed to the wheelchair, and then CNA 1 hit Resident 1 on the head five times, and Resident 1 said, Stop hitting me in the head, and CNA 2 was laughing. Student 1 stated that she thought that was abuse and she told her instructor (LVN 1) who told Student 1 to ignore it and then she brushed it off. Student 1 stated she called her instructor at the training program (RN 1) and reported the incident. In an interview on 12/9/16 at 3:07 p.m., Student 2 stated that on 11/28/16 she was assigned to work with CNA 2 and their assignment included caring for Resident 1. At approximately 1:00 p.m., (on 11/28/16) CNA 2 began to change Resident 1's brief while she was in her bed. Student 2 stated CNA 1 came into Resident 1's room and sat in a chair. Resident 1 became agitated and told CNA 2 she did not want her (CNA 2) to change her brief. Student 2 stated CNA 2 continued to try to change the brief and Resident 1 then began to spit at her (CNA 2). Student 2 stated CNA 1 then came over to the bed and held Resident 1's arms down while CNA 2 worked on changing the brief. Resident 1 then started to spit at both CNA 1 and CNA 2 and she told them to stop (changing her brief). Student 2 stated CNA 1 and CNA 2 continued to try and change the brief. Student 2 stated Resident 1 was screaming and yelling and said, Don't hit me in the head again. Student 2 stated CNA 1 and CNA 2 then transferred Resident 1 into her wheel chair and both CNA1 and CNA 2 tried to tie a towel around Resident 1's mouth, but it fell off. Student 2 stated CNA 1 then started to hit the top of Resident 1's head with both of her hands and said Resident 1 was a Nasty b*#ch. Student 2 stated CNA 2 witnessed CNA 1 hitting the top of Resident 1's head and did not say or do anything. In an interview on 12/9/16 at 3:49 p.m. Student 2 stated she reported what she witnessed to LVN 1 and LVN 1 said she did not want to get involved. In an interview on 12/9/16 at 2:59 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she recalled Students 1 and 2 reported to her that CNAs 1 and 2 had been verbally rough with Resident 1. LVN 1 stated she told the students to report the incident if they believed they had witnessed an intent to harm Resident 1. During an interview on 12/12/16 at 4:15 p.m. the Administrator (ADM) stated the facility ensures CNA students are trained in abuse when the facility sets up the contract with the CNA schools - students were to watch two Department of Justice (DOJ) videos on elder abuse. The ADM also stated the teacher (LVN) onsite was responsible for the students - the LVN prepared with the students and worked closely with the students. In an interview on 12/13/16 at 9:10 a.m., the Administrator (ADM) stated she just could not believe CNA 1 or CNA 2 would do this or lie about it. The ADM stated she had known them forever and would trust them with her life. The ADM stated she was still working on the facility's investigation. Review of the contract between the facility and the training program showed: .2. Responsibilities of School .(the School), its students, and faculty will adhere to all policies and procedures set forth by (the facility) .2(B)(10) (the School) and Clinical site (facility) will enforce rules and regulations governing the workers that are mutually agreed upon by the School and the Clinical site (facility) .2(B)(A) the .School will notify the students that they are responsible for: 1. Following the administrative policies of the clinical site Record review of the facility's policy and procedure titled, Abuse Prevention and Reporting, dated 11/2008, indicated Policy .All employees of (the facility) are considered 'mandated reporters' relative to Elder Abuse or Neglect .10. Any staff member who identifies a suspicious event that may be evidence of abuse is responsible to report their concerns .10(a). An internal event report is filled out, documenting the time, place and situation of concern .10(b). The Administrator or On-Call Administrative staff is notified The IJ was removed on 12/14/16 at 12:02 p.m. after the ADM stated CNA 1 self-terminated. The ADM also stated all staff (including CNA 2) would be in-serviced again, through lecture and question and answer, on (recognizing) abuse and their responsibilities as mandated reporters. The ADM stated the facility would closely monitor CNA 2's performance by pairing her up with another CNA and also checking for complaints with her assigned residents.

