Every finding on record at Citrus Nursing Center

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices and sanitary environment were followed when:a. Resident 101's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated.b. Resident 84's oxygen tubing (is a small flexible plastic tube that connects to an oxygen source) [like machine or tank] was not labeled and dated per facility's policy and procedure (P&P). c. A facility's janitor ([DATE]) removed multiple pillows from several trash containers and placed them on a handrail at the facility's rear entrance/exit next to the laundry room.These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 85 medically compromised residents and staff in the facility.Findings: a. During a review of Resident 101's admission Record (contains medical and demographic information), the “admission Record” indicated Resident 101 was admitted to the facility on [DATE] with the diagnoses which included chronic respiratory failure with hypercapnia (lungs are unable to exchange oxygen leading to too much carbon dioxide in the blood), Cardiomegaly (enlarged heart), and Myocardial Infraction (heart attack). During a review of Resident 101's Physician Order dated July 28, 2025, the “Physician Order” indicated, Change oxygen nasal cannula q [every] day shift, on Sunday and PRN [as needed]. During an observation on July 28, 2025, at 3:21 PM, in Resident 101's room, Resident 101 was lying in bed, watching television. There was an oxygen nasal cannula tubing in use by Resident 101, attached to an oxygen concentrator (device that provides supplemental oxygen). The oxygen nasal cannula tubing was unlabeled and undated. During a concurrent observation and interview on July 28, 2025, at 3:27 PM, with a Licensed Vocational Nurse 2 (LVN 2), in Resident 101's room, LVN 2 inspected Resident 101’s oxygen nasal cannula tubing. LVN 2 stated the oxygen nasal cannula tubing was not labeled and should have been labeled and dated. During a concurrent interview and record review on July 31, 2025, at 8:31 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration,” dated May 2024 was reviewed. The P&P indicated, . 4.b. Change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The DON stated the P&P was not followed and should have been for infection control prevention. b. During a review of Resident 84’s “admission Record (contains demographic and medical information) the admission record indicated Resident 84 was admitted to the facility on [DATE], with the diagnoses of acute respiratory failure with hypoxia (not enough oxygen in the blood), heart failure, unspecified (heart not pumping enough blood), and hypertensive heart disease with heart failure (condition that forces the heart to work harder that it should). During an observation on July 28, 2025, at 1:17 PM, Resident 84 with a nasal cannula tubing in place (oxygen through a nose) was sitting in a wheelchair in the south nursing station flipping through magazines. Resident 84’s nasal cannula oxygen tubing was connected to a portable oxygen tank (oxygen storage) that was stored behind the wheelchair. There was no label and no date on the nasal cannula oxygen tubing. During an interview on July 28, 2025, at 1:20 PM with a Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the oxygen tubing was not labeled and is unsure when it was changed. During an interview on July 28, 2025, at 1:21 PM with Registered Nurse 1 (RN 1), RN 1 stated the oxygen tubing was not labeled and has no date. During a review of Resident 84’s “Physician Order” dated March 24, 2025, the “Physician Order” indicated, “…Oxygen via Nasal Canula at 2 liters per minute (L-liters-unit of measurement/min-minutes) may titrate (slowly increase or decrease over a period of time) O2 (Oxygen) to maintain SPO2 (levels of oxygen in the blood) greater or equal to 92% (95-100 is considered normal, with lower levels being acceptable for COPD), as needed for sob (shortness of breath) r/t (related to), CHF (congestive heart failure…”) During a concurrent interview and record review on July 31, 2025, at 8:31 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration,” dated May 2024 was reviewed. The P&P indicated, . 4.b. Change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. The DON stated the P&P was not followed and should have been for infection control prevention. c. During an observation on July 29, 2025, at 2:28 PM, there were five pillows (without pillowcases) observed to be on the handrail at the rear entrance/exit of the facility near the laundry room. The pillows were tucked between the handrail and a wooden fence where multiple staff members were observed to be entering and exiting the building. During an observation on July 30, 2025, at 9:45 AM, the five pillows observed to be on the handrail near the entrance/exit of the facility were still on the handrail. During an interview on July 31, 2025, at 2:05 PM, with the Environmental Services Director (ESD), the ESD stated janitor 1 ([DATE]) placed the pillows on the handrail between the railing and the fence outside the exit/entrance door near the laundry room because the ([DATE]) thought the pillows needed to be washed and returned to residents. ESD stated the pillows actually were meant to be thrown away by the laundry staff and needed to be replaced. ESD stated [DATE] thought they were mistakenly placed in the trash so he ([DATE]) removed them from the trash and placed them on the handrail. ESD further stated the pillows should never have been removed from the trash and should have remained in the trash and been discarded with the trash. During an interview on July 31, 2025, at 2:40 PM, [DATE] stated the ESD had previously told him to be on the lookout for things in the trash that may not actually be trash but were in the trash bins. When asked about the pillows observed to be on the handrail near the rear entrance/exit of the facility. [DATE] stated he removed multiple pillows from trash bins which were part of the dirty linen and trash bin carts (a cart with wheels that has two bags, one bag is for dirty linen while the other bag is allocated for trash) located throughout the facility. [DATE] stated the dirty linen/trash bin carts which he retrieved the pillows from were from multiple different carts throughout the facility and stated the carts contained dirty linen and trash from resident rooms throughout the facility. [DATE] stated he thought the pillows were placed in the trash side of the cart by accident, so he removed them (the pillows) from the trash and placed them on the rail for processing by laundry staff. During an interview on July 31, 2025, at 2:46 PM, with the Infection Preventionist (IP), the IP stated the janitor should not have removed anything from the trash and the pillows he removed from the trash should not have been placed on the railing outside the laundry area. The IP further stated the pillows were already in the trash and disposed of and were dirty with “who knows what kind of bacteria or germs so once its in there it should be discarded.” During an interview on July 31, 2025, at 3:20 PM, with the Director of Nursing (DON), the DON stated the trash should stay in the trash containers and pillows should not have been removed from trash receptacles and placed on the rail near the laundry because of infection control reasons. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention and Control Program,” dated September 2, 2022, the P&P indicated, “This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines…9. Equipment protocol: …c. Reusable items potentially contaminated with infectious materials shall be placed in a impervious clear plastic bag. Label bag as “CONTAMINATED” and place in the soiled utility room for pickup and processing…11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection…”

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for residents who reside in the facility when on July 29, 2025, the North hallway shower room was found to have black substance on the shower stalls.This failure had the potential to exposed the residents using this shower room to increased risks of developing allergies, skin irritation, and serious respiratory issues.Findings:During an observation on July 29, 2025, at 2:30 PM in the residents' shower room in North hallway, the three shower stalls were found to have a black substance on the shower stalls floors, walls, and where the wall meets the floor and the ceiling. The substance was also present on the wall joints, and on and between the tiles. During an interview on July 29, 2025, at 2:40 PM, Certified Nursing Assistant 1 (CNA 1) confirmed and stated that this shower room is used by all residents in North hallway.During a concurrent observation and interview with the Environmental Services Director of Maintenance (ESD) on July 29, 2025, at 2:58 PM, the ESD acknowledged the presence of a black substance on the shower stalls floors, walls, and where the wall meets the floor and the ceiling in the North Hallway shower room multiple shower stalls. The ESD stated this black substance might be a buildup from shampoo oils and soap scum. He mentioned a black crack where the ceiling meets the wall noting that this was the first time he had observed the ceiling issue since he started working at the facility in April 2025.During an observation and interview with the Director of Nursing (DON) on July 29, 2025, at 3:33 PM, the DON inspected the North Hallway shower room multiple shower stalls. She identified and confirmed the presence of black substances between the tiles, on tile surfaces, and observed black mold bleeding from the walls and ceilings. When ask about the suitability of the shower room for resident's use, the DON acknowledged that the showers were not suitable for residents in their current state.During a concurrent interview and record review on July 30, 2025, at 4:12 PM the facility's Policy and Procedure (P&P) titled, Routine bathroom cleaning, revised on December 19, 2022, was reviewed with the Administrator (Admin) and the ESD. The facility's P&P indicated, It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of health care associated infection (HAI) . Procedure 1. (h) clean shower/tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout for mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head. Allow sufficient contact time for disinfectant according to manufacturer's recommendations. Rinse and wipe dry. Inspect shower curtain and replace as required . 4. Report areas of mold, cracked, leaking or damaged items in need of repair. The ADMIN and the ESD stated the facility's P&P were not followed.

Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff accurately and consistently monitored and documented fluid intake and output (intake refers to the total amount of fluids a person consumes, while output refers to the total amount of fluids the body eliminates) for one of one resident reviewed for urinary catheters (Resident 100), when Resident 100's intake and output record had blanks (no data recorded), documentation was not in the correct milliliter (ml - unit of measure) format, and there was no policy and procedure regarding monitoring and documenting intake and output as specified in Resident 100's care plan (an individualized plan for the medical care of a resident).These failures resulted in inconsistencies in the monitoring and documentation of Resident 100's intake and output which had the potential for Resident 100's medical record to inaccurately portray his fluid balance, and functional urinary status.Findings:During a review of Resident 100's admission Record (contains medical and demographic information), the admission Record, indicated Resident 100 was admitted on [DATE], with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (the non-cancerous enlargement of the prostate gland, causing a range of urinary problems), hereditary and idiopathic neuropathy (hereditary neuropathy is a group of genetic disorders causing peripheral nerve damage, while idiopathic neuropathy refers to nerve damage with an unknown cause), and secondary malignant neoplasm of the brain (cancer that has started somewhere else in the body has spread to the brain).During a concurrent observation and interview on July 29, 2025, at 10:00 AM, with Resident 100, Resident 100 was observed lying in bed. Resident 100 stated he recently had an indwelling urinary catheter placed because he was not able to urinate on his own.During a review of Resident 100's physician's orders, dated July 22, 2025, indicated, Record intake & [and] output every shift x14 [for fourteen] days. Reassess continuation of intake & output after 14 days.During a review of Resident 100's physician's orders, dated July 23, 2025, the order indicated Resident 100 had an indwelling foley catheter (a thin, flexible tube inserted into the bladder to drain urine).During a concurrent interview and record review on July 31, 2025, at 9:51 AM, with the Director Of Nursing (DON), Resident 100's Monitor Record (document used by licensed nursing staff to record intake and output), dated July 1, 2025, through July 31, 2025, was reviewed. The Monitor Record, indicated the following:-For Friday, July 25, 2025, during the 7:00 AM - 3:00 PM nursing shift, and Tuesday, July 29, 2025, during the 3:00 PM - 11:00 PM nursing shift, there were blanks where Resident 100's intake and output was supposed to be documented.-For thirteen (13) of 26 documented shifts, output was documented as x1 (one time) or x2 (two times) and was not in milliliter (volume) format.-For 10 of 26 documented shifts, output was documented as milliliters volume.The DON acknowledged Resident 100's intake and output Monitor Record, for the month of July 2025 had blanks where intake and output was not documented by staff and stated licensed nurses should have documented the resident's intake and output on the days where there were blanks but stated they did not. Additionally, the DON stated output should have been recorded in milliliter volume instead of the number of times the resident urinated and stated the documentation was incorrect. The DON stated the certified nursing assistants (CNA) also recorded the amount of urine output they drained from the catheter bag but stated she was not sure if the CNA documented values were in addition to the values recorded by the licensed nurses. The DON stated the documentation for intake and output seemed to be inconsistent.During a review of Resident 100's care plan titled, The resident has indwelling catheter: neurogenic bladder [a condition where the nerves that control bladder function are damaged or impaired] . dated July 23, 2025, the care plan indicated, the resident has indwelling catheter: neurogenic bladder.Monitor and document intake and output as per facility policy.During an interview on July 31, 2025, at 2:05 PM, with the DON, when asked for the facility's policy and procedure (P&P) regarding monitoring and documenting of intake and output as specified in Resident 100's care plan. The DON stated she was not sure if the facility had a P&P regarding monitoring and documenting intake and output and stated the Nurse Consultant (NC) would know.During a concurrent interview and record review on July 31, 2025, at 2:06 PM, with the NC, Resident 100's care plan titled, The resident has indwelling catheter: neurogenic bladder . dated July 23, 2025, was reviewed. The NC acknowledged the care plan indicated Monitor and document intake and output as per facility policy. The NC stated the facility did not have a P&P regarding monitoring and documenting intake and output as specified in Resident 100's care plan and that she had looked but was unable to find one.During a review of the facility's P&P titled, Documentation in Medical Record, dated December 19, 2022, the policy indicated, .Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.3. Principles of documentation include, but are not limited to: .