Every finding on record at Coalinga Regional Medical CTR Dp/Snf

Based on interview and record review the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in any part of the urinary system) for one of three sampled residents (Resident 1), when the facility staff did not schedule or follow up on a physician ordered specialty referral to the urologist (a medical doctor and surgeon who specializes in diagnosing and treating conditions of the urinary tract) for Resident 1's frequent UTI's for more than one year. This failure placed Resident 1 at risk for delayed diagnosis and frequent urinary tract infections.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Urinary tract infection. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 4/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated, Resident 1 had moderate cognitive impairment. During an interview on 7/9/26 at 10:40 a.m. with Resident 1 in Resident 1's room. Resident 1 stated that during her stay in the facility, she had experienced multiple UTI's. Resident 1 stated her physician had referred her to a urologist for evaluation more than six months ago and the facility had not scheduled the appointment. Resident 1 stated she had a history of UTI's but was experiencing UTI's more frequently than before. Resident 1 stated she was concerned about her frequent UTI's and the facility's lack of attention to the physician's order to schedule an appointment with the urologists. During a concurrent interview and record review on 7/9/26 at 10:55 a.m. with Licensed vocational nurse (LVN) 1, Resident 1's electronic medical record (EMR) was reviewed. LVN 1 stated there was no indication in the EMR that Resident 1 was seen by a urologist in the past prior to June 2026. LVN 1 stated the facility process was for the nurse in charge to document the referral in the electronic medical record and then notify the director of nurses (DON) and social services. LVN 1 stated social services was responsible for scheduling appointments for referrals submitted from the physician and was responsible for ensuring appointments were scheduled. During a concurrent interview and record review on 7/9/26 at 11:13 a.m. with Social Services (SS), Resident 1's Order Summary, dated 6/2/2025 was reviewed. The summary indicated, . May have urologist eval and treat as indicated. The SS stated she was not the social worker in the facility at the time of the initial order on 6/2/25 for Resident 1's referral to a urologist. The SS stated the facility process was for the nurses to input the physician order for a referral into the residents EMR. The DON and SS are notified to ensure the referrals were completed. Then residents are scheduled for specialized services. The SS stated the urologist referral ordered on 6/2/25 for Resident 1 should have been completed and should have been scheduled at that time. During an interview on 7/9/26 at 12:36 p.m. with Registered nurse (RN), the RN stated the facility process for submitting physician referrals was for the nurses to document the order into the residents EMR. The RN stated the referral was then given to the SS to schedule the appointment and transportation for the residents to receive specialty services. The RN stated the referral for Resident 1 received on 6/2/25 should have been scheduled by the SS at the time and the SS should have confirmed Resident 1 was transported to the specialty appointment. The RN stated it was not an acceptable practice to wait a year to follow up on a physician ordered referral as Resident 1 required the services as part of her care. During a concurrent interview and record review on 7/9/26 at 1:15 p.m. with the DON, Resident 1's Order Summary, dated 6/2/2025 was reviewed. The summary indicated, . May have urologist eval and treat as indicated. The DON stated she was not aware of the physician order for Resident 1 submitted on 6/2/25 for a urologist's consultation. The DON stated that the facility had experienced administrative and staff changes during this time. The DON stated there was no indication in Resident 1's EMR that the referral was completed or that Resident 1 had seen a urologist at that time. The DON stated the facility process was for the SS to schedule the appointment for the specialty referral and to ensure appointments were completed. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/2008, the P&P indicated, Social services personnel shall coordinate most resident referrals with outside agencies. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. Referrals for medical services must be based on physician evaluation of resident need and a related physician order. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social services will document the referral in the residents' medical record.