Based on interview and record review, the facility failed notify and consult with the physician of one of two sampled discharged residents (1) regarding the resident's swollen, painful and disfigured right leg, before transferring the resident to skilled nursing facility B, resulting in the resident being sent to the emergency room soon after arriving at facility B. At the emergency room Resident 1 was diagnosed with [REDACTED]. Findings: On[DATE] record review of the Tansfer Summary from the acute care hospital A for Resident 1, dated [DATE], showed Resident 1was a [AGE] year old female admitted on [DATE] with a new [DIAGNOSES REDACTED]. She had bilateral lower extremity paraparesis (paralysis of her legs) which was getting worse due to her bed bound status at the hospital and she had increasing pain. At acute care hospital A, Physical Therapy tried to work with her, but she had declined secondary to pain. The Transfer Summary further reflected that she had [MEDICAL CONDITION] on her right iliac crest (hip bone) and a pathological [MEDICAL CONDITION] hip and she needed skilled nursing care. According to the facility nurses notes dated [DATE] at 2:30 p.m,. an urgent call was placed to the physician regarding the resident's increasing pain and refusal of her routine pain medication [MEDICATION NAME] 5 mg. (milligrams). The note further revealed that the (physician's) "receptionist" was told of the condition and was asked to page the physician for authorization of [MEDICATION NAME] or [MEDICATION NAME] and a right knee x-ray because the resident was complaining of pain in the right knee while transferring with physical therapy. The nurse's note dated [DATE] at 4:30 p.m. revealed that the physician called back and asked to speak with the resident and the resident stated that she would like to leave the facility. The physician gave an order to discharge the resident with her medications and gave an order to start [MEDICATION NAME]. The note did not mention if the nurse spoke with the physician about the earlier request for an X-ray of the right knee. A nurses note dated [DATE] at 11:30 a.m. reflected, "Late entry...@10:30 a.m. Screaming out for pain during ADL's (activities of daily living)...R (right) leg mostly tender to touch, R leg slightly shorter than L (left) leg and externally rotated (turned outward), [MEDICATION NAME] sulfate 0.5 ml po s/l (by mouth under the tongue) given." The note went on to reveal that the physician was called and the nurse spoke with the physician's administrative assistant who relayed that the physician would be informed when he come in at 2 p.m. The note ended with "Elder remains stable at this time, transported by two EMT's (emergency medical technicians) via gurney to (receiving skilled nursing facility)." There was no indication that the nurse spoke to the physician about the symptoms of pain,swelling of the right leg and asking the physician to delay the transfer until x-ray was done. In a telephone interview with the physician on [DATE] at 10:30 a.m. he stated that he visited the resident on [DATE] and at that time she was not complaining of pain in her leg. The nursing staff didn't say anything to him about the right knee or leg swelling. He said that the resident's daughter called him on [DATE] in the morning either in the midst of her transfer or after her transfer telling him that her mother was complaining of pain in her leg. Then he stated that the new skilled nursing facility where the resident had just been transferred to called regarding her painful leg. The physician asked if they could get a "stat" (right away) x-ray and they weren't comfortable with that and wanted to call 911, which the physician said "O.K" He suspected a pathologic fracture given her [DIAGNOSES REDACTED]. According to the receiving skilled nursing facility admission nursing note written on [DATE] at 1:13 p.m. "admitted a [AGE] year female...by ambulance gurney...Pt (patient) accompanied by daughter. Pt screaming and yelling on admission...Pt uncooperative due to body pains when move, turn to sides..." Another nurses note revealed on [DATE] at 4 p.m. "(physician) called and gave order for stat x-ray of right hip to r/o (rule out) fracture...Assessment done on patient since (physician) is calling with concerns about the right hip being fractured. VS (vital signs) 97 46 8 ,[DATE] (97 temperature, 46 pulse, 8 respirations, ,[DATE] blood pressure - (all sub normal vital signs) unable to obtain 02 (oxygen) saturation, patient has pinpoint pupils, very cold hands with purple discolorations and patient is extremely lethargic and only opens her eyes when she is touched or talked to very loudly. Right leg is turned outward and in an awkward position. Oxygen applied via mask at 15 liters/min and 911 called." Upon review of the acute care medical record on [DATE] the Portable hip X-ray taken on [DATE] revealed that the Resident's right femur (upper leg bone) was fractured at the proximal third (upper third of the leg bone closer to the hip) and was "...highly suspicious for a pathologic fracture (caused or affected by disease e.g. [MEDICAL CONDITION])...". The discharge summary dated [DATE] from the acute care hospital revealed that the resident was admitted on [DATE] and died on [DATE]. The "Hospital Course" section of the discharge summary reflected that the resident was admitted with significant pain and low blood pressure. She had a history of [REDACTED]. The Pain was controlled. She had a right [MEDICAL CONDITION] with significant foreshortening and external rotation of the right leg. After discussing the case with the resident's daughter and granddaughter, and given her very poor prognosis, a comfort care modality was pursued and the resident died on [DATE].