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observation, interview, and record review, the facility failed to ensure the Order Summary Diet Order (a list of provider orders) was followed for one of three residents (Resident 21) reviewed for dining observations when Resident 21 did not receive his physician ordered Boost VHC ( nutritional supplement, very high calories) with meals for lunch on July 29, 2025 and for breakfast on July 30, 2025.These failures had the potential to have contributed to Resident 21's weight loss.Findings:During a review of Resident 21's admission Record (contains medical and demographic information), it indicated Resident 21 was admitted to the facility on [DATE], with the diagnoses which included Myocardial infraction (heart attack), Dementia (a progressive state of decline in mental abilities) and immunodeficiency( a condition where the body's immune system is weakened, making it less able to fight off infections and diseases).During a review of Residents 21's Order Summary Diet Order, dated July 18, 2025, the Order Summary Diet Order indicated, receive boost VHC TID (three time a day) with meals . During a review of Resident 21's weight record, the weight record indicated Resident 21's weight on March 28,2025 was 118 pounds, and 102 pounds on July 8, 2025 (Resident 21 lost 16 pounds from March 28, 2025, to July 8, 2025).During a review of Resident 21's IDT (Interdisciplinary Team) Progress Notes, dated July 16, 2025, indicated .weight loss of 13 pounds in one month and a 15-pound weight loss in three months due to poor meal intake range of 10%-70% average per week. Registered Dietitian recommended appetite simulant. add Boost VHC TID with meals.During a lunch observation on July 29, 2025, at 12:42 PM in Resident 21's room, Resident 21 was sitting at the edge of the bed with a lunch tray on his side table. No Boost VHC was observed on the tray, and none was provided after Resident 21 finished eating. During a breakfast observation on July 30, 2025, at 7:30 AM, in Resident 21's room, Resident 21 was sitting at the end of the bed with a breakfast tray on his side table. No Boost VHC was observed on the tray, and none was provided after Resident 21 finished eating.During a concurrent observation, interview, and record review on July 30, 2025, at 8:06 AM with a Licensed Vocational Nurse 4 (LVN 4) in Resident 21's room, Resident 21's meal tray did not have Boost VHC. LVN 4 reviewed Resident 21's Order Summary Diet Order and stated the order was not followed and should have been. During a phone interview on July 30, 2025, at 1:22 PM with the Registered Dietician (RD), the RD stated Resident 21 currently has a Boost VHC ordered TID and should be given with meals.During a concurrent interview and record review on July 30, 2025, at 1:43 PM with the Director of Nursing (DON), the Order Summary Diet Order dated July 18, 2025, was reviewed. The Order Summary Diet Order indicated, Boost VHC TID with meals. Subsequently, the DON reviewed Resident 21's medical record from July 18,2025 to July 29, 2025. The DON stated there was no documentation for Resident 21's Boost VHC intake. During a concurrent interview and record review on July 30, 2025, at 2:09 PM, with the DON, the facility's policy and procedure (P&P) titled, Nutritional and Dietary Supplements, dated December 2022 was reviewed. The P&P indicated, .2. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs.The DON stated the P&P was not followed for Resident 21.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of three sampled medication carts (South Cart ) with narcotics when Resident 100's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) was found to be inaccurate.This failure had the potential to place the facility at risk for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff .Findings:During a review of Resident 100's clinical records, the admission Record, indicated Resident 100 was admitted on [DATE], with diagnoses which included, pressure ulcers stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), spinal stenosis (a condition where the spinal canal narrows, putting pressure on the spinal cord and/or the nerves), and neuropathy (damage to or disease affecting the nerves, outside the brain and spinal cord).During a review of Resident 100's Order Summary, dated July21, 2025, indicated, Pregabalin (medication used to treat neuropathic pain) oral capsule 25 mg (miligrams-a unit of measurement), give 1 capsule by mouth two times a day for Neuropathy.During a concurrent observation, interview, and record review on July 31, 2025, at 9:00 AM, with a Licensed Vocational Nurse 4 (LVN 4), at South Unit Station Cart, the South Unit Station Cart CDR was inspected. Resident 100's Pregabalin 25 mg CDR indicated 13 tablets were administered (one tablet was unaccounted for). Resident 100's Pregabalin 25 milligram pill bubble packet (a card that packages doses of medications within plastic bubbles organized by day and time of the day) indicated it contained 28 quantities. LVN 4 counted the contents of the bubble pack and stated there were 14 remaining tablets, and 14 tablets had been administered to Resident 100. During a follow up interview on July 31, 2025, at 9:10 AM, with LVN 4, LVN 4 stated one pill was given to Resident 100, and she forgot to document it on the CDR but did document it in the EMR. She further stated the expectation is when a controlled medication is given it should be documented in the CDR and the EMR and the contents of the bubble pack should match its CDR to prevent drug diversion.During a concurrent interview and record review, on July 31, 2025, at 12:24 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Controlled Substances Administration & Accountability, dated June 2023, was reviewed. The P&P indicated, .1. General Protocols. f. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the medication administration record, controlled drug record, or other facility specified form and placed in the patient's medical record. h. The controlled drug (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient specific narcotic dispensed from the pharmacy.4. Obtaining/Removing/Destroying Medications.a. The entire amount of controlled substances obtained or dispensed is accounted for. The DON stated the licensed nurse is expected to document dispensed narcotics in Resident's MAR and CDR to prevent potential drug diversion.The DON further stated the facility's policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure medical supplies were labeled and stored in accordance with currently accepted professional principles when an intravenous (giving medications through the vein) (IV) cart (a mobile cart used to store and transport medications and other supplies to patients) was found with expired supplies.These failures had the potential for the supplies to be less effective and compromised health and safety for the highly vulnerable population of 85 Residents in the facility.Findings:During a concurrent observation and interview on [DATE], at 12:23 PM, with the Director of Nursing (DON), the intravenous (IV) cart (a mobile storage unit designated to hold and transport medical supplies for intravenous medication and other treatment) was inspected. The following items were found expired and available for use:1. Six alcohol swabs (small, disposable pads or wipes that are saturated with isopropyl alcohol) were found with the following expiration dates: three with an expiration date of [DATE] (484 days expired) and three with an expiration date of March,2025 (119 days expired).2. Two povidone -iodine swab sticks (two swab sticks per pack- an antiseptic prep used on the skin to decrease risk of infection) were found with an expiration date of [DATE] (861 days expired).3. Eight Chlora prep triple swab sticks (sterile skin antiseptic swab stick) were found with the following expiration dates: one with an expiration date of [DATE] (908 days expired), Five with an expiration date of [DATE] ( 849 days expired), one with an expiration date of [DATE] ( 605 days expired), and one with an expiration date of [DATE] (574 days expired).4. Five luer lock tip caps (tip used to keep material in a syringe or IV when not in use and prevent contamination) were found with an expiration date of [DATE] (88 days expired).5. 24 red end caps (end caps used to keep material in a syringe or IV, when not in use, protected and to prevent contamination) were found with an expiration date of [DATE] (23 days expired).The DON acknowledged the items in the IV cart were expired and should have been discarded. The DON further stated the license staff are responsible for checking expiration date in the IV cart every shift. During an interview on [DATE], at 4:10 PM with the DON, the DON stated that the facility does not have a policy for supply storage and management.

Based on observation, interview, and record review, the facility failed to adequately protect and safeguard the healthcare identifiable information for two out of 25 sampled residents (Resident 7 and 89) when on July 30, 2025, the laptop screen of the Electronic Medical Record (EMR) (electronic form of record keeping) used by Licensed Vocational Nurse 3 (LVN 3) were:1. Left open, unsecured and unattended from 05:44 AM to 5:47 AM, for a total of 3 minutes in the North hallway for Resident 7.2. Left open, unsecured and unattended from 6:08 AM AM to 6:12 AM, for a total of 4 minutes in the North hallway for Resident 89. This failure resulted in the exposure of health-related identifiable information for Residents 7 and 89 when records were left unsecured and unattended in a location easily accessible to residents, visitors, and other unauthorized individuals, which led to a breach of resident confidentiality, violations of resident's privacy, potential loss of sensitive personal information.Findings:1. During an observation on July 30, 2025, at 5:44 AM, LVN 3 was in the North hallway preparing the morning medications for Resident 7. LVN 3 frequently referred to the Electronic Medical Records (EMR) displayed on a laptop situated on top of the medication cart. After performing hand hygiene and locking the medication cart, LVN 3 entered Resident 7's room leaving the EMR laptop screen containing Resident 7's medical information open, unsecured, and unattended. During an observation on July 30, 2025, at 5:47 AM, LVN 3 exited the Resident 7's room. Upon stepping back into the hallway, LVN 3 realized that the EMR laptop screen was open and unsecured. LVN 3 immediately stated that she usually turns off or hides screens containing private information because she understands the importance of protecting patient confidentiality and knows that leaving the screen open constitutes a Health Insurance Portability and Accountability Act (HIPPA is a U.S. federal law enacted in 1996 and primarily aims to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) violation confirming she should have not left the EMP laptop screening open, unsecured, and unattended. A review of the Resident 7's Face Sheet (document containing demographic information) indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which include this dysphasia (difficulty swallowing), chronic obstructive pulmonary disease (lung diseases that block airflow, making it difficult to breathe), hypertension (high blood pressure).A review of Resident 7's History and Physical (H&P) dated April 2, 2025, indicated Resident 7 does not have the capacity to understand and make decisions.2. During an observation on July 30, 2025 at 6:08 AM, LVN 3 was stationed on the North hallway. Further observation, LVN 3 unlocked the laptop screen situated on top of the medication cart to check Resident 89's physician orders. LVN 3 left the North hallway, leaving the laptop screen unlocked, unsecured, and unattended, with Resident 89's medical information visible to anyone passing by. LVN 3 returned to the medication cart at 6:12 AM, explaining that she had gone to the nursing station to wash her hands. LVN 3 confirmed the laptop screen remained open and acknowledged that she had forgotten to lock it and secure it again. A review of the Resident 89's Face Sheet indicated Resident 89 was admitted to the facility on [DATE], with diagnoses which include chronic obstructive pulmonary disease (lung diseases that block airflow, making it difficult to breathe), heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), diabetes mellitus (a disease that occurs when your blood sugar is too high).A review of the resident 89's History and Physical (H&P) dated May 21, 2025, indicated Resident 89 does not have the capacity to understand and make decisions.During an interview with LVN 4 on July 31, 2025, at 10:22 AM, LVN 4 was asked how staff protect electronic medical records from unauthorized viewing. LVN 4 explained she uses a lock button feature that hides the screen when not in use and states she locks the screen every time she turns away or steps away from the laptop. LVN 4 further emphasized the importance of adhering to stringent security protocols to safeguard sensitive patient information. LVN 4 highlighted that consistently utilizing the lock button feature significantly reduces the risk of unauthorized access to electronic medical records. LVN 4 underlined that this practice is in accordance with HIPPA regulations which requires strict measures to protect patient data.During an interview with Registered Nurse 1 (RN 1) on July 31, 2025, at 10:33 AM, RN 1 was asked how staff protect electronic medical records from unauthorized viewing. RN 1 explained her approach to safeguarding electronic medical records (EMR) by completely turning off and logging out of computers when stepping away, rather than just relying on privacy screens. She emphasized this practice is especially important when using mobile computers for medication administration.During a concurrent interview and record review on July 31, 2025, at 10:52 AM, with the administrator (ADMIN), the facility's Policy and Procedure (P&P) titled, Safeguarding of Resident Identifiable Information, revised on December 19, 2022, was reviewed. The P&P states, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records. Policy explanation and compliance guidelines: .4. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information . 7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. The ADMIN confirmed that staff are expected to lock computers when stepping away to protect resident information. The ADMIN confirmed LVN 3 did not follow the facility's P&P.During a concurrent interview and record review on July 31, 2025, at 11:15 AM, with the Director of Nursing (DON), the P&P titled, Safeguarding of Resident Identifiable Information, revised on December 19, 2022, was reviewed. The P&P states, 4. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information . 7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. The DON acknowledged LVN 3 did not follow the facility's P&P.

Based on interview and record review, the facility failed to ensure proper care was provided to prevent a blister (a painful swelling on the surface of the skin), for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired blister to the right heel (back of the human foot below the ankle) developed while in the facility. Findings: During a review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which there is too much sugar in the blood and the body is not able to control the sugar ), muscle wasting and atrophy (a condition with shrinking and loss of muscle), and depression (a condition with feeling of sadness and hopelessness). During an interview on November 19, 2024, at 8::55 AM, with Resident 1, Resident stated, They told me, I got a blister on my foot. I did not have any wounds on my feet until I got here. During an interview on November 19, 2024, at 10:15 AM, with Wound Treatment Nurse (WTN), WTN stated, She has a wound on her right heel which started as a blister some weeks ago. During an interview on November 19, 2024, at 10:20 AM, with Assistant Director of Nursing (ADON), ADON stated, The blister on her right heel developed after admission but was already there before November 1, 2024. During a phone interview on December 3, 2024, at 10:40 AM, with the ADON, ADON acknowledged that Resident 1 did not have wounds on her heels upon admission (October 5, 2024). ADON stated, A fluid blister was observed on October 30, 2024. Review of following facility records: 1. Admission Skin Issues: October 5, 2024, 10:43. Skin warm and dry, skin color within normal limit and turgor (the ability of skin to change shape and return to normal) is normal. Resident does not have an external device. Foot evaluation completed . Skin Issue: # (number) 001 . Lower back . #002: Right shin . 2. Braden Evaluation ([Severe risk total score: less than 9, High risk total score: 10-12, moderate risk total score: 13-14, Mild risk: total score: 15-18]): .Braden score: 13.0 3. Situation, Background, Assessment and Recommendation (SBAR) communication record dated October 30, 2024, indicate, . Noted fluid blister to right heel 2x2cm, . 4. Progress Notes: Skin issue: .# 003: New skin issue. Location: Right heel. Issue type: Blister. Wound acquired in-house. Wound is new . 5. Order Summary: October 30, 2024, 16:41: Wound Treatment: Wound type: blister. Wound site: right heel. Cleanse with normal saline pat dry apply dry dressing daily, every day shift for 30 days. 6. Care Plan: Focus: The resident is at risk for skin breakdown pressure ulcer r/t (related to) history of pressure injury impaired mobility, incontinence, DM (diabetes mellitus) Date initiated: October 7, 2024. Revision on: November 19, 2024. Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. During a review of the facility ' s policy and procedure (P&P), titled, Pressure Injury Prevention and Management, revised September 2023, the P&P indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .

Based on interview, and record review, the facility failed to provide routine supervision and monitoring for one of 93 residents (Resident 1) and failed to implement interventions developed to help prevent an elopement (unauthorized and unsupervised exit from the facility) when: 1) On August 1, 2023, staff was unaware Resident 1 (a confused resident with cognitive deficit and required assistance with walking) had eloped from the facility. In addition, it was not identified Resident 1 was missing from the facility despite Resident 1 not being present during the evening meal (Resident 1 required direct 1:1 [one to one] staff assistance during mealtime). This failure resulted in Resident 1 subsequently being found (by non-facility staff) in a neighboring backyard unresponsive, on the ground, and covered with vomit. Resident 1 required hospitalization and intubation (a tube placed through the airway to help the resident breath when they are unable to breath on their own). This also had the potential to result in death to Resident 1 due to exposure of the (outdoor) elements and without vital resources such as food, water, and shelter. 2) The facility ' s front door alarm was not armed to audibly alert staff (as specified in the facility ' s policy and procedure for elopement prevention) and staff did not provide supervision of the facility ' s main entrance and exit while the alarm was unarmed. This failure resulted in staff to not be alerted to the unauthorized exit of Resident 1 from the facility and therefore, did not provide staff an opportunity to prevent the Resident 1 ' s elopement by responding to the area in a timely manner to divert Resident 1 back into the facility. Findings: 1) A review of Resident 1 ' s clinical record titled, Admission Record (contains medical and demographic information) dated August 2, 2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Craniotomy (surgical opening in the skull), altered mental status, unsteady gait (walking uncoordinated), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), anxiety disorder (feelings of fear and/or worry that interfere with daily activities), and restlessness and agitation. During a review of Resident 1 ' s Minimum Data Set (MDS), Section C - Cognitive Patterns (section used to determine a resident cognitive functioning status) dated, July 31, 2023, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS a score 0-15 used to determine cognitive functioning) score of 3 (severe impairment). During a review of Resident 1 ' s MDS, Section G Functional Status dated, July 31, 2023, the MDS indicated Resident 1 required, .2 (Limited Assistance .staff provide guided maneuvering of limbs or other non-weight-bearing assistance .one person physical assist.). During a review of Resident 1 ' s History and Physical (H&P) dated July 28, 2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s care plan (an individualize plan of care) dated July 28, 2023, the care plan titled, At risk for re-hospitalization r/t [related to] hx [history of] altered mental status, [confusion] HTN [elevated blood pressure], alcohol dependence [When the person can ' t stop drinking alcohol] craniotomy [surgery of the skull]. The interventions included, .Turn and reposition every 2 hours and PRN [as needed] for circulation and comfort. During a review of Resident 1 ' s physician orders, dated July 27, 2023, the order indicated, one to one feeding assistance . During a review of Resident 1 ' s care plan dated July 28, 2023, the care plan titled, The resident has limited physical mobility r/t weakness/unsteadiness of feet . The interventions included, .Provide supportive care, assistance with mobility as needed . During an interview on August 4, 2023, at 12:28 PM, with the Administrator (ADMIN), the ADMIN stated Resident 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated the facility staff was unaware Resident 1 was missing until around 7:15 PM (four hours later) on August 1, 2023, when Resident 1 ' s family called the facility to notify them Resident 1 was in the hospital. During an interview on August 4, 2023, at 3:23 PM with the Director of Nursing (DON), the DON stated Certified Nurse Assistant 1 (CNA 1) was assigned to care for Resident 1 but failed report to Licensed Vocational Nurse (LVN 1) Resident 1 was not present for, and did not eat his dinner when it was served at 5:00 PM. The DON further stated CNA 1 did not look for Resident 1 to determine the whereabouts of Resident 1. The DON stated the CNA 1 should have checked on Resident 1 more frequently throughout the shift. During an interview on August 7, 2023, at 4:22 PM with CNA 1, CNA 1 stated that she was not aware Resident 1 required 1:1 (one on one) assistance with eating his meals and that CNA 2 delivered Resident 1 ' s meal tray to his room at approximately 5:00 PM on August 1, 2023. CNA 1 further stated she picked up Resident 1 ' s dinner tray at approximately 8:30PM and it was untouched, but she (CNA 1) did not look for Resident 1 and did not assist Resident 1 during dinner mealtime. During an interview on August 8, 2023, at 3:04 PM with CNA 2, CNA 2 stated she delivered Resident 1 ' s dinner tray to his room on August 1, 2023. CNA 2 stated when she delivered the tray, she noticed Resident 1 was not in his room. CNA 2 further stated she asked Resident 1 ' s roommate where Resident 1 was at and the roommate informed her that Resident 1 was in therapy. CNA 2 stated she left the meal tray inside Resident 1 ' s room but never looked for or checked on Resident 1. CNA 2 stated Receptionist 2 (R2) came to Resident 1 ' s room looking for Resident 1, and the tray was still in the room, untouched. CNA 2 stated CNA 1 should have provided Resident 1 assistance with his meal. During a review of the facility ' s job description for Certified Nurse Assistant dated 2003, the job description indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident ' s assessment and care plan as may be directed by your supervisors ., ensure that residents who are unable to call for help are checked frequently ., check each resident routinely to ensure that his / her personal needs are being met in accordance with his/her wishes ., serve food trays. Assist with feeding as indicated (i.e., cutting, foods, feeding assist in the dining room supervision, etc.) . immediately notify the nurse supervisor/charge nurse of any resident leaving/missing from the facility. During a review of CNA 1 ' s Counseling/Disciplinary Notice dated, August 1, 2023, the document indicated, Failure to do rounds adequately to ensure the safety of your patients. During an interview on August 7, 2023, at 3:06 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated it was her first time working with Resident 1 and she did not see Resident 1 from the beginning of her shift around 3:00 PM, because she got busy with her assignment. LVN 1 further stated, CNA 1 did not report to her that Resident 1 did not eat his dinner. LVN 1 stated she did not check on or look for Resident 1. During a review of the facility ' s job description for Licensed Vocational Nurse dated 2003, the job description indicated, The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by nursing assistants ., make daily rounds of your unit / shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards ., make periodic checks to ensure the prescribed treatment are being properly administered by certified nursing assistants and to evaluate the resident ' s physical and emotional status ., ensure that residents who are unable to call for help are checked frequently . During a review of LVN 1 ' s Counseling / disciplinary notice, dated, August 1, 2023, signed by LVN 1, the document indicated, .Failure to be accountable for your patients to ensure their safety. During an interview on August 7, 2023, at 3:47 PM with Receptionist 2 (R2), R2 stated that on August 1, 2023, around 7:15 PM she received a phone call from Resident 1 ' s family member to inform the facility Resident 1 was admitted to the hospital. Resident 1 ' s family wanted to speak to the facility ' s Registered Nurse 1 (RN 1). During an interview on August 7, 2023, at 4:45 PM with RN 1, RN 1 stated on August 1, 2023, around 7:15 PM, Resident 1 ' s family called to inform the facility Resident 1 was missing from the facility and Resident 1 was admitted to the Emergency Department. RN 1 stated she looked around the facility for Resident 1, but she was not able to find him. RN 1 further stated the ADMIN checked the surveillance camera located by the main entrance and noticed Resident 1 walked out of the facility at approximately 3:30 PM. RN 1 stated she knew Resident 1 needed full assistance with meals. RN 1 stated she did not check if Resident 1 received assistance with his meals. During a review of the RN job description dated 2003, the job description indicated, The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty ., ensure that all nursing service personal are in compliance with their respective job description ., make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standard. Report findings to the Director . During a review of Resident 1 ' s care plan titled, Resident 1 has impaired cognitive function or impaired thought process related to head injury/craniotomy ., dated July 28, 2023, the care plan indicated, .Interventions .Cue, reorient and supervise as needed. During a review of Resident 1 ' s care plan titled, Resident 1 is at risk for falls related to poor safety awareness. dated July 28, 2023, the care plan indicated, .Interventions .The resident needs a safe environment. During a review of Resident 1 ' s care plan titled, Resident 1 has risk for re-hospitalization related to history of altered mental status, HTN, Alcohol dependence, craniotomy . dated July 28, 2023, the care plan indicated, .interventions .Diet as ordered and assist with meals as needed. During a review of Resident 1 ' s medical records from the hospital, dated, August 1, 2023, at 6:08 PM, the records indicated, [AGE] year-old male who presents with a GCS [Glasgow Coma Scale used to describe the extent of impaired consciousness] of 3 [the lowest possible score, unresponsive] after he was found outside someone ' s yard. Patient also noted to be hypotensive [low blood pressure] and have emesis [vomit] on his clothes. He was intubated in the Emergency Department. 2. During an interview on August 4, 2023, at 12:28 PM with the Administrator (ADMIN), the ADMIN stated Resident 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated Resident 1 eloped from the facility after the main entrance door alarm was disarmed by the receptionist 1 (R1). A review of Resident 1 ' s clinical record title, Interdisciplinary (IDT - team composed of staff from various disciplines) dated August 2, 2023, at 4:50 PM, indicated, per charge nurses, (pt) patient was seen last approx. [approximately] August 1, 2023, at 3:15 PM. Resident was seen in walking from his room to the hallway without helmet. Resident was redirected and encourage to wear his helmet for safety. Resident went back to the room and put on his helmet patient [Pt] has a medical history and not limited to altered mental status, unsteadiness of feet, seizure, HTN (elevated blood pressure) alcohol dependence, (is the body ' s inability to stop drinking) Craniotomy (Surgery into the skull) ., RN supervisor received a call from the hospital, stating that resident was found at someone ' s backyard unresponsive and was brought to [the admitting hospital] for further evaluation ., recommendations: ., all exit door alarm must be functional ., front door alarm will remain armed at all times ., if at any time, the alarm goes off, receptionist / designee needs to be reset alarm immediately to remain functional. During an interview on August 7, 2023, at 2:30 PM, with the ADMIN, the ADMIN stated the facility had a protocol which indicated the door alarm was to be kept ON at all times to prevent elopement of their residents. The ADMIN further stated it was an error from the staff to disarm the main entrance door alarm. During an interview on August 8, 2023, at 8:53 AM with R1 via telephone, R1 stated on August 1, 2023, at 3:00 PM, she disarmed the main entrance alarm because she was working by herself, and it was hard for her to answer the phone calls. R1 stated it was hard to be in two places at the same time, and when Resident 1 eloped from the facility she was probably busy doing something because she missed it. She further stated she was aware that main entrance alarm should be ON at all times to alert the staff if someone was leaving through the front door. During a review of the facility ' s policy and procedure (P&P) titled, Elopement and Wandering Resident ' s dated, December 19, 2022, the P&P indicated, 1. The facility is equipped with door locks / alarms to help avoid elopements., 2. Alarm are not replacement for necessary supervision, Staff are to be vigilant in responding to alarms in a timely manner .d. Adequate supervision will be provided to help prevent accidents or elopements . During a review of the facility ' s P&P titled, Accidents and Supervision dated, December 19, 2022, the P&P indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard and risk (s) ., 3. Implementing interventions to reduce hazard (s) and (risk) ., 4. Monitoring for effectiveness and modifying interventions when necessary ., 5. Supervision-Supervision is an intervention and means of mitigating accident risk. The Facility will provide adequate supervision to prevent accidents. Adequacy of supervision: A. Defined by type and frequency ., B. based on the individual resident ' s assessed needs and identified hazards in the resident environment. An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents) on August 8, 2023 at 2:16 PM, after determined Resident 1 did not receive supervision and monitoring required to keep Resident 1 safe on August 1, 2023 when Resident 1 was found to have eloped from the facility. The IJ was called in the presence of the Director or Nursing (DON) and Administrator (ADMIN). A Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on August 10, 2023, at 2:52 PM and included the following: Facility staff activated the entrance alarm as soon as she finished answering the phones on August 1, 2023, at approximately 3:30 PM. Facility Head Count was completed on August 1, 2023, with a total count of 93 in-house residents. Facility head count will continue to be performed on a daily basis. The DON, and designee(s) re-evaluated 93 residents for risk for wandering/elopement using an elopement risk assessment tool on August 2, 2023. The residents (5) identified on elopement risk continue the use of wander guard. As of August 2, 2023, four of the five residents as who are at elopement risk continue with use of wander guard system, while the other one resident previously identified at risk for elopement is on every two-hour monitoring, due to non-compliance with wearing the wander guard bracelet. Effective August 10, 2023, at 12:00 PM, all elopement risk residents will be monitored every hour on a daily basis. This monitoring will be ongoing at this time. Nursing will continue to monitor. Facility staff assigned to resident on August 1, 2023, received an In-service education as it relates to monitoring/supervising of assigned resident by the DON/Administrator. On August 3, 2023, the facility administrator provided an in-service education to the receptionist related to the facility alarm. The facility licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel received education on wandering, elopement, wander guard use, and resident safety as per facility policy and procedure, on August 1, 2023, August 2, 2023, and August 3, 2023, from the DON and designee. Any staff on leave will receive education on their next scheduled workday. Facility will continue to perform on going in-service trainings regarding wandering, elopement, resident safety, wander guard use, and resident monitoring/supervision to facility staff monthly for 3 months. Receptionist desk was re-located next to the entry door to increase supervision and monitor alarm on August 2, 2023. A keyed security box was placed over the alarm keypad to ensure that the alarm can ' t be turned off on August 2, 2023. Everyone must use the bypass keypad to disarm alarm for 45 supervised seconds. The receptionist/administrative team were given an in-service education training regarding these changes on August 2, 2023, and August 3, 2023. Elopement and wandering resident ' s policy was reviewed on August 2, 2023. Residents identified at risk for elopement were reviewed by the DON/Designee for appropriate care plan interventions on August 2, 202. If wander guard is implemented, they were checked for appropriate placement, function, and documentation. An in-service education training was provided to facility staff on August 1, 2023, August 2,2023, and August 3, 2023. On August 3, 2023, an IDT meeting was conducted for residents at risk for elopement to discuss the identified residents at risk for elopement, with documentation in the identified medical record. An ongoing daily check of facility doors and alarms are performed by the Maintenance Department to ensure function and securement. An increase in the frequency of facility door and alarm checks was initiated on August 2, 2023. Elopement risk binders were reviewed by the DON/Designee on August 2, 2023, and were up to date. Elopement risk binders are available at each nursing station and at the reception area. Elopement binders are updated by the DSD Monthly and PRN with oversite by the DON. On August 2, 2023, the administrator reviewed the elopement binder and residents at risk for elopement with the receptionist. Elopement code drills were initiated on all shifts starting on August 2, 2023, and will continue to perform drills monthly for three months then quarterly thereafter. New hires will receive education on wandering, elopement, and resident safety by the Director of staff development (DSD). All In-service education training will continue to be performed with lesson plans. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on August 11, 2023, at 3:40 PM, in the presence of the ADMIN and DON.