Based on interviews and record review, the facility failed to ensure residents were free from verbal, mental, and physical abuse for five of the ten sampled residents (Resident (Res) 2, Res 3, Res 4, Res 5 and Res 6 when:Certified Nursing Assistant (CNA) 2 and CNA 3 mocked, laughed and engaging in demeaning behavior towards Res 2.CNA 2 and CNA 3 did not change Res 3's soiled briefs and did not provide appropriate perineal care (cleansing of the genital and anal area essential for preventing infections, reducing odors, and maintaining skin integrity), or hygiene, failing to clean Resident 3 prior to changing Res 3's brief.CNA 3 struck Res 4 in the face with a chuck pad while cleaning a bowel movement, constituting physical abuse.CNA 2 and CNA 3 were reported by multiple residents to not provide quality care by delaying or not responding to call lights, indicating a pattern of abusive and neglectful practices.Facility staff were aware that activity staff left residents unmonitored during activities and on 6/8/26 Res 5 hit Res 6 on the left side of the face and left arm during activities in the dining room.These failures resulted in Res 2, Res 3, Res 4 and Res 5 subjected to ongoing verbal, psychological, and physical abuse, and placed all residents in the facility at risk for abuse and neglect by CNA 2 and CNA 3. Findings: During an interview on 6/3/26 at 11:35 a.m. with the Director of Nursing (DON), the DON stated that she was familiar with the incident with Res 2, the DON stated that it was reported to her by a staff member (MN) that he felt uncomfortable how Res 2 was treated by CNAs [CNA 2 and CNA 3]. The DON stated she had asked for [MN's] statement. The DON stated (MN) did not provide names for the CNAs until later in the statement. The DON stated that she had started the investigation on 5/6/26 by notifying the Director of staffing development (DSD) and risk (QRM) for the facility. The DON stated that it was not until the DSD was doing in-services the following week that staff came forward with the reporting and two particular staff CNAs name (CNA 2 and CNA 3) came up. The DON stated during the investigation the facility identified additional residents that were mistreated by these two CNAs. The CNO stated that CNA 2 was suspended on 5/15/26 and CNA 3 was suspended on 5/19/25. The CNO stated no other issues were identified, the DON stated all appropriate notifications were completed and resident's care plan was updated. The DON stated that the investigation concluded that significant abuse and neglect occurred within the identified rotation. The actions of [CNA 3] and [CNA 2] constitute violations of resident rights, dignity, and safety, including verbal abuse, psychological abuse, neglect, and in [CNA 3's] case, physical abuse.During an interview on 6/3/26 at 1:20 p.m. with the DSD, the DSD stated that she had been working at this facility since March 2026. The DSD stated she was on vacation from 5/5/26 to 5/13/26. The DSD stated upon returning on 5/13/26, she checked her email and found out about the incident with Res 2. The DSD stated that she immediately started reaching out to her colleagues and started to follow up. The DSD stated that she immediately started in-services with staff on Resident Rights, dignity and abuse prevention/reporting. The DSD stated that one of the staff members [CNA 5] after the in-service, came to her and stated that she needed to discuss what she observed. The DSD stated that staff member [CNA 5] stated on 5/5/25 that she observed CNA 2 yelling at Res 2's face I am wet. The DSD stated that [CNA 5] stated that she had observed CNA 2 being mean to Res 2, disrespectful, taunting Res 2, mocking the behaviors of Res 2. The DSD stated that [CNA 5] stated that her rotation was very bad and CNA 2 was bad to other patients. The DSD stated that she immediately notified facility's HR, reported to state [California Department of Public health (CDPH)] and ombudsman. The DSD stated she was further notified by CNA 4 that he had observed CNA 3 being disrespectful to other residents and one occasion, first week last month [May 2026], observed CNA 3 hitting Res 3 with a chuck pad (highly absorbent, waterproof bed pad used to protect mattresses, furniture, and wheelchairs from bodily fluid) on the face. The DSD stated during interviews with staff and other residents, the facility identified other residents that expressed concerns with care provided by CNA 2 and CNA 3. The DSD was asked if the reporting for Res 3's incident [witnessed by CNA 4 - Res 3 was hit on the face with Chuck pad by CNA 3] that was identified during investigation was completed. The DSD stated she was not aware if the facility reported it. The DSD stated she had also interviewed Res 2 and Res 2 stated that CNA 3 will take her out, mock her and leave her outside for extended period.During a concurrent interview and record review on 6/3/26 at 1:43 p.m. with the DON, the facility document titled HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name ], undated was reviewed. The HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name ], indicated . Case Information . Investigator: [DON] & [DSD] . Date of Report: 5/26/26 . Date Investigation Opened: 5/15/26 . Employee involved . [CNA 2] . [CNA 3] . Complainants . Multiple residents . Allegations types . Verbal Abuse, Neglect, Psychological Abuse, Violation of resident rights, Failure to report . Summary of Initial Allegation On 5/6/26 [MN], Maintenance reported that he had observed CNA's [CNA 2] and [CNA 3] laughing and mocking a resident. His concern was escalated to [QRM], Quality/Risk Manager and [DSD] for follow up. On 5/15/26, following an in-service training on de-escalation and resident rights/dignity in response to the previous reported incident, [CNA 5] reported an incident that occurred on 5/5/26 to [DSD] . [CNA 5] stated she observed [CNA 2] mocking a resident by repeating phrases the resident frequently says, including I'm wet. The resident [Res 2] involved is a [AGE] year-old female diagnosed with anoxic brain damage [Serious, life-threatening condition caused by a complete lack of oxygen to the brain] and unspecified dementia [when a patient shows clear signs of memory loss and mental decline, but the specific cause cannot be precisely identified or categorized], with a [Brief Interview for Mental Status (BIMS - standardized assessment used primarily in nursing homes and long-term care settings to evaluate a person's brain function, memory, and orientation, range from 0-15, higher number indicating better functioning)] score of 11, indicating moderate cognitive impairment [noticeable decline where individuals require assistance with complex daily tasks]. [CNA 5] reported no other staff involvement on that specific day but stated, That rotation is horrible, implying ongoing concerns. HR was notified immediately, and [CNA 2] was removed from the schedule pending investigation . Investigation Steps . Interview with initial reporter (CNA 5) . Removal of [CNA 2] from schedule pending investigation on 5/15/26 . Interviews with additional CNAs, LVNs, and RNA . Review of resident statements during care conferences . Abuse screening interviews with residents . In-service training initiated for LVNs on chain of command and mandatory abuse reporting . SOC 341 A [Report of Suspected Dependent Adult/Elder Abuse] acknowledgment forms signed by LVNs . Assignment of [NAME] training module on Recognizing and Managing Abuse and Violence . Removal of [CNA 3] from schedule on 5/20/26 pending investigation . The DON was asked what steps were taken between 5/6/26 to 5/15/26 [Date of investigation open] to ensure residents were safe, free from abuse and neglect from CNA 2 and CNA 3 after the MN reported incident on 5/6/26 and the investigation open date listed was 5/15/26. The DON stated she sent an email with MN's concerns reported to her on 5/6/26 to QRM and DSD, and QRM was supposed to follow up. The DON stated she was not able to comment on what steps were taken during that time [5/6/15 to 5/15/26] by QRM or the facility to ensure resident's safety from CNA 2 and CNA 3. The DON was asked if the potential abuse was reported on 5/6/26 to all authorities as needed after she was made aware of the concerns by MN. The DON stated the facility was investigating and the concerns were not reported [SOC 341 filled out 5/15/26] until 5/15/26. The DON reviewed the staffing schedule and stated that CNA 2 worked on 5/8/26, 5/9/26 and 5/13/26 until she was suspended on 5/19. The DON stated CNA 3 worked on 5/8/26, 5/9/26, until she was terminated on 5/19/26. The DON stated that she was waiting on QRM as they were leading the investigation. During a review of Res 3's admission Record [AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information], undated, the AR indicated that Res 3 was [AGE] year-old male and admitted to the facility on [DATE]. Res 3's medical history included diagnosis of failure to thrive (progressive physical and cognitive decline), Type 2 diabetes (chronic condition where body maintain normal glucose levels), mood disorder (mental health condition that primarily affect emotional state), major depressive disorder (MDD- severe, recurring mood disorder characterized by pervasive sadness, loss of interest in activities, and low energy), and muscle weakness.During a review of Res 4's AR, undated, the AR indicated that Res 4 was [AGE] year-old male and admitted to the facility on [DATE]. Res 4' medical history includes diagnosis of Paraplegia (partial or complete paralysis of the lower half of the body, including both legs), Type 2 diabetes, bell's palsy (an unexplained, temporary weakness or paralysis of the facial muscles), and failure to thrive. During an interview on 6/3/26 at 12:51 p.m. with Res 4, Res 4 stated the facility had two CNAs that were not cleaning him while changing his briefs, were only changing briefs. Res 4 stated those CNAs only change at times when I poop and will not clean when I urinated. Res 4 stated it was causing him grief and discomfort. Res 4 stated this was ongoing for some time and now everything is better.During a concurrent interview and record review on 6/3/26 at 2:00 p.m. with the DON, the facility document titled HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name], undated was reviewed. The HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name ], indicated . [CNA 4] (reported on 5/22/26) . Described an incident in early May involving [CNA 3], [CNA 2] . assisting with a resident who had a bowel movement on the floor . Reported that [CNA 3] called the resident [Res 3] disgusting and ugly. Reported that after the cleanup, [CNA 3] slapped the resident [Res 3] across the face with a chuck pad . Resident Statements . One resident [Res 4] reported that [CNA 3] and [CNA 2] change his brief together, speak Spanish (which he cannot understand), and do not clean him, instead removing the soiled brief and applying a new one without wiping . Multiple residents reported . Poor care from [CNA 3] and [CNA 2] . Staff hiding outside or huddling at the nurse's station instead of providing care . Delayed or absent responses to call lights . The DON was asked if the change of condition notification, and abuse reporting was completed for Res 3 and Res 4. The DON stated that it was part of same investigation as Res 2, and the facility did not complete SOC 341 or reporting of potential abuse for Res 3 or Res 4. The DON stated after the facility was notified by CNA 4 that Res 3 was hit by CNA 3 on the face with chuck social services did not follow up with Res 3 and also did not follow up with Res 4 after his reported concerns. The DON was asked if the interdisciplinary team (IDT - a coordinated group of healthcare and support professionals that collaboratively plan and evaluates care) met to evaluate plan of the care plan for Res 3 and Res 4 after it was identified that both potentially experienced abuse and or neglect. The DON stated she was unable to find any documentation in the medical record for Res 3 and Res 4 that indicates that their plan of care was evaluated or if the IDT met to discuss these identified concerns with Res 3 and Res 4 or recommended any changes to ensure Res 3 and Res 4 well-being.During a concurrent interview and record review on 6/3/26 at 2:26 p.m. with the DON, the facility policy and procedure (P&P) titled, Reporting abuse to Facility Management, undated was reviewed. The P&P indicated, . Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Services Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation . Unless the resident requests otherwise, the social service representative will give the Administrator and the Director of Nursing Services a written report of his/her findings . The DON stated she was not aware of this requirement in the facility policy and social services did not follow up in accordance with facility policy with Res 2, Res 3 and Res 4.During an interview on 6/3/26 at 2:30 p.m. with MN and DON, MN stated that he had been in his role at the facility for two years. MN stated that on 5/5/26 he went to check the scale in physical therapy room and observed CNA 2 talking to Res 2. MN stated Res 2 was making some noises and appeared fussy. MN stated he observed CNA 2 mimicking those noises and it was making Res 2 more irritated. MN stated that CNA 2 was getting close to Res 2's face and laughing, mimicking her noises and it was making Res 2 more irritated. MN stated that Res 2's stuff toy fell on the floor and CNA 3 told Res 2 that you are running over him, following her along and just being disrespectful and rude towards Res 2. MN stated CNA 2 and CNA 3 were being rude, disrespectful and were laughing while mimicking Res 2. MN stated it bothered him, and he could not locate DON or leadership that day therefore next day [5/6/26] he saw DON and reported the incident. MN stated if it was his family member being treated this way, he would be very upset, and it was not okay for Res 2 to be treated this way by staff. During an interview on 6/3/26 at 2:45 p.m. with DON, the DON reviewed her email sent on 5/6/26 at 1:08 p.m. to DSD and QRM. The DON stated that her email on 5/6/26 at 1:08 p.m. to [DSD] and [QRM] indicated . Today It was brought to my attention by another staff member that a few CNAs were mocking a patient in residence presence which was making the resident physically upset. The incident occurred at [site location] and were reported as [CNA 2], [CNA 3] and one other CNA that they couldn't remember the name. The staff member who reported this stated it made him feel very frustrated and upset thinking if it was his family member he would have been very upset . The DON stated she had escalated to DSD and QRM and was waiting for guidance on the next steps. The DON stated QRM was supposed to be lead on this investigation and reporting. The DON stated it was not until DSD came back from vacation that services were started and when another staff member notified DSD about the same incident that SOC was filled out and report of potential abuse for Res 2 was submitted. The DON stated she was made aware of the names of the CNA's on 5/6/26 and they both remained on schedule and worked with residents until 5/15/26 for CNA 2 and 5/19/26 for CNA 3. The DON stated she should have followed up with the concerns reported by MN on 5/6/26 with QRM and started investigation, however, she was waiting on QRM. The DON was requested to speak with QRM. The DON stated QRM was out of office on leave. The DON stated five day report of investigation was not submitted to the CDPH.During a concurrent interview and record review on 6/4/26 at 1:59 p.m. with the Interim Facility Administrator (IADM) the facility document titled HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name], undated was reviewed. The IADM stated that she was made aware of the incident on 5/15/26 by DON. The IADM stated that facility immediately suspended the CNA 2 and the second CNA, CNA 3 was suspended on 5/19/26. The IADM stated she was unaware that these allegations were reported on 5/6/26 as outlined in HR INVESTIGATION REPORT: Alleged Abuse, Neglect, and Violation of Resident Rights [facility name]. The IADM stated that she was made aware of the incident on 5/15/26 by DON. The IADM stated that facility has provided all staff training on abuse reporting, and patient rights. The IADM reviewed her folder and stated that she did not realized that the incident was first reported on 5/6/26 as listed on HR INVESTIGATION REPORT. The IADM stated she was not copied in DON's email to QRM and DSD. The IADM stated that investigation should have started right away when the concerns were first reported by MN on the 5/6/26. The IADM stated she expected the facility DON and leadership to ensure that CNA 2, CNA 3 and any other staff witnessed potentially abusing the patient had not remained assigned to patients until those allegations were thoroughly investigated. The IADM stated that CNA 2 and CNA 3 should have been removed from direct patient care pending investigation. The IADM stated it was not acceptable that CNA 2 and CNA 3 remain assigned to patients and had access to patients from 5/6/26 until they were suspended [CNA 2 on 5/15/26 and CNA 3 on 5/19/26]. The IADM was asked to see if the QRM was available and IADM stated QRM was out on leave at this time. The IADM was asked if additional residents [Res 3 & Res 4] that were identified as potentially being abused and/or neglected by CNA 2 and CNA 3 were reported and SOC 341 was filled out. The IADM stated the facility did not report any additional residents as potentially victim of abuse from staff as they were identified as part of the investigation for same resident, Res 2.During a concurrent interview and record review on 6/4/26 at 2:25 p.m. with the IADM and Social Services Coordinator (SSC), the facility policy and procedure (P&P) titled, Reporting abuse to Facility Management, undated was reviewed. The P&P indicated, . when an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the lime lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy . A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator . Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Services Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation . Unless the resident requests otherwise, the social service representative will give the Administrator and the Director of Nursing Services a written report of his/her findings . Inquiries concerning abuse reporting and investigations should be referred to the Administrator and/or to the Director of Nursing Services. The SSC stated she has not followed up with Res 2, Res 3 or Res 4. The SSC stated that no one had reached out to her and asked her to follow up with either of these residents. The SSC stated she was not aware that she had to follow up and DON did not ask her to investigate as stated in the facility P&P. The SSC stated as far as she was aware no one from social services had followed up with these residents after the incident as outlined in the policy. The IADM stated she was also not made aware right away, and unsure if the Administrator (ADM) that was out country was aware at that time. The IADM stated facility process for abuse investigation and reporting was not followed.During an interview with DSD and Medical Record In charge (MR) on 6/4/26 at 2:40 p.m., the DSD stated she had reviewed the Electronic Medical Record (EMR ) for Res 3 & Res 4 with MR and neither of the residents had IDT notes, care plan updates and SOC 341 filled out after the investigation revealed potential violations of resident rights, dignity, safety, including abuse and neglect. The DSD stated that SOC 341 should have been filled out promptly as required for each resident. The DSD stated since the incident as part of her training she had created the binder to include resources for Abuse and reporting. The DSD stated it was important to report to ensure resident safety whether it was abuse or not. The DSD stated that Res 2 incident should have been reported after the concerns shared by MN on 5/6/26 and she was unable to comment on why it was not reported and stated that she was out of office at the time of incident. The DSD stated it was concerning to her and she immediately started training staff as soon she saw the email from DON regarding MN's concerns upon returning to office on 5/13/26. The DSD stated staff witnessed Res 3 being stuck on the face by chuck pad by [CNA 3] and failed to report. The DSD stated it was not acceptable. The DSD also stated that she was unable to find any documentation related to the incident of social services follow up, abuse screen, care plan, IDT notes and assessment of psychosocial wellbeing after the facility staff was aware of the incident by CNA 4. The DSD stated plan of care should have been updated, residents should have been assessed for any injuries and the incident for physical abuse should have been reported regardless of time lapses when it was discovered.During an interview on 6/9/26 at 11:45 a.m. with the SSC, the SSC stated she was made aware by facility staff that on 6/8/26 there was an incident in which Res 5 slapped Res 6 on the left side of the face and left arm. The SSC stated the incident occurred in the dining room during resident activities. The SSC stated there were no physical injuries observed but both Res 5 and Res 6 confirmed the incident had occurred.During a review of Res 5's AR, the AR indicated, Res 5 was admitted to the facility on [DATE] with diagnosis of MDD, Anxiety (feelings of tension, worried thoughts, and physical changes like a racing heart).During a review of Res 5's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/7/26, the MDS indicated, Res 5's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 5 was cognitively intact.During a review of Res 6's AR, the AR indicated, Res 6 was admitted to the facility on [DATE] with diagnosis of Dementia without behavioral disturbance.During a review of Res 6's MDS, dated 5/11/26, the MDS indicated, Res 6's BIMS score was 12 out of 15, which indicated Res 6 had moderate cognitive impairment.During a review of Res 6's Progress Note, dated 6/8/26 at 2:35 p.m., the progress note indicated, . [Res 6] stated that she was in fact hit in face by [Res]. [Res 6 also stated she put her hand up to block [Res 5]. [Res 5] also was asked if she hit [Res 6] and [Res 5] stated yes I did, because [Res 6] hit me back after [Res 5] hit her. All residents remain separated at the moment. [Res 6] is not in any pain, distress noted.During an interview on 6/9/26 at 12:26 p.m. with Res 5, Res 5 stated that she recalled the incident when Res 5 went to the dining room for activities which led to a physical altercation with Res 6. Res 5 stated Res 6 had pointed a finger at her and refused to let Res 5 retrieve supplies from the table where Res 6 was sitting. Res 5 stated she proceeded to hit Res 6 with a closed fist but could not recall the location of the hits.During an interview on 6/9/26 at 12:46 p.m. with Res 6, Res 6 stated she was physically hit by Res 5 in the dining room during activities. Res 6 stated she recalled sitting in the dining room working on a project when Res 5 suddenly forced herself to sit at the table and Res 6 stated she asked Res 5 to leave the table. Res 6 stated that Res 5 refused to leave and proceeded to slap Res 6 on the left side of face and arm. Resident 6 stated that during the altercation there were no staff members present in the dining room.During an interview on 6/9/26 at 1:20 p.m. with the director of staff development (DSD), the DSD stated Res 5 and Res 6 had an altercation in the dining room on 6/8/26 during activities. The DSD stated she was in the facility during the altercation and stated there were no staff members present in the dining room during the altercation. The DSD stated that the activities assistant was assigned to complete other duties. The DSD stated the facility process was for the staff to monitor the residents during activities in the dining room.During an interview on 6/9/26 at 1:36 p.m. with certified nursing assistant (CNA) 6, CNA 6 stated that on 6/8/26 Res 5 and Res 6 had an altercation in the dining room during activities. CNA 6 stated she recalled walking into the dining room after hearing screams coming from the area. CNA 6 stated there were no staff members present in the dining room activities during the altercation. CNA 6 stated the process was for staff to monitor residents when they were in activities to ensure safety.During a telephone interview on 6/10/26 at 2:00 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated that on 6/8/26, there was yelling from the dining room during activities that prompted her to investigate further. LVN 5 stated Res 5 and Res 6 were observed yelling at each other and Res 6 had reported that Res 5 had slapped her on the face and arm. LVN 5 stated that when she entered the dining room, there were no staff present in the room during the altercation. LVN 5 stated the facility process was for an activity assistant to be present during activities to monitor the residents' safety.During an interview on 6/9/26 at 1:50 p.m. with the director of nurses (DON), the DON stated the facility process was for the staff to monitor the residents during activities in the dining room. The DON stated that residents should not have been left alone during the time of Res 5 and Res 6 altercation as there should have been an AA present. The [NAME] stated the lack of activity staff was an ongoing issue as the activity staff were assigned other duties when they should have been assigned to stay in the dining room for activities.During a telephone interview on 6/12/26 at 10:00 a.m. with the activities director (AD), the AD stated the expectation was for the activity assistant to remain in the dining room for activities with the residents. The AD stated that due to other activity assistant duties, the facility required two assistants to ensure one staff member was present during the dining room activities and another would perform other duties but since the facility only had one, there was no monitoring for residents in activities during the time of other duty completion.During a telephone interview on 6/12/26 at 2:00 p.m. with Activity Assistant (AA), the AA stated that on 6/8/26 she was informed that Res 5 and Res 6 had an altercation in the dining room during activities. The AA stated she was not present in the dining room during the altercation due to completing other AA duties. The AA stated she was the only staff member for activities present in the facility at the time of the incident and therefore the dining room was unmonitored. The AA stated residents should not have been left in the dining room during activities for their safety and the facility would benefit from scheduling to separate AA to ensure the dining room activities were monitored.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 2016, the P&P indicated, Our residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will, protect our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. implement measures to address factors that may lead to abusive situations, provide staff with opportunities to express challenges related to their job and work environment. identify and assess all possible incidents of abuse.During a review of the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting, dated 2017, the P&P indicated , . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual . The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Role of the Investigator . Interview the person(s) reporting the incident . Interview any witnesses to the incident . Interview the resident (as medically appropriate) . Interview staff members ( on all shifts) who have had contact with the resident during the period of the alleged incident . Interview the resident's roommate, family members, and visitors . Interview other residents to whom the accused employee provides care or services . The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process . If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken . The investigator will consult daily with the Administrator concerning the progress/findings of the investigation . Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator . Reporting . All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies . The State licensing/certification agency responsible for surveying/licensing the facility . The local/State Ombudsman . The Resident's Representative (Sponsor) of Record . Adult Protective Services (where state law provides jurisdiction in long-term care) . An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than . Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or . Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Notices will in

Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident (Res) 1) received necessary care and services in accordance with professional standards of practice when:The facility staff failed to identify, assess, investigate, and document an unwitnessed fall reported by Res 1.Nursing staff did not initiate required post-fall protocols, including timely assessment, neurological checks, ongoing monitoring, and implementation of appropriate fall-related interventions in accordance with facility policy.The facility failed to ensure timely physician assessment, and implementation of physician-ordered interventions following the resident's complaint of pain and subsequent diagnosis of a right knee fracture.Res 1's medical record lacked timely documentation of physician involvement and did not reflect prompt follow-through of recommended interventions, including the use of a knee immobilizer.The facility staff failed to update the resident's comprehensive care plan to reflect the change in condition, increased fall risk, and required interventions following the self-reported fall resulting in confirmed fracture.These failures had the potential to cause delay in diagnosis and treatment, unmanaged severe pain, and caused decline in the resident's mobility and functional status. These failures placed the resident at risk for further injury, complications, and unmet medical needs including interventions such as knee immobilizer and elevation of injury site.Findings: During a review of Res 1's History and Physical (H&P), dated 5/19/26 from Hospital A, the H&P indicated, [AGE] years old female with past medical history of [Major Depressive Disorder (MDD - serious mental health condition characterized by a persistently low or depressed mood and a loss of interest in activities)], hypertension [high blood pressure - condition where the force of blood against your vessels is consistently too high], hyperlipidemia [excess fat in blood], chronic back pain [any back discomfort, stiffness, or aching that lasts for three months or longer], history of hematuria [he presence of blood cells in your urine], hypothyroidism [occurs when the butterfly-shaped gland in neck doesn't produce enough hormones causing the body's metabolism to slow down, leading to symptoms like persistent fatigue, unintentional weight gain, and sensitivity to cold], type 2 diabetes mellitus [a condition where body's cells stop responding well to insulin, a vital hormone that regulates blood sugar (glucose) levels by allowing cells to use it for energy making it hard to turn food into energy] presenting as a direct admit [a hospital admission process where a patient's doctor arranges their hospital stay in advance allowing the patient to bypass the Emergency Department (ED) entirely and go straight to an inpatient bed ]for right knee fracture [broken bone]. Patient states she was in a wheelchair in her bathroom and attempted to get up to the sink when she slipped on urine on the bathroom floor resulting in a ground-level fall. She reports subsequent right knee pain and inability to ambulate.During a concurrent interview and record review on 6/3/26 at 9:15 a.m. with the Director of Nursing (DON), the facility's document titled Administrative Investigation- 5 Day Report for the incident date 5/13/26 was reviewed. The document titled Administrative Investigation- 5 Day Report indicated, . [Res 1] began complaining of right knee pain on 05/12/2026 [MD 1] notified, order for x-ray obtained and carried out. Results received and sent to MD for review on 05/13/2026. On 05/14/2026 [MD 1] contacted regarding worsening pain of right knee and reviewing of x-ray [painless imaging test that uses safe bursts of invisible energy to snap a picture of the inside body] results. [MD 1] ordered [oxycodone/acetaminophen (medication to treat moderate to severe pain)] . [one time order] for worsening pain and stated he would speak with surgery in the morning. [Res 1] sent to [Hospital A] for treatment of the fracture on 5/19/2026. Investigation: The right knee fracture of unknown origin was identified on 5/14/26. [Res 1] was observed exhibiting unsafe self-transfer and self-positioning behaviors while repeatedly verbalizing threats to intentionally throw herself on the floor or jump from the bed or chair if she does not receive pain medication. Review of [medication administration record] confirmed resident was administered [oxycodone/acetaminophen] as ordered. At approximately [2:30 p.m.] on 5/12/26 resident reported a new onset of right knee pain. Nurse completed assessment and notified [MD 1]. An order for x-ray was obtained as well as a one-time order for [oxycodone/acetaminophen]. Orders carried out in a timely manner. No witnessed fall event was reported prior to onset of pain nor was a report of an unwitnessed fall noted. On 05/13/2026 x-ray results were obtained and forwarded to [MD1] for review. [MD 1] requested imaging films . for complete evaluation. Facility staff coordinated and retrieved requested films and forwarded them to [MD1]. 5/14/26 physician reviewed imaging films and stated he would consult with surgery regarding the findings. Due to confirmation of fracture and inability to determine mechanism of injury SOC 341[standardized Report of Suspected Dependent Adult/Elder Abuse form used across California] completed. On 5/18/26 [MD 1] discussed surgical recommendations with resident and requested communication with her son as well . On 05/19/26 resident chart documentation, diagnostic information, and transfer packet were completed per [MD 1] request and resident was transferred to [Hospital A] for surgical intervention. Investigation findings do not substantiate staff abuse or neglect. Injury appears consistent with resident's repeated unsafe self-positioning behaviors and impaired safety awareness. The DON stated that she was in charge of this investigation and had completed the investigation report. The DON stated as documented in the investigation report, no indication of fall or abuse was identified or mentioned by anyone during the investigation.During a concurrent observation and interview on 6/3/26 at 10:40 a.m. with the DON in the acute hospital on Swing Bed unit, Res 1 was observed sitting at the edge of bed in a wheelchair. Res 1 she had a knee fracture over at the skilled nursing side. Res 1 stated that my roommate at that time had peed everywhere, and when she went to the bathroom in a wheelchair she attempted to stand up with sink and had slipped in the bathroom on the urine puddle. Res 1 stated she wanted to do it herself and did not ask for help. Res 1 stated the facility staff helped afterward. Res 1 stated two facility staff members and nurse had to assist her back up from the bathroom floor. Res 1 stated she was not sent to the ED afterwards and she was not happy about it. Res1 stated she wanted to go the ED. Res 1 was asked if she recalls the date and time of incident and Res 1 stated facility staff had to pick me up and help me, stated they all knew I had a fall and should have record of date and time. Res 1 stated she was unable to recall the exact date, but it was late night going to early morning. Res 1 stated she felt really sore in her leg after the fall. The DON stated that no one else witnessed Res 1 falling and facility investigation did not reveal that Res 1 had experienced any fall prior to the complaint of knee pain.During a concurrent interview and record review with the DON and MDS Coordinator (MDS) on 6/3/26 at 2:10 p.m. Res 1's Electronic Medical Record (EMR) was reviewed. The DON reviewed Nursing Notes from 4/23/26 to 5/19/26 and stated that only fall listed in Res 1's record was on 4/24/26 at 11:59 p.m. The DON stated physician was notified and Res 1 was assessed. The DON stated the nursing note on 4/23/26 at 11:59 p.m. mentions tenderness on no right foot, no right knee injury documented at that fall or on assessment afterwards. The DON stated the Nursing note on 5/12/26 at 5:21 a.m. indicated . Resident was witnessed attempting to slide off wheelchair to the floor screaming for a pain pill. This writer and x3 staff attempted to stop resident from sliding off the wheelchair and repositioned her back into wheelchair, then to back to bed. Resident continued to scream for pain pill. Resident threatened to jump off bed and wheelchair if not given a pain pill. Resident also stated that she was not helped to bed all night. Residents have history of false accusations. All witnesses have helped resident to bed to restroom and back to bed. Resident asked for pain pill every hour this nightshift, changing her pain from back' knee arm head neck and threatening to jump off bed and wheelchair. This writer administered pain pill [as needed] at due time and implemented therapeutic pain preventive measurements, and calmed resident. DON and MD aware. The DON stated resident had history of pain seeking behavior and false accusation and care plan was already in place for these behaviors. The DON stated this was the only documented note regarding patient behavior after the last documented fall [4/24/26] and on 5/12/26 at 2:30 p.m. [nine hours and nine minutes later] nurses note indicated . Notified [MD 1] regarding [night] nurse witnessing [Res 1] attempting to slide off wheelchair and threatening to throw herself on floor if pain pill was not given. [Res 1] continued to request for pain medication during this shift for right knee pain. Pain medication given [as needed] as scheduled by [MD 1]. Notified [MD1] regarding resident's complain of right knee pain. Per [MD1] received order for x-ray to right knee [related to] pain. The DON stated EMR indicated X-ray results were received on 5/13/26 at 6:50 p.m. and MD 1 was made aware. The DON stated nurses note indicated . Resident [compliant of] pain to right knee with confirmed fracture. Right knee pain level 10/10 [10/10 pain score indicates the worst possible, debilitating pain imaginable]. Right knee is warm and tender to touch. Notified [MD 1] of resident's x-ray results to right knee, MD reviewed results and requested actual x-ray film and order for monitor right knee for worsening. No further orders regarding x-ray results given by [MD 1] at this time. Called radiology to request film and received QR code with resident's imaging results. QR code given to medical records to access files for MD to review . The DON stated nurses note on 5/14/26 at 9:00 p.m. indicated MD 1 reviewed resident's x-ray film/images. [MD 1 was also notified of resident's worsening pain to right knee, pain level 10/10. Per [MD 1], will talk to the surgeon in the morning and new order: [oxycodone/acetaminophen] [one time] order.DON aware. The DON stated Nurses Note on 5/15/26 at 11:41 a.m. also indicate that MD 1 was made aware, and Res 1 was in pain. The DON stated Nurses Note dated 5/18/26 at 4:49 p.m. indicates [MD 1] called and spoke with resident regarding possibility of surgery [related to] knee fracture. resident stated she is okay with surgery . The DON stated nurse's notes indicate on 5/18/26 at 5:19 p.m. MD 1 requested Res 1's record to be sent over to [Hospital A]. The DON stated the Nurses note dated 5/19/26 at 8:36 a.m. indicated . [MD 1] requesting all medical records, X-ray's to be faxed to [Hospital A] so that the orthopedic surgeon [surgeon name] can review for possible surgical intervention. The DON stated Nurses Note dated 5/19/26 at 10:59 a.m. indicated MD 1 called and gave verbal order to hold Clopidogrel Bisulfate [blood thinner- use to prevent clot] Tablet 75 [milligram (MG- unit of measurement] (Clopidogrel Bisulfate) and [apixaban - medication to prevent blood clot] Oral Tablet 5 MG (Apixaban) indefinitely until after surgery. Medications placed on hold. The DON stated the order was received to transfer out Res 1 to [Hospital A] on 5/19/26 at 2:43 p.m. and shortly afterwards. The DON reviewed the EMR and all notes between 5/11/26 to 5/19/26 again and stated she was not able to find any documented progress notes, assessment or updates by MD 1 or any physician between 5/11/26 until Res1 was transferred out on 5/19/26. The DON stated confirmed fracture was identified and MD1 reviewed the results on 5/13/26, however Res 1 was not transferred out until 5/19/26. The DON stated she was unable to comment why the Res 1 was not transferred out sooner to [Hospital A] or another area hospital for assessment and management of Res 1's injuries. The DON stated no new interventions were ordered, besides pain medication order. The DON stated Res 1 remain in moderate to severe pain and she was unable to comment on whether the injuries were appropriately managed without physician documentation. The DON stated nursing staff updated the care plan and resident fracture was assessed every shift.During an interview on 6/3/26 at 2:25 p.m. with the MDS Coordinator, the MDS Coordinator stated she had observed Res 1 not getting out bed after the injury/fracture on the 5/12/26 and stated [Res 1] was no longer getting out of bed, was not even going for smoking and choosing to use briefs, and her status declined. The MDS stated Res 1 prior to this injury was able to transfer herself to the bathroom, was in wheelchair and required minimum assistant. The MDS Coordinator stated that this was a change from Res 1's condition. The MDS Coordinator also stated that she was unsure why Res 1 was not transferred out or physician plan was from 5/12/26 until 5/19/26.During an interview on 6/4/26 at 10:05 a.m. with the Licensed Vocational Nurse (LVN)1, and Director of Staffing Development (DSD), the DSD checked the staffing assignment and stated LVN1 was assigned to Res 1 on 5/15/26, 5/16/26 and 5/17/26. LVN 1 stated that she was familiar with Res 1. LVN 1 stated she had gotten a report of knee pain and was told probably fracture and MD 1 was aware. LVN 1 stated she does not recall exact dates or timeline of events. LVN 1 stated Res 1 was in generalized pain and always requesting pain around the clock pain medications. LVN 1 stated she does not recall exact medication orders or what Res 1 was getting. LVN 1 stated she does not recall additional details or whether the resident functional ability declined.During an interview on 6/4/26 at 10:25 a.m. with the Certified Nursing Assistant (CAN 1) and DSD, CNA 1 stated she had been working here at the facility for a year. CNA 1 started she had worked consistently with Res 1 and was familiar with Res 1. CNA stated she had worked with Res 1after her knee fracture as well. CNA stated she was unsure when resident got the injury or how she got the injury. CNA stated she was made aware X-ray was completed and resident have a fracture. CNA stated Res 1 was in lot of pain in her knee. CNA 1 stated Res 1 stayed in bed for the most part and did not even go for the smoke after her injury. CNA 1 stated Res 1 would complain of significant pain even while in bed when she was moved from side to side. CNA 1 stated Res 1 stayed bed bound for the most part after the knee X-ray till she was transferred. CNA 1 stated Res 1 appeared to her more stressed, frustrated and was complaining that she could not get up and was hurting. CNA 1 stated Res 1 was asking to use brief and could not get up. CNA 1 stated that it was different for Res 1 and she recalls notifying LVN 1 that Res 1 was in lot of pain and unable to get up. CNA. The DSD reviewed the staffing assignments and stated that CNA 1 was assigned to Res 1 on the shifts of 5/12/26, 5/15/26 and 5/17/26. During a phone interview on 6/4/26 at 10:39 a.m. with DSD, Medical Record In-charge (MR) and Res 1's physician (MD 1), MD 1 stated he was familiar with Res 1. MD 1 stated he was contacted regarding Res 1 pain and initially X-ray was completed. MD 1 stated he spoke with Surgeon at [Hospital A], and he was advised nothing urgently was needed as the Res 1 was wheelchair/ bed bound. MD 1 stated he works at [Hospital A] with the Surgeon and had shown the X-ray results to the surgeon. MD 1 stated Res 1 was always in pain; he attempted to wean opioids and Res 1's body cannot tolerate. MD 1 stated no urgent or emergent interventions were needed per surgeon and in his medical decision-making patient did not require transfer to another facility for immediate interventions. MD 1 stated ortho [medical specialty focused on diagnosing, treating, and preventing conditions of the musculoskeletal system such as bones] consult would have taken a long time, and it was best for Res 1 to be stabilized and transfer when surgeon was ready. MD 1 stated per surgeon Res 1's fracture was very bad. MD 1 was asked if he had documented anything in the Res 1's medical record. MD 1 stated he was not sure and unable to comment at this time. MD 1 stated he did assess the resident, was working on the plan with surgeon and had communicated the plan with recommendation. The DSD and MR both validated that they were unable to find any documentation by MD 1 or any physician regarding the assessment, plan and recommendations for Res 1's Fracture or whether it was ok for Res 1 to stay at the facility, between 5/12/26 when the X-ray order was received and until Res 1 was transferred out to [Hospital A]. MD1 stated he will add his documentation in Res 1's medical record today [6/4/26]. During an interview on 6/4/26 at 10:53 a.m. with the Interim Administrator (IADM), the IADM stated that facility administrator (ADM) was out of country, and she is covering as interim ADM. The IADM stated she was not involved in the investigation for Res 1's injury, however, she was provided with updates of the investigation, and she had signed it off on 5/22/26 as no abuse of neglect. The IADM stated the facility could not determine the cause of the injury leading to fracture of right knee in Res 1. The IADM stated there was no evidence that Res 1 had a fall and people at this age can bang their knee and can cause fracture. The IADM was asked if Res 1 should have been transferred out for an assessment and whether facility process was followed. The IADM stated that she does not have scope to make this decision and trust MD 1 decision making. The IADM stated she was not aware of the plan for ortho consult and it should have been documented by MD 1. The IADM stated it was not ideal for MD 1 not to document his assessment and plan in the medical record for Res 1. The IADM stated she has a close working relationship with MD 1 and trusts him to do the right thing. The IADM was asked if the facility has a policy that outlines expectations for physician documentation timeframe. The IADM stated she was unsure of the timeframe requirement and facility policy and stated she would have to check.During an interview on 6/4/26 at 11:20 a.m. with the Res 1 in the acute hospital on Swing Bed unit, Res 1 stated she had a fall and that's when her knee started to hurt. Res 1 stated it was not for five or six days they sent her out to the hospital. Res 1 stated she kept asking the staff to send her to ED and the staff stated it was up to her physician. Res 1 stated she did not see any physician at the facility prior to transfer out for surgery. Res 1 stated she was certain she had a fall, and she had notified staff multiple times about the fall.During an interview with LVN 2 on 6/4/26 at 11:25 a.m., LVN 2 stated Res 1 was alert and oriented to time, place, person and situation in her assessment.During an interview on 6/4/26 at 12:50 p.m. with the DSD, the DSD stated that she had reviewed the EMR for Res 1 and she was not able to find any documentation that indicate Res 1 had a fall that potentially resulted in the injury to Right Knee leading to fracture. The DSD stated none of the staff recalls Res 1requesting to go the ER. The DSD stated Res 1behaviour potentially could have caused the injury. The DSD stated the Res 1 pain was managed and care plan was updated for fracture. The DSD stated that mandated reporting was completed as required.During a phone interview on 6/5/26 at 12:01 p.m. with the MDS, the MDS stated she was the interim DON up until first week of May 2026. The MDS stated she was familiar with Res 1 and had reviewed her EMR for the right knee fracture incident. The MDS stated that Res 1 did experience a fall. The MDS stated Res 1 was trying to get up to go to the bathroom and fell by the toilet. The MDS stated Res 1 did notify the [LVN 3] and [LVN 3] thought Res 1 was faking it. The MDS stated Res 1 was in a wheelchair prior to the fall and was going out to go smoke, Res 1 was getting out of bed to go to the bathroom, and she was getting out of bed to the wheelchair. The MDS stated after the injury, she became bed bound. The MDS stated Res 1 definitely had a fall, however, in reviewing the EMR, fall was not documented. The MDS stated that she was made aware on 5/12/26 in the afternoon and she had advised the nurse assigned [LVN 4] to get an X-ray. The MDS stated that nurse [LVN 4] interviewed Res 1 and her roommate, and they both stated that Res 1 had a fall. The MDS stated that it was on 5/12/26 when the nurse called the physician to get an X-ray order. The MDS stated she should have documented the fall and [LVN 4] should have assessed the Res 1 after she was made aware of the unwitnessed fall. The MDS stated that she had updated the resident care plan for fracture, however, she did not notify Interdisciplinary team or updated the care plan for unwitnessed fall. The MDS stated no additional fall prevention interventions were in place were not assessed and no new interventions were place. The MDS stated Res 1 was at high risk for fall and already had fall last month [April 2026]. During a phone interview on 6/5/26 at 12:37 p.m. with LVN 4, LVN 4 stated that she had worked at the facility since September 2021 and was familiar with Res 1. LVN 4 stated that when she arrived for her shift [5/12/26], the resident complained of knee pain, and the ordered pain medication was not effective. LVN 4 stated she had called MD 1 and suggested obtaining an X ray of the knee. LVN 4 stated that MDS coordinator was also in agreement with getting an X-ray for Res 1. LVN 4 stated that she documented resident's prior behavioral issues as reported in report from night nurse and MD 1's order to get X-ray. LVN 4 stated on 5/12/26 after speaking with MD 1, she had interviewed Res 1 and her roommate, and both residents provided detailed descriptive accounts indicating an unwitnessed fall on 5/12/26 prior to start of her shift. LVN 4 stated she documented the interviews and provided to DON. LVN 4 stated she did not document interviews in Res 1's EMR and had another nurse in the room as witness during her interviews with Res 1 and her [Res 1's] roommate. LVN 4 stated Res 1 had a history of false accusation, and the nurse before her shift had also documented Res 1 trying to roll down the wheelchair, therefore she had a witness during the interview of Res 1. LVN 4 stated after assessing Res 1's knee, she placed the bed in the lowest position, applied bilateral floor mats, and reinforced call light use. LVN 4 stated staff had to assist the resident with transfers after the injury due to declining function. LVN 4 stated Res 1's pain worsened, she notified the physician [MD1], who ordered the resident sent out for further evaluation/surgery later [5/19/26]. LVN 4 stated that the resident after the fall required gurney transport for X ray, whereas previously she self transferred to the restroom. LVN 4 stated she did not start any additional assessment, documentation or interventions as required per facility policy and process for unwitnessed fall. LVN 4 stated she does not recall whether she updated fall risk assessment or care plan after she identified unwitnessed fall. LVN 4 stated that MDS coordinator was aware of the unwitnessed fall for Res 1. LVN 4 stated she did not document the fall in the EMR. LVN 4 stated she MD 1 was made aware of worsening pain, and she does not recall any additional interventions ordered by MD 1.During a phone interview on 6/5/26 at 1:28 p.m. with the MDS, the MDS stated that she was not aware of the 5-day investigation report and summary of findings. The MDS stated this incident should have been reported as unwitnessed fall. The MDS coordinator stated unwitnessed fall policy should have been followed, and Res 1 should have been assessed for delayed injuries and potential head injuries. The MDS stated she was unable to find updated fall risk assessment or any documentation that indicates fall prevention interventions that were in place were reevaluated after the unwitnessed fall.During a phone interview on 6/5/26 at 1:52 p.m. with the MDS and MD1, MD 1 stated he does not recall whether he was informed of the fall or not. MD 1 stated fracture of Res 1 was consistent with fall, and it would be very hard to have this type of injury without the fall. MD 1 stated he ordered X-ray and interventions. MD1 was asked about the note he placed on 6/4/26 at 11:26 a.m. [Late Entry] for effective date of 5/13/26 at 11:15 a.m. The MD progress note indicated . Recommended knee immobilizer, ice, elevation, and pain control. Patients have a [history of] drug pain seeking behavior and will be careful with opiates. MD 1 stated he communicated these interventions to nursing staff and expected them to be followed. MD 1 was asked about assessment of Res 1 after unwitnessed fall and MD 1 stated he expected residents to be assessed by nurse post fall as per facility policy. MD 1 stated it was important to assess as residents may not complain right away, and neuro checks were important to identify delayed injuries. The MDS stated that the documentation does not reflect that knee was elevated or knee immobilizer was provided. The MDS also stated that these interventions were not discussed in the inter-disciplinary team after the injury and were not care planned. The MDS stated that she could not comment whether the nursing staff was informed of these recommendations and medical record did not have any documentation that these interventions were discussed or recommended by MD 1During a phone interview on 6/5/26 at 3:11p.m. with the IADM, IADM stated that as far she was aware Res 1 fracture to the right knee was from unknown injury and she was not made aware of any unwitnessed fall for Res 1. The IADM stated she was not aware of any statements made by residents about a fall or nurse interviewing resident and resident's roommate. The IADM stated if the resident stated unwitnessed fall to nurses, then she expected her staff to do resident assessment and implement interventions such as neuro checks, reporting etc. as per facility policy for unwitnessed fall. The IADM stated she had reviewed Res 1's medical record and was unable to find any documentation regarding fall. The IADM stated she also could not find any physician documentation regarding right knee fracture, assessment and plan up until physician made a late entry note.During a phone interview on 6/5/26 at 3:29 p.m. with the IADM and the DON, the DON stated that she was not made aware of the fall, and the SOC 341 documentation was left on her desk. The DON stated that she was unaware of any resident interviews regarding this incident and had not seen any statements from Res 1 or Res 1's roommate. The DON stated she had spoken with [LVN 4] and she only mentioned about Res 1's knee pain and getting an X-ray ordered. The DON Stated she had spoken with the night nurse [LVN 3] and the night nurse also did not mention any falls and resident compliant of fall on the night of 5/11/26 going in to 5/12/26 day shift. The DON stated she did not interview any other staff, CNA or the resident's roommate. The DON stated she does not recall Res 1 expressing concerns to her or anyone about the fall on 5/12/26 or afterwards. The DON stated she also does not recall any staff stating that residents wanted to go to the ER for knee pain. The DON stated nothing was documented in the EMR regarding a fall and she could not conclude if the injury was related to the fall. The DON stated if the patient was stating to nurses that she had an unwitnessed fall then Res 1 should have been assessed for unwitnessed fall as per facility policy. The DON stated that Res 1 had a history of false accusation and pain medication seeking behavior, physician was aware, and care plan was in place for those behaviors. The DON stated she has been off work since 6/3/26 and have not seen the MD note placed on 6/4/26 for 5/13/26 and unable to comment on that. The ADM validated she could not find the MD recommended elevation and knee immobilizer for the effective date of 5/13/26 [late entry, note entered on 6/4/26] in care plan or interventions implemented in nursing documentation. During a review of the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive, dated 2010, the P&P indicated, . An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Each resident's comprehensive care plan is designed to . Incorporate identified problem areas . incorporate risk factors associated with identified problems . Reflect the resident's expressed wishes regarding care and treatment goals . Reflect treatment goals, timetables and objectives in measurable outcomes . Identify the professional services that are responsible for each element of care . Aid in preventing or reducing declines in the resident's functional status and/or functional levels . Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans . When there has been a significant change in the resident's condition . When the desired outcome is not met . During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated 2009 the P&P indicated, . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . Care plan goals and objectives are defined as the desired outcome for a specific resident problem . When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly . Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . Goals and objectives are reviewed and/or revised . When there has been a significant change in the resident's condition . When the desired outcome has not been achieved .During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2015 the P&P indicated, . The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . An accident or incident involving the resident . A discovery of injuries of an unknown source . significant change in the resident's physical/emotional/mental condition . A need to alter the resident's medical treatment significantly . Refusal of treatment or medications (i.e., two (2) or more consecutive times) . A need to transfer the resident to a hospital/treatment center . Significant change of condition is a decline or improvement in the resident's status that . Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting) Impacts more than one area of the resident's health status . Requires interdisciplinary review and/or revision to the care plan . Ultimately is based on the judgment of the clinical staff . The Nurse Supervisor/Charge Nurse will record in the residen

Based on interview and record review, the facility failed to maintain complete and accurate documentation and follow its policy and procedures titled Falls - Clinical Protocol and Charting and Documentation for two of six sampled residents (Resident 1 and Resident 2), when the Licensed Vocational Nurse (LVN) 1 did not complete the neuro-check (a focused assessment of the nervous system used to identify acute changes in an individual's functional status) on 11/17/25 and 11/18/25 for Resident 1 after an unwitnessed fall on 11/15/25, and the Director of Nursing (DON) did not complete IDT (Interdisciplinary Team; a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) note for Resident 2 on 12/18/25 after an unwitnessed fall on 12/17/25. These failures had the potential to result in the delayed detection of neurological changes which could lead to irreversible functional impairment for Resident 1 after an unwitnessed fall on 11/15/25 and the potential for the IDT to miss opportunities to discuss, intervene, and care plan for Resident 2 after an unwitnessed fall on 12/17/25.Findings: During a record review of Resident 1's admission Record, dated 2/17/26, the AR indicated Resident 1 had a diagnosis of Type 2 Diabetes Mellitus (a chronic metabolic disorder where the body develops insulin resistance resulting in high blood sugar level), Osteomyelitis of the right ankle and foot (an infection and inflammation of the bone or bone marrow), Chronic Obstructive Pulmonary Disease (a progressive lung condition characterized by chronic respiratory symptoms and persistent irreversible airflow limitation), and Chronic Heart Failure (a long-term, progressive clinical syndrome where the heart muscle is too weak or stiff to pump sufficient blood throughout the body). During a record review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated 1/23/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive (mental process) status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 12 out of 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment) which indicated Resident 1 had moderate cognitive impairment. During a record review of Resident 1's SBAR ([Situation, Background, Appearance, Review] Communication Form; a communication tool licensed staff use to share pertinent information with the resident's physician and responsible party when there is a change in the resident's condition), dated 11/15/25, the SBAR indicated, .Primary Care Clinician Notified: Yes. Date: 11/15/25. Time: 11:25 a.m. Recommendations of Primary Clinicians: Send to ER (Emergency Room) for scan of head and right shoulder. During a record review of Resident 1's Progress Notes (PN), dated 11/15/25, the PN indicated, Writer was called to the dining room by Certified Nursing Assistant (CNA), resident was sitting on the floor next to wheelchair. Resident stated she stood up to get coffee and slid to the floor landing on bottom then falling sideways hitting her right shoulder and head. notified [name of primary care physician] got order to send to ER for evaluation. During a concurrent interview and record review on 2/17/26 at 9:52 a.m. with the DON, Resident 1's Neuro Checklist (NC), dated 11/15/25 was reviewed. The NC indicated, Interval: Every 30 min. X2 (every 30 minutes two times an hour), Every 1 hour X3, Every 2 hours X24 hours, Every 4 hours X5, Every 8 hours (for 24 hours). The NC indicated the initial V/S (Vital Signs-blood pressure, Temperature, Pulse, Respiration), Level of Consciousness, Right Pupil, Left Pupil, Right Hand Grip, Left Hand Grip, and Nurse Initial was not completed for 11/17/25 and 11/18/25. The DON stated LVN 1 was assigned to Resident 1 on 11/17/25 and 11/18/25 and LVN 1 should have completed the NC for 11/17/25 and 11/18/25 to indicate that Resident 1's neurological status was assessed. The DON stated that a delay in recognizing early neurological changes could delay the management of a serious neurological problem which could lead to serious negative outcomes such as permanent impaired cognition (mental process), speech, function and mobility. The DON stated medical records should be complete and accurate to reflect the care provided. During a record review of Resident 2's AR, dated 2/11/26, the AR indicated Resident 2 had a diagnosis of Alzheimer's Disease (a chronic, progressive, and irreversible neurodegenerative brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple daily tasks), and Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). During a record review of Resident 2's MDS, dated 12/31/25, the MDS indicated, Resident 2's BIMS score was 2 out of 15 which indicated Resident 2 had severe cognitive impairment. During a record review of Resident 2's SBAR, dated 12/17/25, the SBAR indicated, .Primary Care Clinician Notified: Yes. Date: 12/17/25. Time: 3:00 a.m. Recommendations of Primary Clinicians: Notified MD of unwitnessed fall, implemented neuro checks, monitor for delay injuries, one time order CT (Computed Tomography; a medical imaging procedure that uses X-rays and computer technology to create detailed cross-sectional of the body used to visualize bones, blood vessels, and soft tissues) of the head. During a record review of Resident 2's Progress Notes (PN), dated 12/17/25, the PN indicated, Writer was notified by CNA that resident had unwitnessed fall in the bathroom. Resident walked to the bathroom and lost his balance. Small abrasion noted on left big toe. Order for CT of the head place. During a concurrent interview and record review on 2/11/26 at 11:49 a.m. with the DON, Resident 2's IDT Post Incident Meeting (IDT), dated 12/18/25 was reviewed. The IDT indicated, .A. IDT Meeting. 1. Date & Time: 12/18/25 4:18 p.m. The remainder of the record was not completed. The DON stated the IDT note should have been completed to indicate the IDT met to discuss Resident 2's fall, the cause of the fall, interventions to prevent the fall from recurring, who was notified and acknowledge any new orders. The DON stated she should have completed the IDT note and did not. During an interview on 2/11/26 at 11:49 a.m. with the Medical Record Director (MRD), the MRD stated residents' medical records should be complete and accurate to reflect the care provided. The MRD stated partially completed or incomplete documentation of records indicated the service was not provided. During an interview on 2/18/25 at 10:03 a.m. with the Administrator (ADM), the ADM stated the facility was required to maintain complete and accurate documentation of records to reflect the care provided for the residents. The ADM stated the neuro-check was required to be completed to ensure the resident received the proper level of care. The ADM stated the IDT note was required to be completed after an incident to ensure the resident was aligned with the appropriate care plan and the IDT did not miss anything. The ADM stated the IDT was made up of leadership individuals from different departments (nursing, rehabilitation, social services, etc.) to collaborate and provide holistic care (a comprehensive approach to health that treats the whole person which includes physical, emotional, mental, social, and spiritual rather than just symptoms or a specific disease) for the residents. The ADM stated an in-service (education and training) will be provided for the staff, so all departments would be aware of documentation requirements. The ADM stated an in-service will be provided to leadership staff who participate in the IDT to document the importance of the meeting to coordinate care for residents. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 9/2012, the P&P indicated, Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-Up: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma (a dangerous, often life-threatening collection of blood that gathers between the brain's surface and its outer covering) have been ruled out or resolved. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. During a review of the facility's P&P titled, Charting and Documentation, dated 4/2008, the P&P indicated, Policy Statement: All services provide to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.