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for one of three sampled residents (Resident A) who was identified as a wanderer and had a history of elopement. This failure resulted in Resident A leaving the facility on foot without staff's knowledge and being found 1.8 miles away, having crossed a main thoroughfare, placing him at risk for injuries or even death. Findings: During an unannounced visit to the facility on [DATE], at 3:30 PM, to investigate a Facility Related Incident for the elopement of Resident A, an interview was conducted with Administrator at 3:46 P.M. The Administrator stated he was notified of the elopement on January 26,2023 at 12:45 P.M. He stated the resident was alert to name only and had confusion. The Administrator's stated that it is his belief that Resident A exited through the front door of the building. He further stated Resident A was found on Citrus and Foothill (1.8 miles from the facility) and verbalized he wanted to go home. During a review of Resident A's Admission Record (contains demographic information), undated, indicated Resident A was admitted [DATE], with a diagnosis of urinary tract infection (infection of the bladder), Streptococcal (bacteria) infection, and personal history of other mental and behavioral disorders (unspecified). During a review of Resident A's minimum data set (MDS: a computerized assessment tool) record, under Section C: Cognitive Patterns, dated November 19, 2022, indicated Resident A's Brief Summary of Mental Status (BIMS a screening tool assess cognition) BIMS score is 00. ( A score of 13-15 = cognitively intact; 8 - 12 = moderate impaired; 0-7 = severely impaired.) During an interview on February 1, 2023, at 9: 11 A.M., with the Receptionist, she stated her role as a receptionist was to make sure the front door was locked, the alarm was activated, and residents did not go out without staff supervision. She stated she was on duty when Resident A eloped and knew he did not leave through the front door because she would have seen him and stopped him. She further stated she was told by management after they had reviewed the cameras that Resident A would have left through a back door. During an observation in the reception area, several residents were observed near the front door unsupervised including Resident A and one other who was identified as being a wanderer . During an observation on February 1 ,2023, at 9:26 A.M., in the north hallway where Resident A had resided prior to his elopement on January 26, 2023, it was observed staff going in and out of resident's rooms and residents sitting outside of their room, walking or self-propelling their wheelchairs in the hallway. During an interview on February 1, 2023, at 10:37 A.M., with the Director of Nursing (DON), DON stated, it was her expectation that staff would be closely monitoring residents identified as an elopement risk such as Resident A. The DON further stated it is her belief that Resident A exited though a door at the far end of the North hallway and nobody had noticed. During an interview on February 1, 2023, at 10:52 A.M. with the Administrator, the Administrator stated, I am assuming the resident exited at the North end door where there is a lot of traffic . He stated when he had interviewed staff he was informed that no one had noticed or saw Resident A exit the building. Administrator stated there are cameras mounted only at the front of the building not in the back and upon reviewing the camera footage the direction Resident A had taken when he left the facility was not shown. During a concurrent interview and record review, on February 2, 2023, at 10:00 A.M., with the Administrator, Resident A's Elopement Risk - V(version)2 dated November 30, 2022, was reviewed. It indicated .Category: at risk for elopement . score: 4.0 ( indicates a high risk for elopement) . The Administrator stated Resident A did not have a Wander Guard ( a bracelet worn by a resident that will set of an alarm when a door with a sensor is approached ) until after his 2nd elopement attempt. During a concurrent interview and record review, on February 2, 2023, at 10:33 A.M., with the DON Resident A's care plan created after an elopement attempt dated November 30,2022 was reviewed. The care plan indicated, Focus: the resident is an elopement risk/wanderer disoriented to place, Resident wanders aimlessly. Goal: The resident's safety will be maintained through the review date .Interventions .Safety measures in place . When asked what the safety measures were the DON stated neuro check assessments, visual checks every 30 minutes, wander guard monitoring device and redirecting the resident. However, the DON stated, We didn't have anything in place before this incident. We just had the nurse's keep an eye on the resident . implemented interventions as stated in their policy. During an interview on February 6, 2023, at 9:50 A.M. with a Certified Nurse Assistant (CNA2), CNA2 stated she noticed the North end (back) door alarm was not working when she went and got an extra cereal for her resident on the morning of January 26, 2023. She stated she had notified the maintenance staff but failed to notify the DON or the Administrator. During an interview on February 6, 2023, at 10:03 A.M. with the Administrator, the Administrator stated it is staff's responsibility to monitor Resident A and when asked if this occurred on January 26, 2023, prior to Resident A leaving the building he replied. No. no staff was supervising Resident A .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when the Registered Nurse (RN 1) saw a Certified Nursing Assistant (CNA 1) shaking Resident 1' s shoulders. This failure had the potentia; for an unsafe environment for Resident 1 due to her feelings of fear and emotional suffering. Findings: During a review of Resident 1' s Admission Record (a document containing clinical and demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical, dated May 12, 2022, indicated Resident 1 has fluctuating (continually change or shift back and forth) capacity to understand and make decisions. During a review of State of California Form 341 (SOC 341-Report of Suspected Dependent Adult/Elder Abuse), dated June 21, 2022, it indicated a report was submitted by the facility regarding an alleged physical abuse by CNA 1 to Resident 1. Further review indicated .On June 21, 2022 at around 6:30 PM, the facility administrator [Name of Administrator], received a report from RN [Registered Nurse] Supervisor [Name of RN Supervisor] regarding an incident of an alleged staff to resident physical altercation involving [Named of Resident 1] - and [name of CNA 1] .RN Supervisor followed without CNA knowing and saw him shaking resident [initials of Resident 1] from both her shoulders while in bed . RN Supervisor interviewed the CNA about the incident and, after the interview, instructed the CNA to go home . A review of Resident 1' s Interdisciplinary Progress Note, dated June 22, 2022, indicated DON [Director of Nurses] visited resident [Resident 1] in her room . DON interviewed resident regarding incident. Resident states CNA [CNA 1] nurse was forcefully putting macaroni and cheese inside my mouth, scratch her gum, and never wanted to stop when she was crying. Resident goes I was scared till the nurse immediately removed the CNA. Assessed resident mouth and gum with no redness, no bruises, and no swelling noted at this time. No injury noted, no redness or bruises not on resident's skin at the time of interview. Asked resident if she is still scared, Resident responded NO, I ' m not scared because, CNA was removed immediately. Asked resident if she is safe in the facility, Resident states I feel safe and happy that the CNA nurse is no more working here . A review of the facility ' s conclusion letter for the RE: Resident [named of Resident 1 vs [named of CNA 1 (facility CNA) reported on 6/21/22, dated June 27,2022, indicated .concluded that her allegations were substantiated due to the what the RN supervisor had witnessed during the incident, . the facility has terminated the CNA' s employment to the facility and will continue to provide in-service trainings to current staff on elder abuse prevention and reporting in the facility . During an interview with the Administrator, on July 6, 2022, at 5:30 PM, the Administrator stated the facility has substantiated the alleged physical abuse by CNA 1 towards Resident 1. He further stated the facility has terminated CNA 1. During concurrent observation and interview with RN 1, on July 21,2022, at 4:40 PM, the RN 1 stated she followed CNA 1 to Resident 1 ' s room and saw CNA 1 shook Resident 1 ' s shoulders with both of his hands. RN 1 further stated she asked CNA 1 to leave Resident 1 ' s room and later sent CNA 1 home after reported the situation to the Administrator. A review of facility ' s policy and procedure titled Abuse -Prevention Program revised November 2016, indicated . the Facility does not condone any form of resident abuse, neglect and/or mistreatment, and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention policies and training .Procedures .term Abuse Is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish

Based on interview and record review, the facility failed to ensure that the physician's orders were followed for one of three sampled residents (Resident 1) when the facility did not schedule two post operative appointments for Resident 1. These failures led to Resident 1 not being evaluated in a timely manner by the Internal Medicine Physician (specialty in medicine that treats a broad range of health concerns) and the Vascular (focused treatment on veins and arteries) Surgical Center following a Below the Knee Amputation (BKA [removal of a body part]) of the left leg. Findings: 1.During a review of Resident 1's Admission Information (document contains demographic information), indicated, Resident 1 was admitted on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent phone interview and review of Resident 1's clinical record, on July 7, 2022, at 11:54 AM, with Social Services 1, DocuSign Envelope ID:459DC741 ., dated February 20, 2021, was conducted. The DocuSign Envelope ID:459DC741 . indicated, Physician 1 ordered: 1.Follow up with the Internal Medicine Physician in one week. 2.Follow up with the Vascular Surgical Center in two weeks. During a phone interview with Social Services 1, on July 7, 2022, at 11:55 AM, Social Services 1 acknowledged, Facility 1 did not follow Physician 1's orders when Resident 1 did not receive a follow up appointment with the Internal Medicine Physician within one week and the Vascular Surgical Center within two weeks. During a concurrent phone interview and review of Physician 1's orders, on July 7, 2022, at 12:18 PM, with the Director of Nursing (DON), DocuSign Envelope ID:459DC741 ., dated February 20, 2021, was conducted. The DocuSign Envelope ID:459DC741 . indicated Physician 1 ordered: 1. Follow up with the Internal Medicine Physician in one week. 2. Follow up with the Vascular Surgical Center in two weeks. During a phone interview with the DON on July 7, 2022, at 12:20 PM, the DON stated, Facility 1's Social Service or the Case Management Department was supposed to make Resident 1's follow up appointments. The DON acknowledged, Physician 1's orders were not followed when Facility 1 did not make follow up appointments for Resident 1 with the Internal Medicine Physician (one week post operative) and the Vascular Surgical Center (two weeks post operatively). During a concurrent phone interview and job description (JD) review, on July 19, 2022, at 11:02 AM, with the Administrator, Case Management Purpose and Responsibilities (job description), dated September 1, 2017, was conducted. The JD titled Case Management Purpose and Responsibilities (job description) indicated: 1.Purpose .That services are provided to meet the assessed need of each patient in a prompt and efficient manner . 2.Oversee the coordination and integration of health and case management functions in order to achieve a common goal . 3.Monitor the quality of health care provided to patients to ensure they are up to acceptable standards . During a phone interview with the Administrator, on July 19, 2022, at 11:05 AM, the Administrator acknowledged the Case Management's JD was not followed when the Case Manager did make post operative follow up appointments for Resident 1. During a concurrent phone interview and JD review, on July 19, 2022, at 11:06 AM, with the Administrator, Social Worker, undated, was conducted. The JD titled Social Worker indicated, Administrative Functions . Assist in arranging transportation to other facilities when necessary. The Administer acknowledged, arranging transportation is part of the Social Worker's job description, and transportation was not arranged for Resident 1's post operative appointments with the Internal Medicine Physician and the Vascular Surgical Center. During a phone interview with the Registered Nurse (RN) 1, on July 19, 2022, at 12:30 PM, RN 1 stated, if a resident does not attend a post operative appointment following a BKA, there are risks for infection, delayed wound healing, and potential for medical problems to be missed. RN 1 stated, when a newly admitted resident comes to Facility 1, RN reviews the discharge summary notes (from the transferring facility) to verify if any follow up appointments need to be made. RN 1 stated, the RN contacts Facility 1's Social Services or Case Management Department to schedule the resident's appointments.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for 2 out of 40 residents (Residents 13 and 62) reviewed for nutrition when: 1. Resident 62 lost 18% of his body weight in the last 6 months. Since September 5, 2021, he had poor food intake. Three different registered dietitians recommended an appetite stimulant on September 28, 2021, October 7, 2021, and March 14, 2022. The appetite stimulant was ordered on April 10, 2022. Consequently, Resident 62 lost 26 pounds during that time. 2. Residents 13 and 62, who were on a fortified diet (diet to increase calories for residents who need to maintain or gain weight) were given fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner daily. These foods were in addition to the foods that were already on the menu. Multiple observations indicated Residents 13 and 62 were not consuming the extra fortified foods provided. This intervention was intended to add additional calories so that residents would either maintain or gain weight. However, a) Resident 13 lost 10 pounds from January 3, 2022, to June 6, 2022. b) Resident 62 lost 23 pounds from January 5, 2022, to June 6, 2022. These failures had the potential to cause additional weight loss and increase Residents 13 and 62 risk of morbidity (the condition of suffering from a disease or medical condition) and mortality (death). A study showed that nursing home residents had a significantly higher mortality rate in the six months after losing 10 percent of their body weight and another study indicated that elderly residents in nursing homes who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. Findings: 1. During an observation on June 9, 2022, 12:20 PM, Resident 62 was in bed. He was able to respond to questions with yes or no. He stated he was not hungry. His food tray was on the side table and appeared untouched. The tray ticket (paper that identifies patient and their diet and food likes, and dislikes) indicated Resident 62 was on a puree diet. A review of Resident 62's face sheet (a document that gives a summary of patient's information) indicated Resident 62 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Registered Dietitian (RD 1), on June 10, 2022, at 11:13 AM, the RD 1 stated she did not have a conversation with the Medical Doctor after he did not follow her recommendation to put Resident 62 on an appetite stimulant. She stated she did not question the Medical Doctors rationale for not ordering the appetite stimulant even though the resident continued to have poor meal intake despite multiple supplement and food interventions and continued to lose weight. During a review of Resident 62's Weights, undated, it indicated the following: January 5, 2022 - 127 lbs. (pound- unit of measurement) February 5, 2022 - 132 lbs. March 6, 2022 - 122 lbs. April 4, 2022 - 116 lbs. May 5, 2022 - 116 lbs. June 6, 2022 - 104 lbs. During a review of Residents 62's Monthly Weight Variance, dated September 28, 2021, documented by RD 3, it indicated RD [Registered Dietitian 3] recommends physician review for addition of appetite stimulant and variable PO (by mouth) intake. During a review of Resident 62's Weight Change Progress Note, dated October 12, 2021, documented by RD 2, it indicated, Recommendation: to have an appetite stimulant [MEDICATION(S)] (brand of appetite stimulant) per MD (medical doctor) consent. And PO (by mouth) intake 26% x 39 meals; resident often refuses to eat. During a review of Resident 62's Weight Change Progress Note, dated March 14, 2022, documented by RD 1, indicated wt (weight) change r/t (related to) poor PO intake; pt (patient) refusing meals consecutively. Recommendation: recommend appetite stimulant per MD order to aid in increasing PO intake. During a review of Resident 62's Weight Change Progress Note, dated April 8, 2022, documented by RD 1, it indicated wt change: significant wt change x three months r/t poor PO intake. Pt refusing meals with poor appetite. Recommend appetite stimulant per MD order to aid with increasing PO intake. During a review of Resident 62's Order Listing Report, dated June 10, 2022, it indicated April 10, 2022 order date and May 27, 2022 discontinued- [MEDICATION(S)] (medication for depression also used to stimulate appetite) tablet 15 mg (milligrams) give one tablet by mouth at bedtime for depression m/b (manifested by) loss of appetite. And May 27, 2022 order date - [MEDICATION(S)] tablet 15mg .give one tablet by mouth at bedtime for depression m/b self report of sadness. During a review of Resident 62's Nutritional Assessment, dated October 17, 2021, it indicated Assessment: wt change: current wt 116# (pounds) (10/4/21): -7# (-5.7%) x one month; -18# (-13.4%) x three months; -16# (-12.1%) x six months; all are significant (weight loss), d/t (due to) inadequate calorie intake; resident is put on RNA (restorative nursing assistant) feeding program at this time; Average percentage of meals eaten: 56% x 33 meals .Dietary supplements/nutritional interventions/other: Boost (high calorie drink) QD (every day), Health shake (high calorie drink) with meals, prostat (high protein drink) QD; fortified food with lunch and dinner. During a review of Resident 62's Nutritional Assessment, dated April 20, 2022, it indicated Assessment: current wt : (April 4, 2022) 116# ; (April 16, 2022 120#, wt change; significant wt change x three months. Pt (patient) with BMI (calculation using height in weight to determine health risk) underweight, currently on appetite stimulant expected new weight gain, beneficial for pt overall health. Noted increase in PO intake. Average Percentage of meals eaten: 46% x seven days . Dietary Supplements/nutritional interventions/other: HS (Health Shake) BID (two times a day), Prostat BID, Boost TID (three times a day), Fortified cereal with breakfast. 2. a) During a concurrent observation and interview with Resident 13, in his room, on June 9, 2022, at 12:45 PM, Resident 13 was sitting up in bed, eating his lunch. Resident 13 did not eat the mashed potatoes that were in a separate bowl to the side of this plate. He stated, I don't like mashed potatoes. His meal ticket on his tray indicated that he was on a regular diet with fortified mashed potatoes for lunch. A review of Resident 13's face sheet indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on June 9, 2022, at 1:15 PM with Dietary Services Supervisor (DSS), the DSS stated the practice of the facility was to serve fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner. She stated the doctor's orders indicate whether they will get the fortified foods and for what meal. She stated if mashed potatoes was not the menu for dinner they will serve a fortified soup. During an interview with a Certified Nursing Assistant (CNA 1), on June 9, 2022, at 1:40 PM, CNA 1 stated Resident 13 gets mashed potatoes every day on his meal trays and sometimes does not eat them. During an interview on June 10, 2022, at 10:30 AM, with the RD 1, the RD 1 stated there was no system in place to document or track if fortified items are being consumed by residents. The RD 1 also stated she had not done any in-service (training) for CNAs on promoting and encouraging fortified items to be consumed first. During an interview with the DSS, on June 10, 2022, at 2:45 PM, the DSS stated the fortified diet facility policy and fortified diet description from the facilities Nutrition Care Manual were not being followed. The DSS stated the intent of the fortified diet was to add calories to the diet without adding additional food. The DSS further stated when the former dietitian was employed, there was going to be a change in the practice of mashed potatoes and cereal as the fortified items to avoid overwhelming the residents with too many food items and redundancy of items. During a record review of Resident 13's medical record, it indicated the following body weights of Resident 13: January 3, 2022, weight 131 pounds February 5, 2022 weight 129 pounds March 6, 2022, weight 124 pounds April 4, 2022, weight 124 pounds May 5, 2022, weight 124 pounds June 6, 2022, weight 121 pounds During a record review of Resident 13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a record review of Resident 13's meal tickets (paper include on the tray to indicate what diet the resident is on, and also resident likes and dislikes), dated June 9, 2022, it indicated Breakfast: Fortified cereal - 6 oz (ounces - a unit of measurement), Lunch: Fortified mashed potatoes - 4 oz and Dinner: Fortified mashed potatoes - 4 oz 2. b) During an observation, interview, and record review, on June 9, 2022, 12:20 PM, Resident 62 was lying in bed. He was able to respond to questions with yes or no. He stated he was not hungry. His food tray was on the side table and appeared untouched. The meal ticket indicated Resident 62 was on a puree diet. Each item of the meal was separated into a mug to assist the resident in consuming the food. The menu indicated that he received puree fish with dill sauce, seasoned fries, herbed corn and tomatoes and a wheat roll. An additional mug was on the tray with the fortified mashed potatoes. For a total of 6 mugs with puree food. A review of Resident 62's face sheet indicated Resident 62 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with CNA 2, on June 9, 2022, at 12:46 PM, she stated Resident 62 refused lunch today (June 9, 2022). During an interview on June 10, 2022 at 10:30 AM, with the RD 1, the RD 1 stated there is no system in place to document or track if fortified items are being consumed by residents. The RD 1 also stated that she had not done any in-service (training) for CNAs on promoting and encouraging fortified items to be consumed first. During a review of Resident 62's Order Listing Report, dated June 10, 2022, it indicated Resident 62 had an order on April 21, 2022 fortified cereal with breakfast. During a review of Resident 62's Care Plan, untitled, it indicated interventions/tasks: Fortified mashed potatoes BID (two times per day), fortified cereal with breakfast, date initiated September 28, 2022. During a review of the facility's policy and procedure (P&P) titled Fortification of Food: Increasing Calories and/or Protein in the Diet, it indicated a) .Careful thought is to be given to avoid overwhelming the resident with food. b) Reducing the portions to 1/2 size versus small or regular may help a resident who is eating less than 50% of meal. The portions will not be as overwhelming and better consumption may be viewed as an attainable goal for residents. During a review of a document titled Fortified Diet, dated 2020, it indicated The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Further review indicated Example of adding calories may include: Extra margarine or butter to food items such as vegetables, potatoes, hot cereal, break toast, pancakes, waffles, rice, pasta, etc.; Extra gravy and sauces to meats, casseroles, potatoes, rice and pasta; Non-dairy creamer on half and half to drink, or added to hot cereal or soups; Extra mayonnaise added to sandwiches and mayonnaise based salads; Extra jelly on breads; Non-fat dry milk powder added to soups, puddings and drinks; Commercial calorie and/or protein powder added to beverages, puddings, cereals or soups; Top with whipped topping or chocolate sauce; Add cheese to soups, pasta or vegetables. During a review of the article, Evaluating and Treating Unintentional Weight loss in the Elderly, American Family Physician, Volume 64, Number 2, dated February 15, 2002, it indicated nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to ensure wound care dressings were labeled in accordance with the facility's policy and procedure for four of five residents (Residents 61, 693, 53, 490) reviewed for pressure injury (or pressure ulcers- wounds that happen on areas of the skin that are under pressure). This failure had the potential for inconsistent care coordination, and for Resident's 61, 693, 53, 490, not to receive the optimal care they need, which would hinder the healing of their pressure injuries. Findings: 1. During a review of Resident 61's Admission Record (clinical record with demographic information), on June 7, 2022, at 10:00 AM, the Admission Record indicated Resident 61 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 61's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 4), on June 7, 2022, at 9:30 AM, in Resident 61's room, LVN 4 inspected the wound care dressing at Resident 61's sacral area. It was not labeled by the initial of the licensed nurse who rendered the wound care treatment, and the date and time it was provided. LVN 4 stated she did not label the dressing. An observation of Resident 61's wound care treatment was conducted on June 8, 2022, at 8:42 AM, in Resident 61's room. LVN 4 rendered wound care treatment on Resident 61's sacral pressure injury. The wound care dressing was labeled with a date. It did not include the initials of LVN 4 and the time it was provided. During an interview on June 9, 2022, at 1:20 PM, with LVN 4, LVN 4 stated per facility policy, wound care dressing should be labeled with a date, time, and initials. During a concurrent observation and interview with LVN 4, on June 9, 2022, at 1:22 PM, in Resident 61's room, LVN 4 inspected the wound care dressing at Resident 61's sacral area. It was not labeled by the initial of the licensed nurse who rendered the wound care treatment, and the date and time it was provided. LVN 4 stated she labeled the wound care dressing with a date but did not include her initials and the time it was provided. 2. During a review of Resident 693's Admission Record, on June 10, 2022, at 11:15 AM, the Admission Record indicated Resident 693, was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 693's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with normal saline pat dry apply skin prep and dry dressing q (every) day x 30 days . During a concurrent observation and interview with LVN 5, on June 9, 2022, at 1:14 PM, in Resident 693's room, LVN 5 inspected the wound care dressing at Resident 693's sacral area and left buttocks. The wound dressings were not labeled by the initial of the licensed nurse who rendered the wound care treatment, and time it was provided. LVN 5 stated he did not label the wound care dressings with time because wound care dressing changes was ordered daily. 3. During a review of Resident 53's Admission Record, on June 10, 2022, at 11:20 AM, the Admission Record indicated Resident 53, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 53's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every day shift for 30 days. During a concurrent observation and interview with LVN 4 on June 9, 2022, at 1:25 PM, in Resident 53's room, LVN 4 inspected the wound care dressing at Resident 53's sacral area. It was not labeled by the initial of the licensed nurse who rendered the wound care treatment, and the date and time it was provided. LVN 4 stated she did not label the dressing. 4. During a review of Resident 490's Admission Record, on June 10, 2022, at 11:25 AM, the Admission Record indicated Resident 490 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 490's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with NS (Normal Saline)apply collagen and cover with dry dressing every day shift. During a review of Resident 490's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of Resident 490's wound care treatment was conducted on June 9, 2022, at 12:45 PM, in Resident 490's room. LVN 4 rendered wound care treatment on Resident 490's pressure injury on the left and right buttocks. The wound care dressing was labeled with a date. It did not include the initials of LVN 4 and the time it was provided. During a concurrent interview and record review on June 9, 2022, at 2:35 PM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled Wound Care dated 2002. The Wound Care policy indicated, Steps in the procedure . 13. Dress wound, pick up sponge with paper and apply directly to area. Mark tape with initials, time, date and apply to dressing. The DON stated the policy was not followed. The DON further stated her expectation on wound care dressing are dated, timed, and initialed by the licensed nurse who performed the dressing change.

Based on interview and record review, the facility failed to ensure a process to routinely evaluate staff skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) was implemented for three of four licensed nurses (Registered Nurse 1, Licensed Vocational Nurse 4, and Licensed Vocational Nurse 5). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview on June 10, 2022, at 9:35 AM, with the Director for Staff Development (DSD), the DSD stated he has not done a performance evaluation and skills competencies on any of the staff since he started on this role February 2022. He also stated he has no process of tracking staff competencies and performance evaluations. During an interview on June 10, 2022, at 2:20 PM, with the Administrator and the DSD, the Administrator stated they do not have the following polices: Performance Evaluation and Staff Competencies. During a record review of the employee files, it indicated the following: a. Registered Nurse (RN 1) was hired on February 22, 2019. b. Licensed Vocational Nurse (LVN 4) was hired on July 16, 2013. c. Licensed Vocational Nurse (LVN 5) was hired October 16, 2014. During a concurrent interview and record review with the DSD, on June 10, 2022, at 2:35 PM, the DSD reviewed the employee files of RN 1, LVN 1 and LVN 2, and stated he was unable to find documented evidence to indicate performance evaluation and skills competencies were conducted for the three (3) employees. During a review of an undated facility document titled Facility Assessment Tool, it indicated Staff training/education and competencies, 3.4. If any staff require certification, we validate that it's happened upon hire and routinely thereafter. During a review of the RN Job Description, dated 2003, it indicated, Competency evaluation are required for this position. During a review of the LVN Job Description, dated 2003, it indicated, Competency evaluation are required for this position. The facility was not able to provide a policy and procedure regarding Performance Evaluation and Staff Competencies.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for four of four medication carts (South, South-Center, North, and North-Center carts). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 92 residents. Findings: 1. During a concurrent observation and interview on June 9, 2022, at 12:50 PM, with a License Vocational Nurse (LVN 3), the North-Center medication cart's Controlled Drug Inventory (CDI- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated May 19, 2022, to June 8, 2022, was reviewed. The CDI indicated the following: a. On May 22, 2022, missing signature from the night shift (11:00 PM - 7:00 AM) oncoming nurse and a missing discrepancy count (counting the number of medication present in a particular location compared to the number expected) at 11:00 PM. b. On June 1, 2022, missing signature from the night shift (11:00 PM- 7:00 AM) oncoming nurse. c. On June 7, 2022, missing signature from the night shift (11:00 PM- 7:00 AM) oncoming nurse and missing discrepancy count at 11:00 PM. d. On June 8, 2022, missing signatures from the evening shift (3:00 PM to 11:00 PM) oncoming and evening shift (3:00 PM to 11:00 PM) off going nurses. LVN 3 confirmed missing signatures and missing discrepancy count in the CDI. LVN 3 stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 2. During a concurrent observation and interview on June 9, 2022, at 1:00 PM, with LVN 3, the South-Center medication cart's CDI, dated May 6, 2022, to June 9, 2022, was reviewed. The CDI indicated the following: a. On May 7, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) off going nurse. b. On May 8, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) oncoming nurse. c. On May 12, 2022, missing signature from the evening shift (3:00 PM to 11:00 PM) off going nurse. d. On May 26, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) oncoming nurse and missing discrepancy count at 11:00 PM. e. On June 2, 2022, missing discrepancy count at 11:00 PM. f. On June 7, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) oncoming nurse. g. On June 8, 2022, missing signature from the night shift (11:00 PM to 7:00 AM) off going nurse. LVN 3 confirmed missing signatures and missing discrepancy count in the CDI and stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 3. During a concurrent observation and interview on June 9, 2022, at 1:06 PM, with a Registered Nurse (RN 1), the South medication cart's CDI, dated May 26, 2022, to June 8, 2022, was reviewed. The CDI indicated the following: a. On June 6, 2022, missing discrepancy count at 11:00 PM. b. On June 7, 2022, missing discrepancy count at 7:00 AM and 11:00 PM. c. On June 8, 2022, missing signature from the day shift (7:00 AM to 3:00 PM) off going nurse and missing discrepancy count at 3:00 PM. d. On June 8, 2022, missing discrepancy count at 11:00 PM. RN 1 confirmed missing signatures and missing discrepancy count in the CDI and stated oncoming and off going nurses must sign the form and indicate if there are any missing discrepancy count. 4. During a concurrent observation and interview on June 9, 2022, at 1:25 PM, with LVN 2, the North medication cart's CDI, dated June 3, 2022, to June 9, 2022, was reviewed. The CDI indicated the following: a. On June 8, 2022, missing discrepancy count at 11:00 PM. b. On June 9, 2022, missing discrepancy count at 7:00 AM. LVN 2 confirmed missing discrepancy count in the CDI and stated oncoming and outgoing nurses must indicate if there are any missing discrepancy count. During a concurrent interview and record review, on June 10, 2022, at 9:22 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY: ID3: CONTROLLED SUBSTANCE STORAGE, dated August 2019, was reviewed. The P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility, in accordance with federal and state laws and regulations . At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including the emergency supply, is conducted by two licensed nurses and is documented. The DON stated the policy was not followed. During a concurrent interview and record review, on June 10, 2022, at 9:26 AM, with the DON, the facility's document titled, Job Description- Licensed Vocational Nurse (LVN), dated 2003, was reviewed. The Job Description indicated, Ensure that narcotic records are accurate for your shift.

Based on observation, interview, and record review, the facility failed to follow the menu, and serve the correct size of roast beef for the regular texture diets (food with no modifications) for lunch on June 7, 2022. This failure had the potential to impair the nutritional status of 58 out of 92 residents who receive food from the kitchen. Findings: During a concurrent observation and interview, on June 7, 2022, at 11:45 AM, in the kitchen, during lunch tray line (when the cook puts food on the plates for the residents), a Cook served two ounces of roast beef for the regular textured diets. Cook verified the roast beef should have measured at three ounces per the menu. During a review of the facility's Cooks Spreadsheet - Summer Menus dated June 7, 2022, the spreadsheet menu indicated for lunch as serving size of three ounces of Herb and Spice Roast Beef, the roast beef should have been served for the regular, 2 gm (gram-unit of measurement) Na (sodium), CCHO (consistent carbohydrate diet), Renal diets (special diet for residents with kidney problems), and low fat/cholesterol diets. During a review of the facility's policy and procedure (P&P) entitled Food Preparation, dated 2018, the P&P indicated, 1. To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. 2. A diet scale should be used to weigh meats. 3. It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There were two open style rodent bait traps which had the potential to contaminate the area if a rodent was trapped. 2. There was a meatball, crumbs and loose trash under the food prep table and black grime and crumbs at the side of the stove which had the potential for microorganism (small organism like bacteria, virus, or fungus) growth and attract pests. 3. The underside of the dishwasher counter had a patch and repair area with foam installation and a T-shaped piece of wood supporting the counter. This area was not smooth and easily cleanable, which could lead to microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 92 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on June 7, 2022, at 8:44 AM, in the kitchen, there was an open wire mesh rodent trap under the lower cabinets. The DSS stated she does not handle the rodent traps, and a company comes once a month to check and maintain them. During an observation on June 8, 2022, at 11:00 AM, in the kitchen, under the counter in the dishwashing area there was an open rodent snap style trap. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 7-206.12 Rodent Bait Stations. Rodent bait shall be contained in a covered, tamper-resistant bait station. 2. During an observation and concurrent interview with the DSS, on June 7, 2022, at 8:46 AM, in the kitchen, there was a meatball, crumbs, and loose trash under food prep table. The DSS stated the meatball and trash should have been cleaned up when the meatball was dropped the night prior. During an observation and concurrent interview with the DSS, on June 7, 2022, at 8:50 AM, in the kitchen, there was black grime and crumbs at the side of the stove. The DSS stated the area should be kept clean. During a review of the facility's policy and procedure (P&P) titled General Appearance of Food & Nutrition Department, dated 2018, the P&P indicated a. Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition. b. Floors must be mopped at least once per day. c. Sweep the floor, pushing all debris forward. Use a dustpan to remove and disposed of debris as it accumulates. d. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil mark from baseboards and walls. e. Wipe up all spills as they occur. During a review of the facility's policy and procedure (P&P) titled Food Borne Illness Outbreak, dated 2018, the P&P indicated, Important Factors Which Lead to Many Foodborne Illness Outbreak: Insects and Rodents: Failure to eliminate pest breeding or entry areas; failure to eliminate grime, spilled food, breeding and nesting attractions for pest. 3. During an observation on June 8, 2022, at 11:00 AM, in the kitchen, the counter under the dishwasher had a patch and repair area with foam insulation in the corner and the underside of the counter was supported with a T-shaped piece of wood. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-202.16 Nonfood-Contact Surfaces. Non FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance;

Based on observation, interview, and record review, the facility failed to maintain infection control practices when a Registered Nurse (RN 1) did not wear gloves when disconnecting the IV (a thin bendable tube that slides into one of your veins) tubing on June 10, 2022, for one of six residents (Resident 53) reviewed for intravenous therapy in accordance with the facility's policy and procedure. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to Resident 53. Findings: 1. During a review of Resident 53's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 53's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation for Resident 53's wound care treatment, with Licensed Vocational Nurse (LVN 1) and a Restorative Nurse Assistant (RNA 1), on June 10, 2022, at 10:45 AM, in Resident 53's room, Registered Nurse (RN 1) came inside the room and turned off Resident 53's IV infusion pump (a medical device that delivers fluids, such as nutrients and medications, into a patient's body in controlled amounts). She disconnected Resident 53's IV tubing from her peripheral IV line. RN 1 was not wearing gloves. LVN 1 and RNA 1 asked RN 1 if she wanted gloves and she did not respond. During an interview on June 10, 2022, at 11:00 AM, with RN 1, RN 1 was asked if she should be wearing gloves when hanging IVs, RN 1 stated, Yes, I knew it when I entered the room [Resident 53's room] but I wanted to hurry and stop the machine from beeping. During record review of the facility's undated policy and procedure, titled 3. Infection Control, Universal Precautions, it indicated 5. It is imperative to wash hands prior to and immediately after a procedure .7. Gloves shall be worn during all IV therapy procedures.