Based on observation interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 1), when the licensed nurses did not change Resident 1's wound dressing every shift as ordered by the physician for two days and documented in the electronic medical record that the wound treatment was completed. This failure had the potential to result in delay in care, wound healing, and cause an infection from bacteria buildup.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for injury at C5 level of cervical spinal cord (damage to the nerves in the neck that control muscles in the upper body), Stage 4 pressure ulcer (Stage 1: The skin is intact but looks red, and may feel warm, firm, or painful. Stage 2: The skin breaks, creating a shallow open sore or a ruptured blister. Stage 3: The sore deepens into a crater that reaches the layer of fat beneath the skin. Stage 4: The damage extends through the skin to the muscle, bone, or joints, open wound with exposed bone). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/11/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 11/12/25 at 12:01 p.m. with Resident 1 in his room, Resident 1 stated he had a wound to the coccyx (small bone at the bottom of the spine) that required wound dressing change every day. Resident 1 stated there were days when the nurses would not complete his treatment as ordered by the physician. Resident 1 stated the last time the wound dressing was changed was on 11/9/25. Resident 1 stated he had requested the nurse to change his dressing for the past two days but was unsuccessful. Resident 1 stated he felt neglected by the facility nurses when he would request the wound dressing be changed and the nurses did not complete the treatment order. During a concurrent observation and interview on 11/12/25 at 12:12 p.m. with licensed vocational nurse (LVN) 1, Resident 1's wound dressing and wound to the coccyx were observed. The wound dressing was observed initialed and dated 11/9/25. LVN 1 stated that according to the date on the wound dressing, Resident 1's wound dressing was last changed on 11/9/25. During a record review of Resident 1's, Order Summary Report, dated 10/13/25, the order summary indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. As needed. Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The order summary indicated Resident 1 had a physician order for routine wound dressing changes every shift, everyday and as needed in between. During a record review of Resident 1's, Treatment Administration Record (TAR), dated 11/2025, the TAR indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The TAR indicated, Resident 1's treatment order was signed as completed on 11/9/25, 11/10/25, and 11/11/25. During an interview and record review on 11/12/25 at 12:20 p.m. with LVN 1, Resident 1's, Order Summary Report, dated 10/13/25 and Resident 1's, Treatment Administration Record (TAR), dated 11/2025, were reviewed. The order summary indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. As needed. Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. The TAR indicated, . Coccyx pressure ulcer stage 4- Cleanse with wound Phone cleaner, pat dry, pack loosely with gauze w/ [brand name medication], cover foam dressing. Every shift. LVN 1 stated the TAR indicated the wound dressing treatment order was completed on 11/9/25, 11/10/25, and 11/11/25 but based on the concurrent wound dressing observation, the last date on the wound dressing was 11/9/25. LVN 1 stated the facility process was for the nurse to complete the treatment order from the physician and to initial and date the wound dressing to validate the wound dressing was changed. LVN 1 stated it was important to initial and date the wound dressing to ensure the wound dressing was changed as ordered. LVN 1 stated, documentation on the TAR was false, because observed dressing on Resident 1's coccyx did not match with the TAR. LVN 1 stated it was important to complete and document all wound treatment as orders to prevent a wound infection. During an interview on 11/12/25 at 12:30 p.m. with LVN 2, LVN 2 stated the facility process was to complete all Resident treatment orders. LVN 2 stated the facility process included initialing and dating the wound dressing to ensure the dressings were being changed. LVN 2 stated it was important to complete all treatment orders to prevent infections and to prevent wound deterioration. During an interview on 11/12/25 at 12:54 p.m. with the registered nurse supervisor (RNS), the RNS stated the facility expectation was for the wound dressing to have been completed as ordered by the physician. The RNS stated the facility process was to initial and date the dressing being applied to the wound to ensure the dressing was changed. The RNS stated if a wound dressing could not be completed during a shift, the facility nurse is expected to document it and endorse the treatment to another nurse and let the RNS know. During an interview on 11/12/25 at 1:07 p.m. with the director of nursing (DON), the DON stated the expectation was for the treatment order to be completed for every resident. The DON stated the expectation was for the nurse to notify the RNS when a wound treatment could not be completed. The DON stated it was not acceptable to document a wound treatment was completed when the wound dressing was not changed. The DON stated it was important to have complete and accurate documentation to monitor and treat the wounds as needed. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record. Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

Based on observation interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of three sampled residents (Resident 2), when the certified nursing assistants (CNA) did not document Resident 1's urine output every shift on 10/31/25, 11/1/25, 11/2/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25. This failure had the potential to result in delay in care and cause an infection from not assisting Resident 2 with urine elimination.Findings:During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for cerebral infarction (blocked or reduced blood supply to the brain), calculus of kidney (hard piece of material that form in one or both kidneys), muscle weakness, constipation. During a review of Resident 2's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 7/9/2025, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 8 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 2 had moderate cognitive impairment. During a review of Resident 2's, Bladder Elimination Record, dated 10/31/25-11/12/25, the bladder elimination record indicated Resident 2 had been assisted with urination on: 10/31/25- 5:04 a.m. Amount four times for the day, 11/1/25- 3:26 a.m. amount three times for the day, 11/2/25 5:05 a.m. amount five times for the day, 11/3/25- 4:56 a.m. four times & 5:41 p.m. four times, 11/4/25- 5:59 a.m. amount six times & 5:04 p.m. amount four times, 11/5/25- 5:59 a.m. amount six times for the day, 11/6/25- 5:53 a.m. amount four times & 2:26 p.m. amount three times, 11/7/25- 5:18 a.m. amount five times & 4:49 p.m. four times, 11/8/25- 5:59 a.m. amount six times for the day, 11/9/25- 5:59 a.m. amount six times for the day, 11/10/25- 5:59 a.m. amount six times & 8:50 a.m. five times, 11/11/25- 5:57 a.m. five times & 5:17 p.m. five times, 11/12/25- 5:59 a.m. two times for the day. During a concurrent interview and record review on 11/12/25 at 10:51 a.m. with Licensed vocational nurse (LVN) 3, Resident 2's, Bladder Elimination record, dated 10/31/25-11/12/25, was reviewed. LVN 3 stated the bladder elimination record was completed by the certified nursing assistants (CNA) who were caring for Resident 2. LVN 3 stated the expectation was for the CNAs to document the number of times Resident 2 was assisted during the working shift with urine elimination. LVN 3 stated the bladder elimination record was incomplete, as some of the CNA entries were not completed for the days of 10/31/25, 11/1/25, 11/2/25, 11/5/25, 11/9/25, 11/10/25, 11/12/25. LVN 3 stated the incomplete documentation on the bladder elimination record indicated the care did not occur because it was not accurately documented. LVN 3 stated it was important that CNAs complete all documentation timely and accurately to ensure Residents are monitored appropriately when voiding. LVN 3 stated the CNA documentation was an important part of all residents' care and services provided. During a concurrent interview and record review on 11/12/25 at 1:07 p.m. with the director of nursing (DON), Resident 2's, Bladder Elimination record, dated 10/31/25-11/12/25, was reviewed. The DON stated the expectation was for the CNAs to complete all documentation for all residents before they leave the facility at the end of the shift. The DON stated CNAs were expected to document after each time a resident was assisted to the bathroom, not just at the end of the shift. The DON stated it was important to have complete and accurate documentation to monitor and treat residents as needed. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record. Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

Based on observation, interview and record review the facility failed to ensure residents were free from abuse for one of four sampled residents (Resident 1), when on 7/13/25 the activity assistant (AA) 2 was physically and verbally aggressive toward Resident 1 during the smoking break.This failure resulted in verbal and physical abuse toward Resident 1 and placed Resident 1 in an unsafe living environment.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear), expressive language disorder (condition that affects a person's ability to use language, both written and spoken), dysphasia (disorder that affects the ability to understand, produce or use language).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/3/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During an interview on 10/17/25 at 10:05 a.m. with the interim administrator (IADM), the IADM stated she had received a report on 7/15/25 from Resident 3, stating she had witnessed a AA 2 hitting Resident 1 with a clothing protector during the smoke break and yelling at Resident 1 on 7/13/25. The IADM stated the facility initiated an investigation that revealed Resident 2 and Resident 3 were both witnesses to the incident. The IADM stated the allegation was found to be substantiated and AA 2 was suspended pending termination.During a review of Resident 3's admission Record, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 14 out of 15 which indicated Resident 3 was cognitively intact.During a concurrent observation and interview on 7/17/25 at 10:39 a.m. with Resident 1 and Resident 3, both residents were observed outside during their smoke break. Resident 3 stated on 7/13/25, Resident 1, Resident 2 and Resident 3 were outside preparing for a smoke break accompanied by AA 2. Resident 3 stated AA 2 approached Resident 1 with the clothes protector used while smoking. Resident 3 stated AA 2 placed Resident 1's clothing protector with enough force to hear a thump from Resident 1's chest. Resident 1 observed moving his head to indicate yes in agreement. Resident 3 stated, Resident 1 reacted by standing up in front of AA 2, then AA 2 was heard raising his voice stating, Hit me so I can put you in jail for hitting a healthcare worker. Resident 3 stated Resident 1 had not reacted even though AA 2 tried to provoke and instigate a fight. Resident 1 observed moving his head to indicate yes in agreement.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's BIMS score was 15 out of 15 which indicated Resident 2 was cognitively intact.During a review of Resident 2's, Nurse's Note, dated 7/15/25, the note indicated, . [Resident 2] reported that on Sunday 7/13/25 [Resident 1] was in a foul mood and was walking outside because that's what he likes to do. Later he went outside to smoke, and [AA 2] was real upset with [Resident 1] because he would not go inside earlier and when it came time to put on the smoking vest [AA 2] approached [Resident 1], who was reportedly sitting down on the bench, and very sharply shoved the vest into [Resident 1] chest, you could hear the thump. [Resident 1] stood up and got into a fighting stance and for the first time ever I heard [Resident 1] speak. [Resident 2] then stated that [AA 2] replied with try to touch me, if you do, you'll go to prison for assaulting a healthcare worker. [Resident 2] reported that she did not know exactly what [Resident 1] had said, because Resident 1 did not speak most of the time and when he does you cannot understand him, but she recalls [AA 2] response. After [AA 2] had made that statement [Resident 1] reportedly turned around, put his cigarette out, which he never does, he always finishes it and went back inside. [Resident 1] did not go back outside the rest of the shift until [AA 2] went home for the night. [Resident 2] reports feeling safe in the facility.During an interview on 7/17/25 at 10:47 a.m. with Resident 2, Resident 2 stated that on 7/13/25, Resident 1, Resident 2 and Resident 3 were outside preparing for a smoke break accompanied by AA 2. Resident 2 stated AA 2 approached Resident 1 with the clothes protector used while smoking. Resident 2 stated AA 2 placed Resident 1's clothing protector with enough force to hear a thump from Resident 1's chest. Resident 2 stated, Resident 1 reacted by standing up in front of AA 2, then AA 2 was heard in a volatile voice stating, Hit me I dare you so I can put you in jail for hitting a healthcare worker. Resident 2 stated Resident 1 took off his clothing protector and turned off his cigarette and proceeded to walk inside not reacting to the incident.During an interview on 7/17/25 at 11:00 a.m. with AA 1, AA 1 stated Resident 3 had reported that on 7/13/25, an incident had occurred with Resident 1 and AA 2. AA 1 stated Resident 3 reported AA 2 was aggressive and yelling toward Resident 1 during their smoking break. AA 1 stated, Resident 3 reported AA 2 was instigating a fight with Resident 1, telling him to Hit him so he can go to jail for hitting a healthcare worker. AA 1 stated the incident was verbal abuse and the facility process was to attempt to de-escalate resident behavior and ensure safety.During an interview on 7/17/25 at 11:22 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated the incident that had occurred on 7/13/25 between AA 2 and Resident 1 was a form of abuse. CNA 1 stated when AA 2 escalated the situation by yelling and instigating a fight, he placed Resident 1 in an unsafe environment.During a telephone interview on 7/24/25 at 3:10 p.m. with AA 2, AA 2 stated he was the AA on 7/13/25. AA 2 stated he recalled an incident in which Resident 1 had stood up suddenly when AA 2 went to put on the clothing protector. AA 2 stated, Resident 1 looked as if he was going to hit him because Resident 1 took a step toward AA 2 and puffed his chest. AA 2 stated he stepped backward and immediately went to alert LVN 1 and informed LVN 1 that Resident 1 was threatening to hit him. AA 2 stated, LVN 1 had responded by stating, tell him if he hit you he would go to jail for hitting a healthcare worker. AA 2 stated he then went back outside and told Resident 1 what LVN 1 had stated. AA 2 stated Resident 1 continued to walk toward AA 2 as AA 2 walked backwards. AA 2 stated after the incident, Resident 1 took off the clothing protector and threw his cigarette on the floor. AA 2 stated, he did not feel it was verbal abuse because he was simply relaying the message that LVN 1 told him to de-escalate the situation by telling Resident 1, he would go to jail.During a review of the facility's policy and procedure (P&P) titled, Recognizing signs and Symptoms of Abuse/Neglect, dated 2011, the P&P indicated, . Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of Actual Physical Neglect. Caregiver indifference to resident's personal care and needs.During a review of the facility's P&P titled, Resident Rights, dated 1/2024, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, neglect, misappropriation of property, and exploitation, be supported by the facility in exercising his or her rights.