Based on observation, interview and record review, the facility failed to ensure the development of comprehensive care plan in accordance with the facility policy and procedure for one out five sampled residents (Resident 1) when Resident 1 pressure ulcers was not addressed in the care plan causing a delay in pressure ulcers treatment. This failure had the potential to result in undetected need or delay in medical and nursing care and services when Resident 1 care plan was not initiated to address multiple pressure ulcers on coccyx and buttocks area. Findings: A review of Resident 1 clinical record indicated she was admitted on [DATE]. She had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with LVN I on November 10, 2021, at 11;20 AM, she stated the care plan are initiated during admission once problems are identified. During an observation and record review with MDS coordinator on November 10, 2021, at 11:50 AM there is no care plan to address Resident's 1 pressure ulcers. During a concurrent interview and record review with Administrator on November 10, 2021, at 11:55 AM, he stated there is no care plan for pressure ulcers. During a review of facility policy and procedure titled Care Plan- Comprehensive revised November 2016 indicated the an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assured all medications were acquired and administered to meet the needs of the residents. The facility failed to develop and implement policy and procedures that ensured the availability of prescribed medications and the administration of the medications as ordered by the physician, for 3 of 17 sampled residents (Residents 4, 7, and 10). This failure resulted in residents not receiving all the medications as prescribed by the physician, including pain medications, which resulted in ineffective pain management, and had the potential to adversely affect the residents health and emotional well-being, in a universe of 89. Because of the facility's failure to assure the availability and administering of medications as prescribed by the physician, Immediate Jeopardy was called on 11/27/12, at 3:30 PM. Findings: 1. On 11/26/12, at 8:30 AM, during the initial tour of the facility, Resident 7 was observed to be asleep with a family member sitting at her bedside. Resident 7's family member stated that she (family member) had been at the facility since 4:00 AM that morning after receiving a call from Resident 7 telling her that she was in pain and had a temperature of 102 (degrees Fahrenheit). Resident 7's family member stated that the resident had been in a lot of pain and had not received her pain medication as ordered by the physician. Resident 7's family member stated the resident had chronic pain and had not been sleeping well for a number of days. Resident 7's family member further stated that she (family member) had called the facility on 11/26/12, after the resident had called her to find out what was going on with Resident 7 and why she was in so much pain. Resident 7's family member stated when she first asked the facility when Resident 7's pain patch (Fentanyl patch, a patch applied to the skin with opoid pain medication; a controlled medication, changed every 72 hours) had last been changed she was told that a new patch was applied on 11/23/12. When Resident 7's family member arrived at the facility she found the pain patch on the resident had been changed on 11/20/12, not on 11/23/12, as previous stated by the facility. The facility staff explained to Resident 7's family member that the MAR (medication administration record) had been initialed on 11/23/12 indicating the pain medication patch (Fentanyl patch) had been changed on that date, but the medication had not been available on 11/23/12, and as of 11/26/12 the facility still had not have obtained the medication ordered for Resident 7's pain management regimen. On 11/26/12, at 8:35 AM, Resident 7's Physician 1 was heard stating to Resident 7's family member that he had not been informed by the facility that the resident's pain medication had not been available and he had not been aware that Resident 7 had not been receiving all her medications as ordered. During an interview on 11/26/12 at 12:30 PM, with Resident 7's family member, she stated that based on her conversation earlier that morning with Physician 1, he (Physician 1) confirmed that he was not informed by the facility that Resident 7 was not receiving her pain medication. A record review of Physician 1's progress note, for Resident 7, dated 11/26/12 at 1:08 PM stated: ..."Patient is complaining of pain. Patient did not receive her Fentanyl patch. It has not been delivered by pharmacy"......"CHRONIC PAI[DIAGNOSES REDACTED]. Note: Patient ran out of her patch (Fentanyl). Pharmacy to deliver the patch ASAP (as soon as possible). In the meanwhile to get PRN pain meds." During an interview with Resident 7 on 11/27/12, at 8:00 AM, she confirmed she had been experiencing pain for the last few days, and that she had been having difficulty sleeping. Resident 7 stated that during the night, on 11/26/12, she was in a great deal of pain and started running a fever of 102 degrees. Resident 7 further stated she had called her family member because she was hurting and really needed them to be with her for support. A record review for Resident 7 revealed the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. to stop uncomfortable or odd discomfort in the lower extremities), anxiety (a feeling of apprehension, fear, or worry), and depression (a state of low mood and aversion to activity that can have a negative effect on a person's thoughts, behavior, feelings, world view and physical well-being). Resident 7's history and physical dated 8/22/12, indicated that the resident was her own responsible party. Resident 7's face sheet (a document in the medical record to give resident information), showed that the family member present at her bedside was her closest relative. A record review of Resident 7's last MDS (minimum data set/ as assessment tool of the resident) dated 10/30/12, indicated Resident 7 was cognitively alert, had the ability to understand and be understood, her memory was intact, and she was on a scheduled pain medication regimen. A record review of Resident 7's physician orders for November 2012, included the following prescribed scheduled pain medications and additional pain medications to be given as needed when the scheduled pain medication did not control her pain level. The scheduled pain medications included: Morphine Sulfate 15 mg (milligrams) three times a day. (9:00 AM, 1:00 PM, and 5:00 PM).- for pain (an opioid analgesic prescribed for relief of moderate to severe pain, considered a controlled medication which requires its use to be monitored), ordered on [DATE]. Fentanyl Patch 75 mcg/hr (micrograms/hour) apply locally every 72 hours - for shoulder pain. (used to control moderate to severe chronic (around-the-clock, long-lasting) pain that cannot be controlled by other means. A controlled medication requiring the monitoring of its use), ordered on [DATE] The additional pain medication prescribed to be given as needed for complaints of pain besides the regular scheduled medications included: Ordered by physician on 3/25/11, Tylenol 325 mg 2 tablets by mouth as needed every 4 hours for mild pain, ordered on [DATE] Ordered by physician on 8/30/12, Tylenol #3 1 tablet every 6 hours as needed for moderate pain. (an analgesic drug with codeine to treat pain. A controlled medication requires the monitoring of its use), ordered on [DATE] The physician orders included orders to monitor for pain every shift with a pain scale of: 0 = no pain. 1-3 = slight pain. 4-6 = moderate pain. 7-8 = severe pain. 9-10 = horrible pain. A record review of Resident 7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 7 did not receive her regular scheduled doses of Morphine 15 mg from 11/16/12 after 1:00 PM through 11/21/12, first dose given at 5:00 PM on 11/21/12. The resident had missed a total of 15 doses over a 5 day period between 11/16/12 through 11/21/12. Resident 7's Fentanyl patch was unavailable and not replaced on 11/23/12, which resulted in Resident 7 not receiving the pain medication for 3 days, as prescribed by the physician. Resident 7, during the period between 11/21/12 through 11/27/12, had reported to staff six incidents of having a severe level of pain on the scale of 7 out of 10, and receiving Tylenol #3 to help manage her pain. These incidents of increased pain happened after the resident had not received the 15 doses of Morphine, as ordered, and during the same 3 day period that the Fentanyl patch effectiveness had expired and had not been replaced due to lack of availability of the medication. On 11/26/12, at 4:05 PM, during an interview with the ADON (assistant director of nurses), she stated that the facility had been having a problem getting the controlled medications from the pharmacy. She stated the current system was for the nurses to send the order to the pharmacy and then the pharmacy was to fax the order to the doctor's office, where the doctor had to sign the order and fax it back to the pharmacy before the prescription could be filled or refilled. She further stated it had not been working out very well and sometimes it took a long time for the medications to get to the facility and there were times the medications had not been available to give to the residents as ordered. On 11/27/12, at 9:10 AM, during an interview with the DON (Director of Nurses), she stated that she was aware of the fact that medications were not always available and it had been an on going problem for the facility. The DON further stated that it was under the corporation's control to deal with the pharmacy and her hands were tied in finding a solution to the problem. The DON stated that the nurses were supposed to notify the physicians when the medications were not available and should be documenting it in the nursing notes. The nurses needed to call the physician right away and tell the physician the medication was not available. The DON also stated that she had seen a pattern with the nurses not following through to ensure the medications were available and that they were not notifying her when residents did not have all their medications. On 11/27/12, at 2:00 PM, during an interview with the MD (medical director), he acknowledged the facility has had a problem with this pharmacy and these problems have resulted in prescription refills being delayed, and medications not being available. The MD stated the problems needed to be corrected and in his experience he had problems with this same pharmacy at other facilities. He stated that the pharmacy does not have enough staff to follow up on prescriptions. The pharmacy was not open at night and closed early on the week-ends, and physician orders written in the evening weren't seen by the pharmacy until the next day. The pharmacy was faxing orders requiring the physician's signature to their offices when the physician's office was closed and no one was there to receive the faxes. This pharmacy also does not follow up with the physician, and doesn't make much of an effort to contact the physician when orders have not been signed. On continued interview with the MD on 11/27/12, at 2:00 PM, he stated that the problem with the pharmacy started in June (2012) when the pharmacy started to enforce regulations requiring the physician's signature for the controlled medications. The MD stated that some of the physician's have not been following up with signing the faxes from the pharmacy and didn't realize the residents were not receiving their medications because the signed faxes were not being sent back to the pharmacy. On 11/27/12, at 3:30 PM, the Administrator stated that he had been aware of the problem with the pharmacy and medications not being available. He further stated the issues with the pharmacy were under the control of the corporation and he did not have any say in the matter. On 11/27/12, at 3:30 PM, the Administrator stated he did not feel the problem with the pharmacy affected the over all care of the residents because even when the resident did not receive all their scheduled prescribed medication for a pain management regimen, the nursing staff could give the resident a PRN (prescribed medication to be given as needed) pain medication, to help control their pain. 2. On 11/26/12, a review of Resident 4's medical record revealed that he was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 4's history and physical dated 10/21/12, indicated that he had capacity to make and understand his medical decisions. Review of his admission minimum data set (MDS-an assessment of the resident) dated 10/23/12, revealed that he was able to make himself understood and that he could understand others. During an observation and interview with Resident 4 on 11/26/12 at 1:00 PM, he was observed with a cast and sling to his right arm, and stated that his pain level was a 7 out of 10 (on a scale of 0 to 10) in his arm, lower back and joints. He further stated that he was medicated for pain 2-3 times daily and stated regarding his pain medications, "I don't know what I get, but I guess I'm getting um (medications)." Review of Resident 4's medical record revealed physician's orders to monitor for pain every shift with a pain scale of: 0 = no pain. 1-3 = slight pain. 4-6 = moderate pain. 7-8 = severe pain. 9-10 = horrible pain. Further review of the physicians orders included the following orders: Oxycontin (narcotic pain medication used for moderate to severe pain control) SR (sustained release) 80 milligrams (mg) one tablet (tab) PO (orally) every (Q) 12 hours for pain management, ordered on [DATE]. Oxycodone (narcotic pain medication used for moderate to severe pain control) 30 mg one tab PO Q 4 hours as needed (PRN) for break through pain, ordered on [DATE]. Ativan (a controlled medication used for anxiety), 2 mg one tab PO three times a day (TID); for anxiety, ordered on [DATE]. Salonpas pain patch (an over the counter pain medication), Apply one patch topically Q 8 hours; pain, ordered on [DATE]. Chlorhexidine Gluconate .12% (germicidal topical towelette-used to decrease mouth bacteria) apply topically QD, Diagnosis: [REDACTED]. Review of Resident 4's medication administration records (MAR) for October and November, 2012, indicated Resident 4 missed the following doses of Oxycontin 80 mg SR, from 10/17/12 through 11/7/12: 10/17/12; 9 AM, marked as not given,"medication unavailable" 10/24/12; 5 PM, marked as not given,"Rx still waiting for MD approval' 10/25/12; 9 AM, 5 PM, left blank, no documentation on the MAR 10/26/12; 9 AM, 5 PM, left blank, no documentation on the MAR 10/27/12; 9 AM, 5 PM, marked as not given, "Rx still waiting for MD approval" 10/28/12; 9 AM, 5 PM, marked as not given, "Rx still waiting for MD approval" 10/29/12; 9 AM, 5 PM, left blank, no documentation on the MAR 10/30/12; 9 AM, 5 PM, left blank, no documentation on the MAR 10/31/12; 9 AM, 5 PM, left blank, no documentation on the MAR 11/1/12; 9 AM, 5 PM, marked as not given, "MD's written authorization not received from the pharmacy." 