Based on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition (COC) or Situation, Background, Assessment and Recommendation communication form (SBAR- communication tool that provides critical information and ensures that important details are clearly communicated) for a staff to resident allegation of abuse on 7/13/25.This failure had the potential to result in the inaccurate assessment of Resident 1, delay in care and was at risk for further abuse.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear), expressive language disorder (condition that affects a person's ability to use language, both written and spoken), dysphasia (disorder that affects the ability to understand, produce or use language). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/3/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During a review of Resident 2's, Nurse's Note, dated 7/15/25, the note indicated, . [Resident 2] reported that on Sunday 7/13/25 [Resident 1] was in a foul mood and was walking outside because that's what he likes to do. Later he went outside to smoke, and [AA 2] was real upset with [Resident 1] because he would not go inside earlier and when it came time to put on the smoking vest [AA 2] approached [Resident 1], who was reportedly sitting down on the bench, and very sharply shoved the vest into [Resident 1] chest, you could hear the thump. [Resident 1] stood up and got into a fighting stance and for the first time ever I heard [Resident 1] speak. [Resident 2] then stated that [AA 2] replied with try to touch me, if you do, you'll go to prison for assaulting a healthcare worker. [Resident 2] reported that she did not know exactly what [Resident 1] had said, because Resident 1 did not speak most of the time and when he does you cannot understand him, but she recalls [AA 2] response. After [AA 2] had made that statement [Resident 1] reportedly turned around, put his cigarette out, which he never does, he always finishes it and went back inside. [Resident 1] did not go back outside the rest of the shift until [AA 2] went home for the night. [Resident 2] reports feeling safe in the facility.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Anxiety (excessive worry and fear).During a review of Resident 1's Minimum Data Set, dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status score was 15 out of 15 which indicated Resident 2 was cognitively intact.During an interview on 7/17/25 at 11:28 a.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process was to complete a COC for any change in resident health status. LVN 1 stated there should have been a COC completed for the alleged staff to resident abuse incident. LVN 1 stated the purpose of the COC was to accurately document what had occurred and to communicate it through the electronic medical record (EMR). During a concurrent interview and record review on 7/17/25 at 12:20 p.m. with interim director of nurses (IDON), Resident 1's electronic medical record (EMR) was reviewed. The IDON stated the EMR indicated there was no COC completed for Resident 1's allegation of staff to resident abuse that occurred on 7/13/25. The IDON stated it was important to ensure all documentation was completed for Resident 1's incident of abuse, to monitor Resident 1 for changes in health status and well-being.During a concurrent interview and record review with the interim administrator (IADM), the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, was reviewed. The P&P indicated, . A significant change of condition is a major decline or improvement in the resident's status that will not normally solve itself without intervention by staff. required interdisciplinary review and/or revision to the care plan. the nurse will make detailed observation and gather relevant and pertinent information for the provider, including information prompted by the SBAR . The IADM stated there should have been a COC completed for any resident changes in health status and for the staff to resident abuse incident with Resident 1.During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, RN Coverage Policy, last reviewed by the facility on 05/01/2024, revealed the section titled, A. Minimum RN Coverage, included, 1. An RN will be on duty a minimum of 8 consecutive hours per day, 7 days a week. Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays. A facility nursing schedule for October 2024 indicated there were no RNs scheduled to work on 10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, and 10/27/2024. A facility nursing schedule for November 2024 indicated there were no RNs scheduled to work on 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, and 11/30/2024. A facility nursing schedule for December 2024 indicated there were no RNs scheduled to work on 12/01/2024, 12/07/2024, 12/08/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024 and 12/29/2024. A facility nursing schedule for January 2025 indicated there were no RN's scheduled to work on 01/01/2025, 01/04/2025, 01/05/2025, 01/11/2025, 01/12/2025, 01/18/2025, 01/19/2025, 01/25/2025 and 01/26/2025. A facility nursing schedule for February 2025 indicated there were no RNs scheduled to work on 02/01/2025, 02/02/2025, 02/08/2025, 02/09/2025, 02/15/2025, 02/16/2025, 02/22/2025, and 02/23/2025. A facility nursing schedule for March 2025 indicated there were no RNs scheduled to work on 03/01/2025, 03/02/2025, 03/08/2025, 03/09/2025, 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/2025. A facility nursing schedule for April 2025 indicated there were no RNs scheduled to work on 04/05/2025 and 04/06/2025. During an interview on 04/09/2025 at 9:46 AM, the Director of Nursing (DON) stated she knew the facility was required to have RN coverage at least eight hours every day, and she revealed that from October 2024 to 04/09/2025 they had not had any RN coverage for the weekends. During an interview on 04/09/2025 at 10:28 AM, the Administrator stated he thought the facility only had to have a nurse scheduled, not necessarily an RN, and the facility did not have an RN scheduled for the weekends.

Based on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was identified on the daily staff posting. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Posting of Daily Hours per Patient Day (DHPPD), last reviewed by the facility on 05/01/2024, revealed, The posting shall include: Breakdown of RN, LVN [licensed vocational nurse]/LPN [licensed practical nurse], and CNA [certified nursing assistant] hours Facility nursing schedules for the timeframe from 10/01/2024 through 04/07/2025 revealed RN coverage was provided Mondays through Fridays. A facility document titled, Daily Census & NHPPD [Nursing Hours per Patient Day] for the timeframe from 10/01/2024 through 04/07/2025 revealed the daily posted staffing sheets did not identify RN coverage as part of their nursing staff. During an interview on 04/09/2025 at 4:05 PM, the Staffing Coordinator stated she did not count (document) any RN hours on the daily staffing sheets. During an interview on 04/10/2025 at 1:52 PM, The Director of Nursing (DON) stated she expected the staff to make sure the daily staffing sheets were accurate. During an interview on 04/10/2025 at 2:18 PM, the Administrator stated he expected the daily staffing sheets to be accurate and show the staff who worked.

Based on interview, facility document review, and facility policy review, the facility failed to electronically submit the Payroll-Based Journal (PBJ) (staffing information for all employees in the nursing home based on payroll data submitted on a quarterly schedule) to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year for the facility. Findings included: A facility policy titled, Payroll-Based Journal (PBJ) Reporting Policy, revised 05/01/2024, revealed, [Facility Name] will maintain an accurate and verifiable system for collecting, validating, and submitting staffing and census data to CMS through the PBJ system on a quarterly basis, as required under 42 CFR [Code of Federal Regulations] S[section]483.70(q). The policy revealed the section titled, 5. CMS Submission, included, A confirmation of receipt and validation report will be reviewed and retained. The facility's PBJ Staffing Data Report for quarter one of fiscal year 2025 revealed the facility did not submit the PBJ report for the first quarter (October 1 - December 31) of fiscal year 2025. During an interview on 04/10/2025 at 12:40 PM, the Staffing Coordinator stated that the previous Assistant Administrator was responsible for the PBJ submission. The Staffing Coordinator stated she would be trained to do the PBJ submission now because she was responsible for staffing and the hours per patient day (HPPD) reporting. During an interview on 04/10/2025 at 2:06 PM, the Director of Nursing (DON) stated the Assistant Administrator left the position in late December 2024. The DON stated that when the Assistant Administrator was at the facility, he had been responsible for submitting the PBJ data. The DON stated she was not sure who submitted the PBJ data now. The DON stated she expected the PBJ data to be submitted in a timely manner. During an interview on 04/10/2025 at 2:31 PM, the Administrator stated he was not able to provide evidence that the first quarter PBJ data was submitted. The Administrator stated it was his expectation that facility staff follow all protocol, policy, and CMS regulations for PBJ data to be submitted timely, and the facility staff should have been doing that.

Based on interview and record review the facility failed to ensure accuracy of documentation according to professional standards for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when the assistant director of nurses/minimum data set (ADON/MDS) nurse documented and electronically signed for the social services director (SSD) on 1/3/25 and 1/6/25 in Resident 1, Resident 2 and Resident 3 ' s multidisciplinary care conference (MCC-meeting that could consists of director of nurses, physician, dietary staff, therapy staff, social services, activities, resident and resident representative to discuss resident care) notes. This failure resulted in falsified documentation and could have caused delay in care resulting from the inaccuracy of the documentation for Resident 1, Resident 2, and Resident 3. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for anxiety (constant worry or feeling afraid), dysphagia (difficulty swallowing) and transient ischemic attack (temporary disruption of blood flow in the brain). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/19/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 11 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for muscle wasting, dysphagia (difficulty swallowing), major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 1's BIMS score was 13 out of 15 which indicated Resident 2 was cognitively intact. During a review of Resident 3's AR, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnosis for major depressive disorder (persistent feeling of sadness and loss of interest), cerebral infarction (blood flow is blocked I the brain) and schizoaffective disorder (condition with symptoms of hallucinations, sadness). During a review of Resident 3's MDS, dated [DATE], the MDS indicated, Resident 3's BIMS score was 14 out of 15 which indicated Resident 2 was cognitively intact. During an interview on 3/27/25 at 10:31 a.m. with the SSD, the SSD stated there was documentation being falsified in Resident 1 ' s records. The SSD stated there were documents that were signed on behalf of the SSD department, even when the SSD was not physically in the facility. The SSD stated the resident assessments had to be completed thoroughly and accurately because the assessments were regarding residents ' mood and behavior and contributed to the plan of care. The SSD stated the instances were reported to the administration but felt there was retaliation from administrative staff following the report. During an interview on 3/27/25 at 10:45 a.m. with the licensed vocational nurse (LVN) 1, LVN 1 stated there were instances when LVN 1 was signed as an attendant to resident care conferences or resident assessments but was not in attendance. LVN 1 stated she could not recall the dates or time but had noticed multiple instances in which that had occurred. LVN 1 stated the instances were not reported to the administration for fear of retaliation against LVN 1. LVN 1 stated it was important to have complete and accurate documentation to effectively care for the resident. During an interview on 3/27/25 at 10:51 a.m. with the ADON/MDS nurse, the ADON/MDS stated the role of the MDS was to ensure documentation was complete and accurate. The ADON/MDS stated if the assessments were found to be incorrect, she would delete the documented portion completed by the other department members and correct it. The ADON/MDS stated she would not notify the department members when the documentation was changed or deleted. The ADON/MDS stated she oversaw documenting during the MCC meetings for residents in the facility. The ADON/MDS stated, the only person she would add as physically attending the care conference meetings was the DON, even when the DON was not physically in the facility. The ADON/MDS stated she had not falsified documentation for any resident. During an interview on 3/27/25 at 11:24 a.m. with the director of clinical operations (DCO), the DCO stated there was a complaint made by a former employee regarding instances of false documentation, but it was determined the ADON/MDS was completing the documentation to assist the members of the IDT. The DCO stated documentation should have been complete and accurate according to the residents ' assessments and IDT documentation. During a concurrent interview and record review on 3/27/25 at 11:57 a.m. with the SSD and DON present, Resident 1 ' s, Multidisciplinary Care Conference (MCC), dated 1/6/25, Resident 2 ' s, MCC, dated 1/3/25 and Resident 3 ' s, MCC, dated 1/3/25, were reviewed. Resident 1 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented x3. Resident able to make needs known to staff . Problems/needs, monthly [medical doctor] visit, monthly with [nurse practioner psychiatrist] . discharge goals, long-term care anticipated . Name [social services director electronic signature] . Resident 2 ' s MCC indicated . Attendance at meeting . social worker . Social work summary, orientation status, Resident is alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor] . discharge goals, long-term care anticipated . Name [social services director electronic signature]. Resident 3 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor], monthly discharge goals, long-term care anticipated . Name [social services director electronic signature] . The SSD stated she was not present during the MCC meetings for Resident 1, Resident 2 and Resident 3 but documentation showed the SSD was present during the meeting. The SSD stated the MCC was electronically signed and completed when SSD was not present during the conference. The SSD stated each department in the facility oversaw their portion of the MCC and the SSD portion should not have been completed by any other facility department. During a concurrent interview and record review on 3/27/25 at 12:10 p.m. with the DON and SSD present, Resident 1 ' s, Multidisciplinary Care Conference, dated 1/6/25, Resident 2 ' s, MCC, dated 1/3/25 and Resident 3 ' s, MCC, dated 1/3/25, were reviewed. Resident 1 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented x3. Resident able to make needs known to staff . Problems/needs, monthly [medical doctor] visit, monthly with [nurse practioner psychiatrist] . discharge goals, long-term care anticipated . Name [social services director electronic signature] . Resident 2 ' s MCC indicated . Attendance at meeting . social worker . Social work summary, orientation status, Resident is alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor] . discharge goals, long-term care anticipated . Name [social services director electronic signature]. Resident 3 ' s MCC indicated, . Attendance at meeting . social worker . Social work summary, orientation status, Resident alert and oriented. Able to verbalize needs . Problems/needs, monthly with [medical doctor], monthly discharge goals, long-term care anticipated . Name [social services director electronic signature] . The DON stated all documentation should have been complete and accurate. The DON stated the purpose of the MCC was to bring all departments together and discuss the needs of the resident and how the residents were progressing. The DON stated it was every departments responsibility to only complete the portion that pertained to their department and to not complete the portion of another department as they would not have the knowledge to accurately reflect the care given. The DON stated when a department was not going to be present for the MCC, it was the expectation that no one would be completing their portion of the conference until they returned to the facility. During a concurrent telephone interview and record review on 4/3/25 at 11:00 a.m. with the DON, the SSD ' s, Daily Time Report, dated 1/1/25-1/31/25, was reviewed. The DON stated the Report indicated, the SSD did not have documented working hours on 1/3/25 and 1/6/25. The DON stated the SSD was not present in the facility on the dates of the completed MCC ' s for Resident 1, Resident 2 and Resident 3. During a review of the facility ' s job description titled, ADON/MDS Coordinator, undated, the job description indicated, . The Assistant Director of Nursing (ADON) and MDS Nurse is responsible for assisting in the overall nursing management of the [Facility name] and coordinating the completion of accurate and timely MDS assessments for all residents . Monitor and report on the accuracy and completeness of MDS assessments and related documentation. Provide staff training on MDS processes, documentation, and related procedures . During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice . Documentation of nurses ' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing ' s contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry . During a review of the facility ' s policy and procedure (P&P) titled, Documentation Policy, undated, the P&P indicated, . The purpose of this policy is to establish standardized practices for documenting care, treatment and patient progress in the skilled nursing facility (SNF) setting . this policy applies to all healthcare providers . it is the policy of [facility name] that all healthcare providers document patient care accurately, timely, and legibly in the patient ' s medical record. Documentation must be complete . and reflect a true and accurate account of the patient ' s status, treatments, and outcomes . general requirements . accuracy all entries must be accurate and reflect the patient ' s current condition . signature. All entries must be signed and dated by the healthcare provider responsible for the care. For electronic documentation, this may include an electronic signature . corrections. If errors are made, corrections must be made in a way that maintains the integrity of the original entry .