11/2/12; 9 AM, 5 PM, marked as not given, "MD's written authorization waiting" 11/3/12; 9 AM, 5 PM, marked as not given, "waiting for MD's written authorization" 11/4/12; 9 AM, 5 PM, marked as not given, "medication unavailable" 11/5/12; 9 AM, 5 PM, left blank, no documentation on the MAR 11/6/12; 9 AM, 5 PM, left blank, no documentation on the MAR 11/7/12; 9 AM, 5 PM, left blank, no documentation on the MAR Documentation showed Resident 4 had missed 30 scheduled doses of Oxycontin 80 mg SR from 10/17/12 through 11/7/12. Review of a Resident 4's physician's order on 11/7/12 revealed, "Increase Oxycontin 80 mg SR one (tab) PO every 8 hours (routine pain management)." The physician had increased the frequency of Oxycontin 80 mg SR to be given at 8:00 AM, 2:00 PM, and 10:00 PM. Resident 4 missed the following doses of Oxycontin 80 mg SR from 11/8/12 through 11/26/12: 11/8/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not arrived from Rx. Still waiting for MD" 11/9/12; 8 AM, 2 PM, left blank, no documentation on the MAR 11/17/12; 2 PM, marked as not given, "not available, MD notified, pharmacy called" 11/18/12; 8 AM, 2 PM, 10:00 PM, left blank, no documentation on the MAR 11/19/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not available, called pharmacy still waiting for MD" 11/20/12; 8 AM, 2 PM, 10:00 PM, left blank, no documentation on the MAR 11/21/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not available, called pharmacy" 11/22/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not available" 11/23/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not available, called pharmacy" 11/24/12; 8 AM, 2 PM, 10:00 PM, marked as not given,"med not available from pharmacy" 11/25/12; 8 AM, 2 PM, 10:00 PM, marked as not given, "not available from pharmacy" 11/26/12; 8 AM, 2 PM, marked as not given, "not available from pharmacy" 11/27/12; 8 AM, 2 PM, 10:00 PM, left blank, no documentation on the MAR Documentation showed Resident 4 had missed 30 scheduled doses of Oxycontin 80 mg SR from 11/8/12 through 11/26/12. Documentation on the October and November 2012, MARs showed that when Resident 4 did not receive his regular scheduled doses of Oxycontin 80 mg SR he was given PRN Oxycodone 30 mg medication for pain relief periodically. From 10/17/12 through 11/26/12, documentation showed Resident 4 received 84 doses of Oxycodone 30 mg (PRN) for pain. Further review of the October, 2012 MAR indicated [REDACTED] 10/17/12 at 9 AM, marked as not given,"not received from pharmacy MD notified." 10/17/12 at 1 PM, marked as not given, "not received from pharmacy MD notified." Resident 4 missed two doses of his scheduled Ativan on 10/17/12. Further review of Resident 4's MARs for October, 2012, indicated the Salonpas pain patch (over the counter pain patch) was not administered between 10/17/12 through 10/31/12. Documentation by licensed nursing staff on the October MAR indicated [REDACTED] 10/17/12; 6:30 AM, marked as not given,"Salonpas pad (patch)-unavailable" 10/18/12; 9 AM, marked as not given,"Salonpas patch -unavailable not available, MD notified" 10/19/12; 2 PM, marked as not given, "Salonpas patch -unavailable not available, MD notified" From 10/17/12 through 10/26/12 Resident 4 missed 29 doses of his prescribed Salonpas pain patch. Documentation on the October, 2012 MAR indicated [REDACTED]. The following were noted: 10/17/12; 9 AM, marked as not given, "Chlorhexidine Gluconate...not given, med not received from pharmacy MD notified." 10/18/12; 9 AM, marked as not given, "not available called pharmacy, spoke with (name of pharmacy staff), MD notified." 10/19/12; 9 AM, marked as not given, "...not available called pharmacy, MD notified." Further review of Resident 4's medical record on 11/26/12 and 11/27/12, revealed the following entries to the nurses notes: 10/30/12 ..."Up in the wheelchair for half an hour but wanted to go back to bed because of pain..." 10/31/12..."Spoke to (Dr's name) today that oxycontin refill must be authorized writtenly (in writing) and pharmacy has been faxing form to his office..." 11/1/12..."Oxycontin still on hold due to MD's written authorization, hasn't received from pharmacy, called pharmacy today and asked narcotic dept. to talk to (Dr's name) ASAP so MD can fax the written authorization. MD aware yesterday." During an interview with the Assistant Director of Nurses (ADON) on 11/26/12 at 4:10 PM, she explained the problem with getting controlled narcotics and medications were that the physicians were not faxing the signed prescriptions back soon enough and that the pharmacy doesn't always send the medications when ordered. She further stated at times they would get the needed medications from their emergency (EKIT-medications stored in the event of an emergency). The ADON did not know why the over-the-counter and non-controlled medications were not received from the pharmacy as prescribed. On further interview with the ADON on 11/26/12, at 4:10 PM, when asked to demonstrate the medication refill process, including the form to be used to fax to the pharmacy when resident refills or new orders were needed, she was unable to do so. The ADON replied that she would have to seek assistance from Registered Nurse 1 (RN 1). During a phone interview on 11/27/12, at 1:30 PM, with Physician 2 (Resident 4's physician), he stated he was aware of the problem with getting resident medications, especially narcotics from the pharmacy. Physician 2 stated that there were times after business hours and on weekends when the facility faxed the controlled medication form to him to sign and it would not be signed until he could get to his office, and this unfortunately was a problem. During continued phone interview with Physician 2 on 11/27/12, at 1:30 PM, he stated that he was unaware that Resident 4 had not received his scheduled Oxycontin 80 mg SR twice daily as prescribed in October, 2012, and that was why he had increased the Oxycontin 80 mg SR from twice daily to three times daily, because Resident 4 continued to say his pain was unrelieved when the physician saw him in October. During an interview with the Director of Nurses ( DON) on 11/27/12, at 9:00 AM, she stated that she was aware that there was a problem with getting resident medications. She further stated that the charge nurses were responsible for letting the physicians know if a prescribed medication was unavailable and that, "Our girls (nurses) are constantly bugging the doctors and the pharmacy." She stated that at the quality assurance meetings it was not usually discussed, and that the problem was at a corporate level and "my hands are tied." During a phone interview with the facility Medical Director on 11/28/12, at 3:50 PM, he stated that he was aware there was a problem with residents not receiving their controlled medications as ordered, and that it was an issue at several facilities, especially with this particular pharmacy. The Medical Director further stated that the pharmacy closes early on the weekends, and that makes it difficult to obtain medications at that time. The Medical Director stated that he was concerned about the issue. During a phone interview with the contracted Pharmacist on 11/28/12, at 4:20 PM, he explained that he completes a medication review for the facility every month, and that he had not completed the November medication review yet for the current month of November. He further stated in regards to Resident 4's missed medications, "I don't have that information in front of me," and that he was presently driving to another facility. When asked if he would be available to clarify issues identified with the pharmacy he stated, "Why would I do that?" He did not state if he had identified the missed doses of Oxycontin, Salonpas pain patch, Ativan and Chlorhexidine Gluconate for Resident 4. On 11/30/12, a document provided by the Administrator and titled, "Pharmacy Back-Up Pharmacy Agreement", dated 8/19/11, was reviewed. It showed an agreement between the facility's Pharmacy and an additional pharmacy to provide medications in the event of "an emergency or other unforeseen circumstances, to skilled nursing facilities in the San Bernardino County area." During an interview with the Administrator on 11/30/12 at 2:25 PM, he stated he was unaware of the Pharmacy Back-up agreement, and that it had not been utilized by the facility. On 11/30/12 , a review of a document titled, "Pharmacy Services Provider Agreement", dated October 1, 2011, revealed under the section "Responsibilities of the Pharmacy", that the pharmacy "will", supply products and render services with state and federal laws, "...in a prompt and timely manner..." for residents. Further review on the facility's pharmacy's "C-2 (Controlled) Ordering and Dispensing Protocol", dated April, 2009, revealed that "Our (pharmacy) primary focus at (pharmacy's name) is to provide quality care for the patient. We will work closely with the nurse and prescriber to expedite the authorization process for C-2 medications and deliver them as quickly as possible. Pharmacy recommends that nurse requests an interim order for a non-C-2 Narcotic (Vicodin, Tylenol with Codeine), until the C-2 is available..." 3. On 11/27/12, a review of the clinical record for Resident 10 indicated the resident was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record on 11/27/12, showed a physician's order dated 11/26/12, at 2:30 PM, for gabapentin (Neurontin-a medication used to treat pain) 100 milligrams (mg), 1 tablet by mouth, three times a day, for osteoarthritis. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of Resident 10's clinical record on 11/27/12, revealed there was no documentation or notes to indicate why Resident 10 had not received gabapentin as ordered by the physician on 11/26/12. On 11/27/12, at 8:35 AM, during an interview with Registered Nurse (RN) 1, she said Resident 10 had not received the medication gabapentin because it hadn't been delivered from the pharmacy. On 11/27/12, at 8:25 AM, during an interview with Resident 10, translated by CNA 3, Resident 10 said she was in pain, her back hurt and she did not want to sit up any longer to finish her breakfast. On further interview with RN 1 on 11/27/12, at 8:35 AM, she was unable to answer how soon medications should be started after ordered by a physician and directed the question to the Assistant Director of Nursing (ADON). On 11/27/12, at 8:40 AM, during an interview with the ADON, she stated the medication gabapentin for Resident 10 had not been delivered from the pharmacy on 11/26/12, the day the medication was ordered, and that was why Resident 10 had not received the medication. The ADON further stated that the pharmacy does not have scheduled delivery times and when a medication is ordered late in the day, it is not unusual for the the pharmacy to deliver the medication the next day. On further interview with the ADON on 11/27/12, at 8:40 AM, she said she did not know what the facility policy and procedure indicated regarding how soon medications should be administered after ordered by a physician. On 11/27/12, at 9:30 AM, during an interview with the Director of Nurses (DON), she said the facility's policy regarding medication administration indicates medications other than antibiotics should be started at the next scheduled mediation administration time. The DON continued to say that if a medication was not available, the nurse on duty should follow up with the pharmacy and the physician to obtain another order if necessary. The DON said the nurses should document their efforts to obtain the medication in the nursing notes. On further interview with the DON, on 11/27/12, at 9:30 AM, she said Resident 10 should have received the medication gabapentin on 11/26/12, at 5:00 PM, as that would have been the next scheduled medication administration time. The DON verified there was no documentation or notes of any kind in Resident 10's clinical record to indicate that the pharmacy or physician was notified of the medication gabapentin not being administered to Resident 10 within the required time frame. On 11/17/12, a review of the facility policy and procedure titled, "Administering Medications", dated January 2009, section 6. a indicated, "If a medication cannot be given at the time ordered due to the pharmacy's inability to deliver it, manufacturer's shortage, or any other reason, the physician will be notified and an alternative medication be ordered if necessary. All such communications with the physician will be documented in the nurse's notes, dated, and timed." Because of the facility's failure to assure the availability and administering of medications as prescribed by the physician, Immediate Jeopardy was called on 11/27/12, at 3:30 PM with the Administrator and the Director of Nursing. On 11/27/12, at 5:40 PM, the DON presented a plan of corrective action to the survey team. The plan of correction consisted of the following elements: (1) Residents 4, 7 and 10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (2) All residents with narcotic orders will be reviewed and compared to availability of medication in medication cart. If issues with medications identified, will have medication ordered and delivered to ensure availability of administration. If pharmacy is unable to supply medication, the RN will notify MD for alternate medication. Pharmacy will triple check medication orders, availability and delivery by 11/27/12. (3) Administrator will review contract with pharmacy to clarify the process of ordering and delivering of medications in a timely manner by 11/28/12. Issues will be addressed immediately by the director of the pharmacy and the administrator. Director of Nursing Services (DNS) (DON) will inservice licensed nurses on all shifts regarding policy and procedures of unavailable medications by 11/28/12. The Administrator will contract pharmacies for use as back up if medication not available through current contracted pharmacy by 11/28/12. (4) RN supervisors for each shift to communicate daily with licensed staff of any pharmacy issues and report to DNS (DON) for follow up to pharmacy for correction. The DNS (DON) will monitor medication availability and delivery daily and issues for pharmacy correction will be reported in stand up meeting. Any unresolved issues will be addressed with the Administrator/Medical Director and Pharmacy Director. The Administrator will monitor for trends and report to Quality Assurance (QA) committee monthly. Date of completion 11/28/12 On 11/28/12, at 4:30 PM, the Immediate Jeopardy (IJ) was abated (lifted) in the presence of the Administrator based on the implementation of the plan of correction which included the above mentioned interventions.

Based on observation, record review and interview, the facility failed to ensure that 1 of 20 sampled residents (Residents 4) received the necessary care and services in order for the residents to maintain the highest practicable physical, mental and psychosocial well being when the facility staff failed to take action when Resident 4 experienced a significant change in condition that was reported to the LVN on 2 separate occasions and when the LVN failed to notify the RN and the resident's physician regarding Resident 4's shallow breathing and inability to be aroused. The failure of the facility licensed staff to notify the physician regarding Resident 4's change in respiratory status and level of consciousness resulted in Resident 4 to experience [MEDICAL CONDITION] which required emergency services intervention. Resident 4 expired on [DATE] at 3:57 PM. Findings: A review of Resident 4's medical record on [DATE] indicated that Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's medical record showed an MDS (minimum data set/a tool used to assess the resident) dated [DATE], which indicated Resident 4 had clear speech, was able to make himself understood and was able to understand others. Further review of Resident 4's medical record showed an, "Advanced Healthcare Directive," dated [DATE], which indicated that he was a full code (this indicated he desired all life saving measures be done in the event of a health emergency). On [DATE], at 3:20 PM, an observation was made from the facility's south nursing station. LVN 1 (Licensed Vocational Nurse) yelled for help from Resident 4's room. At this time multiple staff responded to the room, including LVN 2. During further observation conducted in Resident's 4 room, facility staff was observed to initiate cardiopulmonary resuscitation. The nursing staff was then observed to contact emergency services, who arrived and unsuccessfully tried to resuscitate Resident 4. At 3:57 PM, Resident 4 was pronounced dead. A review of Resident 4's physician's orders [REDACTED]. Further review indicated an additional physician's orders [REDACTED]. On [DATE], at 4:30 PM, a phone interview was done with CNA (certified nursing assistant) 2. She confirmed she was the CNA assigned to Resident 4's care on [DATE] and that she had attempted to feed him lunch around noon. She stated he ate a "little bit" and drank about 10 percent of his milk at lunch. She stated he seemed tired but he was "moving around in bed." She stated that another CNA had taken his vital signs that morning, however she was unaware of what they were. She (CNA 2) stated she did not see anything unusual and did not report anything to the charge nurse regarding Resident 4's condition. Review of Resident 4's record indicated no documentation to show that vital signs had been taken and recorded by the CNA on [DATE] as reported by CNA 2. On [DATE], at 10:15 AM, an interview was conducted with OTA 1 (occupational therapy assistant) regarding Resident 4. OTA 1 reported that she was not very familiar with Resident 4, however, when she went in to work with him the morning of [DATE], sometime between 10:00 AM and 12:00 PM, he appeared sleepy and she "couldn't wake him up." She stated his breathing was "shallow" and his eyes were partly open. She stated that the PTA 1 (physical therapy assistant) was attempting to work with Resident 4 in his room before her and they had discussed his condition. During further interview, OTA 1 stated that after she checked Resident 4 in the morning, she went to LVN 2 and reported that "she couldn't arouse him" (Resident 4). OTA 1 stated that she was unaware if LVN 2 went in the room to check on Resident 4. OTA 1 stated that she went back to check on Resident 4 in the afternoon and was still unable to arouse him, and found him with shallow breathing. She immediately notified LVN 1, who was in the same room giving care to another resident. At this time they immediately called for help and started emergency procedures, some of which included taking Resident 4's vital signs, applying oxygen and eventually performing CPR (cardiopulmonary resuscitation). On [DATE], at 10:30 AM, an interview was conducted with PTA 1 (physical therapy assistant). PTA 1 stated he went in to work with Resident 4 on [DATE] around 10:00 AM and he was unable to wake him up. He stated he did a "sternal rub" (a sternal rub is when a rescuers knuckles are firmly rubbed on the breast bone to cause pain and arouse the patient) on Resident 4's chest and still was unable to arouse him. At this time PTA 1 demonstrated a sternal rub by making a fist and rubbing his chest area. He stated he went and verbally reported this to the charge nurse, LVN 2. He did not know if LVN 2 went in to check on Resident 4. PTA 1 stated that he went back to try to perform therapy with Resident 4, in the afternoon (the same day), between 2:00 to 2:30 PM, but again Resident 4's eyes were closed. PTA 1 stated, "I tried to put his legs over the side of the bed and physically sit him up, but that didn't work. I was unable to arouse him." PTA 1confirmed he did not report this second instance to LVN 2. During further interview, when asked what Resident 4's normal behavior was when PTA 1 worked with him, he stated, "He is not very energetic usually, but he gets up in the chair." In an interview with LVN 2 on [DATE], at 8:12 AM, he stated on [DATE] at approximately 9:30 AM, he checked Resident 4's blood pressure and pulse, and then gave the scheduled AM medications right after that. LVN 2 stated that he did not document a blood pressure or pulse in Resident 4's medical record. On [DATE] at 10:40 AM, LVN 2 was interviewed regarding Resident 4. When asked if OTA 1 and PTA 1 notified him of Resident 4's change of condition on [DATE], on two separate occasions, he denied that they notified him and that he was unaware of any concerns regarding Resident 4. On [DATE], at 10:45 AM, a concurrent interview was conducted with PTA 1 and LVN 2, at which time LVN 2 stated that PTA 1 had, in fact, verbally notified him of Resident 4's change of condition. On [DATE], at 10:58 AM, a concurrent interview was conducted with OTA 1 and LVN 2, at which time LVN 2 stated that OTA 1 also had verbally notified him of Resident 4's change of condition. During further interview on [DATE], LVN 2 went on to state that he went in to assess Resident 4 on [DATE] at approximately 10:30 AM and that he found him (Resident 4) tired. He stated that he did a "sternal rub on his chest" and that Resident 4 then opened his eyes and moaned. He took Resident 4's blood pressure and "palpated the wrist" to take his heart rate, then proceeded to give him his 9:00 AM medications by mouth. LVN 2 stated that the resident did not show any symptoms of shallow or difficulty in breathing at that time. Again LVN 2 stated he did not document any of Resident 4's information such as vital signs, his mental status, a physical assessment, or medications taken, on Resident 4's medical record, MAR, or on any other form. A review of Resident 4's therapy notes, on [DATE], showed documentation by PTA 1 and dated [DATE] (2012, no time), that he had notified the nurse regarding difficulty rousing Resident 4. Documentation further showed that PTA 1 would "check back later" (on Resident 4). A review of Resident 4's therapy notes, on [DATE], showed documentation by OTA 1 and dated [DATE] (2012, no time), that she had notified the LVN regarding being unable "to roust" Resident 4 in the "AM", (no specific time given), and that he had "shallow breathing." Documentation by OTA 1 further showed OTA 1 returned to see Resident 4 in the "PM", (no specific time given), at which time his eyes were half open, and that he was "asleep." A review of nurses notes from [DATE] through [DATE], showed no documentation regarding a change in Resident 4's condition as, reported to LVN 2 by PTA 1 and OTA 1 on [DATE]. During a concurrent interview with the DON and DSD (Director of Staff Development) on [DATE], at 9:40 AM regarding Resident 4, both confirmed that they were working in the facility on [DATE], when Resident 4's condition deteriorated. The DON and DSD concurred that neither the RN nor physician had been notified of any change in Resident 4's condition until the afternoon, at approximately 3:20 PM when LVN 1 began yelling for help. On [DATE], at 10:40 AM an interview was conducted with the DON. The DON stated that some examples of a change in a resident's condition would be a high or low blood sugar, abnormal lab values, a fall, a change in behavior or lethargic behavior. She further stated any change in the resident's condition should be reported to the physician. During further interview, the DON stated that lethargic behavior would mean, "Not being able to be aroused," and that since Resident 4 showed symptoms of shallow breathing and difficulty in arousing, the RN and physician should have been notified on [DATE] regarding Resident 4's change of condition. When asked if it is a normal practice of the facility to do a sternal rub to arouse a resident, she replied, "No." During further interview, the DON stated that the facility communicates a change of condition or unusual occurrence on a communication form titled, "Daily Charting" which would be kept at the nursing stations with the residents information and reason for the charting. On [DATE], a review of documentation titled, "Daily Charting" located in both north and south nursing stations for the dates of [DATE] through [DATE], showed no documentation regarding Resident 4's shallow breathing, lethargy and difficulty in arousing as reported by OTA 1 and PTA 1 on [DATE]. During an interview with the DON on [DATE], at 10:42 AM, she confirmed that there was no documentation on the daily charting forms regarding Resident 4's change of condition as reported by OTA 1 and PTA 1 to LVN 2 on [DATE]. In an interview with the DSD on [DATE], at 2:05 PM, she explained that the LVN functions as the charge nurse and provided documents currently used by the facility that outlined the duties and responsibilities of the LVN charge nurse. On [DATE] a record review was conducted of the facility's "Charge Nurse (LVN) job descriptions." Under the section, "Duties and Responsibilities Nursing Care Functions" it indicated that the charge nurse was responsible to, "Notify the resident's attending physician and next of kin when there is a change in the resident's condition."

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the residents' highest practicable physical, mental and psychosocial well being for 1 of 11 sampled residents (Resident 3) and for 2 of 4 unsampled residents (Resident B and C) as follows: 1. For Resident 3, the licensed nurse administered a wound treatment to the multiple open wounds to sacral area (coccyx-tail bone area) without the physician's order. This failure had the potential to result in the resident to experience medical complications. 2. For Resident C, the facility failed to provide an appropriate wheelchair for her to sit comfortably which resulted in Resident C to choose to stay in bed and the potential for Resident C to have a medical complication. 3. For Resident B, the facility failed to assess and treat Resident B's complaints of mouth discomfort which resulted in Resident B to experience pain and for the potential to experience additional medical complications. Findings: 1. A review of Resident 3's clinical record on 3/27/12 revealed that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation of Resident 3 on 3/27/12 at 12:00 PM, she was lying on bed and complaining of pain to her sacral area (coccyx-tail bone). Resident 3's son was at bed side visiting the resident. A review of the physician's order dated 3/22/12 revealed an order "Cleanse sacral redness...apply [MEDICATION NAME] (skin protectant drug product) QD ( daily) and PRN (as needed)..." During an observation of Resident 3 on 3/27/12 at 12:05 PM, Resident 3 was lying in bed. Resident 3 was still complaining of pain to her sacral area. CNA 1 and RN 1 were observed to reposition the resident to her right side. During the time of the observation, there were 3 open wounds observed on the resident's sacral area. RN 1 verified the multiple open wounds at the time of the observation. During an interview with CNA 2 on 3/27/12 at 12:10 PM, she stated that she had been assigned to care for the resident at multiple times. CNA 2 stated "It's been open at least for 2 weeks already. I reported it to the treatment nurse and she applied cream (medicine) to the area." It started with one (1) open wound ." During a wound care observation , accompanied by LVN 1 on 3/27/12 at 12:15 PM, LVN 1 measured the 3 open wounds on the resident sacral area. LVN 1 provided the wound measurement as follows; site 1(top) 0.5 cm (centimeters) by 1 cm, site 2 (middle) 0.5 cm by 0.3 cm and site 3 (below) 0.5 cm by 0.5 cm. During an interview with LVN 1 on 3/27/12 at 12:15 PM, she stated that the sacral wounds site 1 and 2 were described as stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcers and that site 3 was "peeling skin." During an interview with Resident 3's son on 3/27/12 at 12:20 PM, he stated that Resident 3 was admitted to the facility without any open wounds, "it was just redness." He also stated that the facility staff had informed him that his mother (Resident 3) had only 1 (one) open area on her coccyx and that, "I didn't know that she has more than one open wounds." Resident 3's son also mentioned that Resident 3 had been complaining of pain to her sacral area for at least the past 2 weeks. A review of the facility policy and procedure titled, " Prevention of Pressure Ulcers" dated 7/05 revealed, "The licensed nurse will report changes in skin condition to the physician." During an interview with LVN 2 on 3/27/12 at 3:50 PM, she stated that she knew that Resident 3 had multiple open wounds on her sacral area for about 2 weeks ago. " I saw it. I did not call the doctor, but there is a treatment ([MEDICATION NAME] cream) for that already. " LVN 2 stated that LVN 1 had been aware of Resident 3's multiple open wounds about 2 weeks ago. LVN 2 verified that the physician's order for the [MEDICATION NAME] should be used for the redness at the sacral area and should not be used for the open wounds. 2. A review of Resident C's clinical record on 3/29/12 revealed that Resident C was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation of Resident C on 3/29/12, at 9:45 AM, Resident C was observed lying in bed. During an interview with Resident C on 3/29/12 at 9:45 AM, she stated, "I don't feel like getting out of bed. Yesterday they (the facility staff) almost dropped me." Resident C stated that the incident had occured during the transfer from the Hoyer lift (A Hoyer lift is a lift used to transfer persons who cannot support themselves from one location to another) to the wheelchair. Resident C stated, "They asked me to scoot and scoot into the wheelchair, I couldn't because the wheelchair is just too narrow and uncomfortable to sit on." During further interview when asked if she had reported the issue to the facility staff she stated, " They knew it, but that's okay. I prefer to be in bed if I have to sit on a narrow wheelchair. As you see, I am not a regular size person." Resident C stated that she also had an experience to be sitting on a gerichair (recliner chair ) and "that gerchair is too narrow." During an observation on 3/29/12 at 10:00 AM, Resident C had a wheelchair with her name on it. A request made to the facility staff to measure the width of Resident C's wheelchair. RN 1 brought the resident's wheelchair to a physical therapy room and the OT was observed to measure Resident C's wheelchair as 20 inches. There was a folded wheelchair observed in the physical therapy room that belonged to the facility, OT then measured the facility's wheelchair as comparison to the resident's wheelchair, and it was measured by the OT as a 20 inch wheelchair. OT then measured the facility gerichair and it was confirmed as a 20 inch gerichair. During an interview with the OT on 3/29/12 at 10:00 AM, he stated " hers is a 20 inch wheelchair." When asked if the wheelchair size was appropriate for Resident C to use, he responded, "She needs a bigger wheelchair to sit comfortably." According to OT, the facility's regular wheelchair measured from 20 inches to 22 inches. A review of Resident C's clinical record, showed documentation that on 2/24/12, Resident C received a wheelchair however, there was no documentation in the clinical record to show that Resident C was reassessed for the use of her new wheelchair that was received on 2/24/12 in order to determine the appropriate size. The SSD verified during the time of the record review on 3/29/12 at 10:45 AM. During an interview with RN 1 on 3/29/12 at 10:35 AM, she stated that the SSD had made a phone call to Resident C's insurance and that, "they will deliver the right size of wheelchair, which is a 26 inch wheelchair tomorrow. That wheelchair was not the right size for her, it's too small for her." A review of Resident C's care plan for "Self care deficit", dated 4/21/11 revealed that the interventions included, "Up in w/c (wheelchair) QD (daily) as tolerated." During an interview with Resident C on 3/29/12 at 9:45 AM, she stated that she had decided to stay in bed. Resident C stated, "I would love to get out of bed if they could give me a comfortable wheelchair to sit on." 3. A review of Resident B's clinical record on 3/28/12 revealed that Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident B's history and physical dated 8/18/11 indicated she does not have the capacity to understand and make decisions. On 3/28/12, at 11:25 AM, during a facility group meeting Resident B complained that she had pain in her mouth. During an observation on 3/28/12, at 1:00 PM, Resident B was observed sitting in her wheelchair complaining of nausea and pain and reaching for an emesis basin on her bedside table. In further interview on 3/28/12, at 1:30 PM, Resident B said she told LVN 4 of her mouth pain "yesterday", and that the pain was all over in her mouth, pointing to her gums/teeth. She said that she had told nursing staff last week and stated, "I have been telling them (nursing staff) for some time now." An interview was conducted with LVN 4 on 3/28/12 at 1:35 PM; she stated that today was the first day she was notified of Resident B's mouth pain and that she had medicated her for her mouth pain a few minutes ago. Review of Resident B's clinical record indicated a physician's order dated 2/26/12 for Tylenol ES (extra strength) 500 milligrams (mg) 1 tab by mouth every four hours prn (as needed) for mild pain. On 3/28/12 a record review of Resident B's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further record review of the March, 2012 MAR indicated Monitor for pain every shift: 0=no pain, 1-2=slight pain, 3-4=mild pain, 5-6=moderate pain, 7-8=severe pain, 9-10=worst possible pain." On the MAR indicated 0=no pain." Review of Resident 9's nursing care plan (a plan for the resident's needs), dated 11/26/11, indicated Alteration in comfort r/t (related to): Gingivitis. Interventions included observing for verbal/nonverbal signs and symptoms of pain, medication as ordered (Tylenol), and notify MD if pain regimen no longer effective. There was no updated date after 11/26/11 for the plan of care. On 3/28/12, at 1:20 PM, an interview was done with the social services director (SSD). She stated that she was aware of Resident B's mouth pain and confirmed she was notified of it by a CNA last week. She was unable to provide any documentation that she contacted any dental services to obtain a dental appointment for Resident B. She further stated there was a "problem with her eligibility" for her next visit and stated that "I'm working on it." On 3/29/12, at 4:00 PM, an interview was conducted with CNA 6. She confirmed she was Resident B's CNA and said she was familiar with her. CNA 6 stated Resident B is alert and able to make her needs known. She stated that she had notified LVN 4 and the "social worker" (SSD) of Resident B's mouth pain one day last week, but she did not document that she had notified them. She stated that she told the social worker because she is the person who schedules dental appointments for the facility residents. On 3/29/12 further record review of Resident B's "nurses weekly progress note," with the weekly dates of, 3/7/12, 3/12/12, 3/21/12, and 3/28/12, showed entries made by the licensed nurses that indicated Resident 9 had no complaints of pain or discomfort. Further review of the nurses' notes from the date of 3/19/12 until 3/27/12 did not show any documentation of mouth pain or that a physician was notified of Resident 9's mouth pain. On 3/29/12, the facility policy and procedure titled, "Pain Assessment", dated Revised August, 2002, was reviewed. It indicated that its purpose was to assess the resident's pain level and provide optimal comfort. Pain will be assessed and documented at regular intervals and the evaluation of the medication to relieve pain to a level that is acceptable to the resident will occur within 2 hours of administration. If pain is not relieved follow-up with the physician. In an interview with the DON on 3/29/12 at 2:05 PM, he confirmed Resident 9's mouth pain should have been addressed.