Based on interview and record review the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 1), when Resident 1 was left outside for approximately one hour without supervision and the temperature was 92 degrees Fahrenheit on 9/29/24. This failure resulted in Resident 1's body temperature to reach 101.1 degrees Fahrenheit (normal body temperature range from 97 degrees to 99 degrees Fahrenheit) and elevated heart rate of 136 beats per minute (normal heart rate for adults is between 60-100 beats per minute) and had the potential for Resident 1 to experience heat exhaustion, dehydration and/or sunburn of the skin. Findings: During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of abnormalities of gait (walking) and mobility (movement), respiratory failure, conversion disorders with seizures, pain, and muscle weakness During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/10/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During an interview on 10/17/24 at 10:25 a.m. with the director of nursing (DON), the DON stated on 9/29/24, Resident 1 was left outside by the activities assistant (AA). The DON stated the facility staff was alerted by the facility housekeeper that Resident 1 was sitting outside in the heat. The DON stated that the AA was immediately sent home, and Resident 1 was assessed for injuries. The DON stated it was the responsibility of the AA to monitor Resident 1 while he was outside and to have brought him back inside the facility when he was done. During a review of professional reference titled, The Weather Channel, dated 9/29/24, the reference indicated that the outside temperature was recorded at 92 degrees Fahrenheit. During an interview on 10/17/24 at 10:54 a.m. with the activities director (AD), the AD stated he was notified of the incident involving Resident 1 being left outside by AA. The AD stated the AA should have known that any resident including Resident 1 required consistent monitoring especially when they were outside. The AD stated that when Resident 1 was left outside there was a risk for heat exhaustion, heat stroke and dehydration. During an interview on 10/17/24 at 11:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 9/29/24 she was alerted by the housekeeping staff that Resident 1 was sitting outside by himself when the weather was hot. LVN 1 stated the certified nursing assistant (CNA) assisted Resident 1 back into the facility. LVN 1 stated Resident 1 was assessed, and he felt hot with an elevated temperature of 101 .1 degrees Fahrenheit and an elevated heart rate of 136. LVN 1 stated they immediately began cooling measures and continuous monitoring. LVN 1 stated a full head to toe skin assessment was completed, and Resident 1 had no visible injuries. LVN 1 stated she spoke with the AA and concluded Resident 1 was left outside for approximately one hour. LVN 1 stated the AA indicated she had taken Resident 1 outside; forgot he was there, and it was not in her job duties to monitor Resident 1 while he was outside. LVN 1 stated the CNA on shift and LVN 1 were not made aware that Resident 1 was taken outside. LVN 1 stated when Resident 1 was left outside there was a risk for dehydration and heat exhaustion. During an interview on 10/17/24 at 11:32 a.m. with activities assistant (AA) 1, the AA 1 stated part of the activities for the facility was for the residents to have the option to go outside. AA 1 stated every resident should have been monitored when they were sitting outside. AA 1 stated while residents were outside in hot wheather, it was the responsibility of the AA assigned to offer cold water or popsicles to keep residents from overheating. AA 1 stated it was the responsibility of the AA on shift to monitor all residents that were in the activities room. AA 1 stated that residents could have requested to go outside but on days when the temperature was above 80 degrees Fahrenheit, they would not do an outside activity to avoid exposing the residents to the heat. AA 1 stated that when Resident 1 was left outside he could have been sun burned or possibly dehydrated. During an interview on 10/17/24 at 11:38 a.m. with CNA 1, CNA 1 stated it was not appropriate for Resident 1 to have been left outside unmonitored. CNA 1 stated when Resident 1 was left outside there was a potential for heat exhaustion or could have caused Resident 1 to lose consciousness from dehydration. During an interview on 10/17/24 at 12:15 p.m. with the DON, the DON stated it was the facility's expectation for all staff including the activities staff, to monitor all residents when they were outside and to not leave them unattended. The DON stated it was the responsibility of the AA to monitor Resident 1 while he was in the activities room and outside. The DON stated it was not appropriate when the CNA left Resident 1 outside and did not remain with resident to monitor. The DON stated there was a potential for heat exhaustion when Resident 1 was left outside. During a telephone interview on 10/17/24 at 12 :24 p.m. with the administrator (ADM), the ADM stated the employee involved was properly trained on neglect and chose not to follow the training. The ADM stated it was not appropriate for the employee to have left Resident 1 outside unmonitored because he should have been monitored. The ADM stated when he spoke with the employee, she was aware Resident 1 was outside but did not monitor. The ADM stated the employee had been terminated from the facility. During a review of the facility's Activity Assistant Job description, undated, the job description indicated, . To provide routine care and services to clients that supports the medical model of care in the Activities Department . Employees will be required to perform any other job related duties requested by their supervisor . Implements an interactive daily program, including large and small groups, special events, and community outings, provides one to one programming for clients who are unable or unwilling to participate in group programs . Meet the client's mental health and social needs, be aware of developmental tasks and physiological changes associated with the aging process, maintain/ support the client's right to maintain personal choices . Provide supervision and assistance to all residents when participating in indoor or outdoor activities . During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 1/2024, the P&P indicated, . Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . As part of the resident abuse prevention, the administration will, Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .

Based on observation, interview and record review the facility failed to maintain a comfortable environment for one of 35 residents (Resident 12) when the room temperature, measured by the California Department of Public Health (CDPH) thermometer, in Resident 12 ' s room was 84 degrees Fahrenheit. This failure had the potential to result in dehydration (body does not have enough fluids) and heat exhaustion (body overheats and unable to cool itself) for Resident 12. Findings: During a concurrent observation and interview on 6/7/24 at 11:59 p.m. with the unit clerk (UC), the temperature in Resident 12 ' s room was observed. The temperature with the CDPH handheld thermometer read 84 degrees Fahrenheit. The unit clerk was observed checking the temperature of Resident 12 ' s room with the facility ' s handheld thermometer, the temperature was observed at 81 degrees Fahrenheit. The UC stated Resident 12 ' s room felt hot and hot air was being transferred into the room through the air conditioner vent. The UC stated the temperature range should have been 71-81 degrees. During a concurrent observation and interview on 6/7/24 at 12:00 p.m. with Resident 12, Resident 12 ' s room appeared humid and hot, Resident 12 was observed lying in bed covered in a bed sheet and wearing a gown. A floor fan was observed at the corner of the room turned off. Resident 12 stated her room felt hot but did not want the floor fan turned on. Resident 12 stated she did not want an ice pack, floor fan, popsicle or to remove her bed sheet. Resident 12 stated she would have preferred for the facility to fix the AC unit rather than change her comfortability. During a review of Resident 12's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnosis for chronic pain syndrome, rheumatoid arthritis (inflammation of the joints), lupus (illness that attacks the immune system), anxiety (feeling of worry, unease and nervous) and fibromyalgia (disorder that causes pain in the muscles). During a review of Resident 12's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/2/24, the MDS indicated, Resident 12's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 6/7/24 at 1:53 p.m. with the administrator (ADM), the ADM stated Resident 12 ' s room was above the temperature range at 84 degrees due to the air conditioner (AC) not circulating the air properly. The ADM stated the temperature range should have been 71-81 degrees. The ADM stated the technician was onsite to inspect the AC unit and fix the issue. During an interview on 6/7/24 at 2:05 p.m. with CNA 1, CNA 1 stated the facility felt hot the day prior when the temperature outside was high. CNA 1 stated there were complaints from residents about the facility temperature when the temperature would rise. During an interview on 6/7/24 at 2:31 p.m. with LVN 2, LVN 2 stated Resident 12 ' s room felt hot and humid. During an interview on 6/7/24 at 2:43 p.m. with the director of nurses (DON), the DON stated the facility temperature felt hot the day prior due to rising temperatures outside. The DON stated there was a technician onsite to address the issue with the AC not circulating the air in Resident 12 ' s room. The DON stated the temperature in Resident 12 ' s room at 84 degrees should have been 71-81 degrees for the resident to be in a comfortable environment. During a review of the facility ' s policy and procedure (P&P) titled, Emergency Procedure-Utility Outage, dated 1/2024, the P&P indicated, . Residents will remain safe and comfortable during a temporary loss of utility . utilize the following procedures if there is a loss of cooling functions (the facility temperature reaches 85 degrees Fahrenheit and remains so for four hours) . Monitor environmental thermometers .

Based on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with professional standards for 24 of 31 residents when medication blister packs (a type of packing used for resident medication) had orange and green stickers placed over the expiration dates. These failures placed residents at risk for being administered expired medications which may have no longer had the same efficacy and/or side effects. Findings: During a concurrent observation and interview on 1/24/24 at 10:12 a.m., with Infection Preventionist (IP - professional who make sure healthcare workers and residents are doing all the things they should to prevent infections) at medication cart 1, 24 of 31 residents' medication blister packs were observed with no visible expiration date. The expiration date was covered with orange and green stickers indicating am (morning) and pm (afternoon) shifts. IP stated he could not find an expiration date on medication blister packs. IP stated not being able to see expiration date put the residents at risk to receive expired medications. During a concurrent observation and interview on 1/24/24 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was unable to find the expiration date on 24 resident medication blister packs. LVN 2 stated the stickers were placed over the expiration dates. LVN 2 stated she placed the stickers on the blister packs and that was her practice. LVN 2 validated she had been administering these medications to residents. LVN 2 stated she was not following the facility's policy for medication administration because she could not check the expiration date prior to administering medication to residents. LVN 2 stated if the residents received expired medications, the resident could have potential side effects or ineffective treatment due to medication no longer having desired efficacy. During a concurrent interview and record review on 1/25/24 at 10:58 a.m. with Director of Nursing (DON), the facility's policy, and procedure (P&P) titled, Administering Mediations dated 12/2012 was reviewed. The P&P indicated, .9. The expiration/beyond use date on the medication label must be checked prior to administering DON stated stickers should not be placed over the expiration date. The DON stated the nurse would not be able to verify if the medication had expired. The DON stated the nurse could give residents expired medications that may have lost its efficacy. During a review of the Federal Drug Administration (FDA)'s article titled Pharmaceutical-quality-resources/expiration Dates dated 10/2022, the Pharmaceutical-quality-resources/expiration Dates indicated . Drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity .

Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to competently care for 49 of 49 residents at the facility during day-to-day operations and emergencies. This failure had the potential for residents not to receive the services needed to achieve and maintain the highest practicable well-being during day-to-day operations and during an emergency. Findings: During the entrance conference interview with the Administrator (ADM) on 1/22/24, at 9:54 a.m., the facility assessment was requested which was part of the list of documents he needed to provide in a timely manner. The Entrance Conference form indicated the ADM was to provide the facility assessment within 4 hours of entrance. During an interview on 1/24/24 at 10:15 a.m. with the ADM, the ADM stated the skilled nursing facility (SNF) was part of the general acute care hospital (GACH) and the facility assessment was part of the campus wide assessment. The ADM would not directly answer if the SNF was assessed separately to address the individual needs of facility residents. During an interview on 1/24/24 at 4:17 p.m. with the ADM, the ADM was unable to locate a SNF facility assessment. During an interview on 1/25/24 at 4:18 p.m. the ADM provided a copy of the facility assessment dated [DATE] which indicated it had been reviewed on 1/31/24. During a concurrent interview and record review on 1/26/24 at 2:00 p.m., with the ADM, the facility assessment was reviewed. The assessment indicated, . Date(s) of Assessment or Updated . January 4, 2024 . Date(s) Assessment Reviewed w/ QAA/QAPI Committee 1/31/24 . The ADM was unable to explain why the reviewed date was in the future. During an interview on 1/26/24 at 3:58 p.m. with the ADM. The ADM stated he was unable to provide evidence of a previous facility assessment and was unsure if the facility assessment had been updated annually according to regulations. The facility was unable to provide a policy and procedure for the facility assessment.

Based on observations, interviews and record review, the facility failed to maintain a clean and homelike environment for three of three sampled residents (Residents 6, 147 and 19), when: 1. The door frame of Resident 6's Room had missing and chipped paint. 2. Ceiling tiles were peeling, paint missing from Resident 147's room. 3. Resident 19's wall had a TV bracket in place without a television (TV) for over one month, which Resident 19 complained to staff about not having a TV in her room. These failures had the potential to violate the residents' rights to have a clean, sanitary, and comfortable homelike environment. Findings: 1. During a review of Resident 6's Admission Record (AR), dated 1/25/24, the AR indicated Resident 6 was admitted on [DATE] with diagnoses which included quadriplegia (a form of paralysis [the loss of the ability to move and sometimes to feel anything] that affects all of a person's limbs and body from the neck down), chronic pulmonary embolism (blockage of the pulmonary [lung] arteries that occurs when prior clots in these vessels don't dissolve over time despite treatment), and presence of cardiac pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/18/23, the MDS Section C indicated Resident 6 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 6 was cognitively intact. During an observation on 1/24/24 at 9:22 a.m. outside of Resident 6's room, the door frame entering the room had missing and chipped paint. During a concurrent observation and interview on 1/25/24 at 1:32 p.m., with Resident 6, inside of Resident 6's room, Resident 6 stated the missing paint on the door frame bothered him, this was his home, and the facility had not painted the door frame for months. Resident 6 stated, if he was able, he would have painted the door frame immediately after the paint had peeled off. Resident 6 stated, the ceiling tiles and paint missing from the ceiling area above Resident 147's room had been peeling since the COVID (Infectious disease caused by a virus) divider was removed. Resident 6 stated, It is an eye soar, it feels as if the facility does not care about providing a home like environment. During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a home like environment. DON stated this could cause the residents to feel they were not cared for. 2. During a review of Resident 147's AR, dated 1/24/24, the AR indicated Resident 147 was admitted on [DATE] with diagnoses which included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 147's (MDS), dated [DATE], the MDS Section C indicated Resident 147 had a BIMS of 9 which suggested Resident 147 was moderately impaired. During an observation on 1/24/24 at 9:24 a.m. the ceiling area above Resident 147's room, the ceiling tiles were peeling and missing paint from the wall near the ceiling. During a concurrent observation and interview on 1/25/24 at 2:20 p.m., with Resident 147, in Resident 147's room. Resident 147 stated she had to look at the damaged wall and ceiling every time she left her room. Resident 147 stated she felt as if the facility did not care about fixing the building for the residents. Resident 147 stated she was frustrated by the damaged wall and ceiling. During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . DON stated the missing paint on the door frames, wall, and ceiling tiles, should have been repaired quickly. The DON stated the facility did not follow the policy for providing a home like environment. DON stated this could cause the residents to feel they were not cared for. 3. During a review of Resident 19's AR, dated 1/25/24, the AR indicated Resident 19 was admitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, and osteomyelitis, (an inflammation or swelling of bone tissue that is usually the result of an infection). During a review of Resident 19's MDS, dated [DATE], the MDS section C indicated Resident 19 had a BIMS of 15, which suggested Resident 19 was cognitively intact. During a concurrent observation and interview on 1/22/24 at 11:12 a.m. with Resident 19, in Resident 19's room, Resident 19's wall was observed to have a TV bracket, with no TV. Resident 19 stated the TV had been missing for one month. Resident 19 stated her TV broke and it was reported. Resident 19 stated she was still waiting for a TV. Resident 19 stated she was straining her neck trying to watch TV on her roommate's TV. During an interview on 1/24/24 at 11:02 a.m. with the Social Services Director (SSD), the SSD stated she was aware of Resident 19's room missing a TV. The SSD stated Resident 19's TV quit working and they had ordered a new TV, but it did not fit on the old wall mount. The SSD stated new brackets were ordered, but they had not received the brackets. The SSD stated the Assistant Administrator ordered the TV and brackets but had been out on leave. During a review of the Work Order Request Form Maintenance Department (Work Order), dated 12/6/23, the Work Order indicated, .Please install new TV in Resident [19]'s room. TV is in the front office, same TV's, bracket should work . Please order new compatible wall mount . During a concurrent interview and record review on 01/26/24 at 11:42 a.m., with the DON, the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated May 2017, was reviewed. The P&P indicated, .Residents are provided with a safe, clean comfortable environment . The DON stated the facility did not follow the policy for providing a home like environment. This could cause the residents to feel they were not cared for.

Based on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice when: 1. Facility staff did not obtained consent for psychoactive medication (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behaviors), vaccinations (preparation to stimulate the body's immune response against disease), side rails and his Physician Orders for Life-Sustaining Treatment (POLST-a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) while lacking decision-making capacity for informed consent (healthcare provider educates a patient about risks, benefits and alternatives of an intervention and the patient must be competent to make voluntary decisions) for one of three sampled residents (Resident 13) . These failures placed Resident 13 at risk for harm from giving consent without full understanding of the risks versus benefits for the psychoactive medication, vaccinations, side rails and his POLST. 2. One of six sampled Residents (Resident 18) refused medications on multiple occasions and the licensed nurses failed to notify the resident's physician. This failure placed Resident 18's health at risk for not receiving the medication's therapeutic benefits. 3. One of three sampled residents (Resident 14) was given pain medication outside of the physician ordered parameters for administration. This failure placed Resident 14 at risk for his pain being treated inappropriately causing adverse side effects. 4. Licensed nurses administered medication to three of six sampled residents (Residents 18, 26 and 147) without providing privacy. This failure placed Resident 18, 26 and 147's dignity and privacy at risk for being violated. 5. Licensed Vocational Nurse (LVN) 2 left insulin (a medication which controls the amount sugar in the blood) unattended on Resident 18's bedside table. This failure placed Resident 18's health and safety at risk when the medication was left accessible and had the potential for ingestion and contamination of the bottle. 6. LVN 1 left Resident 32's liquid medication unattended at bedside. This failure left Resident 32 at risk for not receiving the therapeutic benefits of the medication. Findings: 1. During an observation on 01/22/24 at 10:27 a.m. in Resident's room, Resident 13 was lying in bed with his eyes closed. Resident 13 did not respond when spoken to. During a review of Resident 13's Admission Record [AR], undated, the AR indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses included sequelae of cerebral infarction (neurological deficits remaining after a cerebral vascular accident [stroke-blockage in a blood vessel in the brain]), dementia (loss of cognitive functioning (thinking, remembering and reasoning), psychoactive substance abuse (drug dependence affecting a person's brain and behavior) and anxiety disorder (persistent and excessive worry). The AR indicated Resident 13 was his own responsible party. The AR also had contact information for two family members. During a review of Residents 13's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 13's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 13 was unable to participate in the assessment. During a review of Resident 13's psychiatrist's progress note dated 12/11/2023, the note indicated, . h/o [history of] Dementia and stroke . He is a poor historian . He is alert and oriented X[times]1 and has periods of confusion . Assessments . Neurocognitive disorder [decreased mental function and loss of ability to do daily tasks] . During a concurrent interview and record review on 1/26/24 at 8:39 a.m. with Licensed Vocational Nurse 1 (LVN) 1, Resident 13's electronic medical record (EMR) was reviewed. LVN 1 stated Resident 13 was forgetful with confusion and only capable of answering simple questions. LVN 1 reviewed Resident 13's Side Rails Informed Consent and Release, and stated Resident 13 signed the consent on 10/31/22 which she had witnessed. LVN 1 stated she was not sure if Resident 13 understood what he had consented to or the risks versus benefits of the side rails. LVN 1 stated she did not think it was appropriate for him to give consent. The informed consents for sertraline (psychoactive medication used to treat depression and other mental illnesses), influenza (highly contagious respiratory infection) and respiratory syncytial virus (RSV-respiratory virus causing infection of the lungs and respiratory tract) vaccinations were reviewed, LVN 1 stated Resident 13 had signed the informed consents, but she did not think Resident 13 could fully understand the risks versus benefits of the medication and vaccinations. Resident 13's POLST was reviewed, Resident 13 signed the POLST on 7/26/23. LVN 1 stated the POLST was a life sustaining decision and Resident 13 should not have signed the POLST himself because she did not think he could fully comprehend it. LVN 1 stated Resident 13's family or the Interdisciplinary Team (IDT-a group of health professionals working together to help a resident make decisions and meet goals) should him to make the decision. LVN 1 stated, I do not think he can make his own decisions. He should not be his own RP [responsible party]. LVN 1 stated if a resident was incapable to be their own RP the facility would reach out to the next of kin, and if next of kin was unable to, the IDT would assist. During a review of Resident 13's care plan for impaired cognitive function, the care plan indicated, . [Resident 13] has impaired cognitive function or impaired thought processes r/t [related to] Dementia . oriented to name only, follows simple direction . able to make simple decisions . such as what clothes to wear . Interventions . Ask yes/no questions in order to determine [Resident 13's] needs . cue, reorient and supervise as needed . Present just one thought, idea, question or command at a time . LVN 1 stated Resident 13 needed time to process his thoughts and could answer one question at a time. During a concurrent interview and record review on 1/26/24 at 9:04 a.m. with the Social Services Director (SSD) Resident 13's sertraline informed consent was reviewed. The SSD stated Resident 13 was difficult to understand when speaking. The SSD stated a Resident would need to be alert and oriented to give consent for psychiatric medication. The SSD stated Resident 13 did not fully understand all risks possible from the medication. The SSD reviewed Resident 13's psychiatrists progress note dated 12/11/23 and stated the note indicated Resident 13 was alert times one which meant only to himself. The SSD stated she had never called Resident 13's family because she never had the need to. The SSD stated Resident 13's family should have been contacted regarding the informed consent. During a concurrent interview and record review on 1/26/24 at 9:18 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 13's diagnosis and BIMS were reviewed. The MDSC stated Resident 13 had a diagnosis of dementia and BIMS of 99 which indicated he was unable to participate in the cognitive assessment. The MDSC stated, It is not appropriate for him [Resident 13] to be his own RP. Resident 13's informed consents for RSV and Flu vaccinations, side rails, sertraline and the POLST were reviewed. The MDSC stated Resident 13 would need to understand what he was consenting to, including the potential risks versus benefits for them to be valid. During an interview on 1/26/24 at 11:07 a.m. with the Director of Nursing (DON), the DON stated informed consents were acquired for admission, treatment, psychotropic medication, side rails and restraints. The DON reviewed Resident 13's EMR and stated Resident 13 had a diagnosis of dementia. The DON stated Resident 13 was not capable of giving informed consent on his own. Resident 13's POLST was reviewed, and the DON stated he had signed his POLST himself, but it not valid because of his limited decision making capacity. The DON reviewed the informed consents for side rails, sertraline, flu and RSV vaccines. The DON stated she did not consider those consents valid and would contact the family. The DON stated if a resident was not able to make decisions or give consent the family should be contacted next. The DON stated the next step would be for the IDT to meet and discuss the risks versus benefits and what was in the resident's best interest. The DON stated the facility had not had an IDT meeting to determine if it was appropriate for Resident 13 to be his own RP. The facility's policy and procedure (P&P) titled, Informed Consent, dated 3/2019, was reviewed with the DON. The P&P indicated, . Informed consent is a process of providing information, ensuring shared understanding and making decisions in the context of the Resident's needs . If is important that information is provided in a language and manner that the Resident understands . This requires an assessment of learning and communication barriers . The DON stated the P&P was not followed. During a phone interview on 1/26/24 at 11:37 a.m. with the Family Member (FM) 1, FM 1 stated Resident 13 was not capable of making decisions for himself without assistance. During a review of a professional reference found at https://polst.org/wp-content/uploads/2018/03/2018.03.01-Surrogate-Definition-and-Role-in-Advance-Care-Planning.pdf titled Advance Care Planning: Surrogates, dated 3/1/2018, the reference indicated, . Because the POLST form orders direct a patient's medical treatments, the patient must have sufficient decision-making capacity to give consent, meaning that the patient has the mental capacity to understand his or her condition, the benefits and burdens of the proposed course of treatment . During a review of the facility's admission agreement titled, California Standard Admission Agreement for skilled Nursing Facilities and Intermediate Care Facilities, dated 5/2011, the admission agreement indicated on page 10-11, . Representative of patient; devolution of rights . Any rights under this chapter of a patient judicially determined to be incompetent or who is found by his physician to be medically incapable of understanding such information, or who exhibits a communication barrier, shall devolve to such patient's guardian, conservator, next of kin, sponsoring agency . During a review of a professional reference found at https://www.aafp.org/pubs/afp/issues/2018/0701/p40.html#:~:text=Capacity%20is%20the%20basis%20of,they%20can%20communicate%20their%20wishes titled, Evaluating Medical Decision-Making Capacity in Practice, dated 2018, the article indicated, .Medical decision-making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment . Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes . 2. During a review of Resident 18's Admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate). During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 18 was unable to participate in the assessment. During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 tested Resident 18's fingerstick blood sugar. LVN 2 stated Resident 18's blood sugar would require insulin 3 units according to the physician's order. Resident 18 had refused the insulin (a medication which controls the amount sugar in the blood) injection. During a concurrent interview and record review on 1/25/24 at 9:10 a.m. with LVN 2, Resident 18's Medication Administration Record (MAR) dated 1/2024, was reviewed. LVN 2 stated when a resident refused medication, a code 2 was entered on the MAR and a progress note was written. LVN 2 stated when a resident refused medication for multiple days the physician would be notified. LVN 2 stated when a resident refused insulin it could cause adverse effects such as going into a coma (deep state of unconsciousness) from high blood sugar. LVN 2 reviewed Resident 18's MAR and stated he refused his insulin on 1/24/24 at 11:00 a.m. which was indicated on the MAR with a 2. LVN 2 reviewed Resident 18's progress notes and was unable to locate a progress note which indicated he had refused his insulin. LVN 2 stated she should have documented the refusal. LVN 2 stated Resident 18 frequently refused his medications. LVN 2 stated the physician should have been notified, but she had not notified him. During a concurrent interview and record review on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), Resident 18's MAR and progress notes were reviewed. The DON stated Resident 18 refused medications on multiple days in January. The MAR dated 1/2024 indicated Resident 18 refused medications with a code 2 as follows: 1/5/24, 1/7/24, 1/18/24- Atorvastatin (for hyperlipidemia-high concentration of fats in the blood), Clopidogrel Bisulfate (for cerebral infarction), Sennosides-Docusate Sodium (for constipation), Xalatan ophthalmic solution (to treat glaucoma [increased pressure in the eye causing loss of sight]) 1/8/24-Allopurinol (for gout [arthritis causing severe pain]), Amlodipine (for hypertension [high blood pressure]), Ascorbic Acid (vitamin C), aspirin, Atenolol (for hypertension), Fish oil (a dietary supplement), Vitamin D3 1/10/24, 1/22/24-Atorvastatin Calcium, Clopidogrel bisulfate (cerebral infarction), Sennosides-Docusate Sodium (constipation) The DON stated her expectations when a resident refused medication was for the nurse to offer it three times, explain the risks versus benefits to the resident and if the resident continues to refuse, notify the physician. The DON stated Resident 18's physician should have been notified since he had multiple medication refusals. The DON stated when Resident 18 refused his insulin on 1/24/24, the nurse should have offered it again and followed up by rechecking the residents blood sugar. The DON stated she was unable to locate a progress note to indicate the nurse had rechecked the blood sugar or notify the physician. During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, dated May 2013, the P&P indicated, . Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician . Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record . The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal . 3. During a review of Resident 14's Admission Record [AR], undated, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included acute subdural hemorrhage (bleeding between the brain and skull), rhabdomyolysis (serious medical condition cause by muscle injury), hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain) and aphasia (disorder which affects ability to communicate). During a review of Residents 14's MDS assessment dated [DATE], indicated Resident 14's BIMS scored 11 out of 15. The BIMS assessment indicated Resident 14 had a moderate cognitive impairment. During an interview on 1/22/24 at 10:24 a.m. with Resident 14, Resident 14 indicated by writing he had shoulder pain, was on pain medication and wanted the medication increased. During a concurrent observation and interview on 1/24/24 at 2:47 p.m. with Resident 14, Resident 14 reported his pain was 10/10 to his left shoulder. Resident 14 was not groaning, grimacing or guarding the shoulder. During an interview on 1/25/24 at 11:07 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 14 rarely complained of pain during care. During a concurrent interview and record review on 1/26/24 at 8:31 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 14's Order Summary Report, dated 1/25/24, was reviewed. The orders indicated, . Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth every 12 hours as needed for severe pain (7-10/10 [pain scale used to measure pain 0-3/10 mild pain, 4-6/10 moderate pain, 7-10/10 severe pain]) related to RHABDOMYOLYSIS . Resident 14's Medication Administration Record [MAR], dated 1/2024 was reviewed. LVN 1 stated the MAR indicated Resident 14 was given hydrocodone-acetaminophen 5-325 mg as follows: 1/11/24 pain level 5/10 1/12/24 pain level 0/10 1/22/24 pain level 6/10 1/23/24 pain level 0/10 LVN 1 stated Resident 14's pain was less than 7/10 and he should not have received hydrocodone-acetaminophen according to the physician's order. LVN 1 stated the physician's order was not followed. During a concurrent interview and record review on 1/26/24 at 11:23 a.m. with the Director of Nursing (DON), Resident 14's MAR and physician order for hydrocodone-acetaminophen were reviewed. The DON stated the nurses administered the medication when the pain was lower than 7/10 and did not follow the physician's order. The DON stated her expectation was for the nurses to follow the physician's order. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner and as prescribed . Medications must be administered in accordance with the orders . 4. During an observation on 1/24/24 at 7:29 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 administered medication to Resident 147 with the privacy curtain and door open. During an observation on 1/24/24 at 7:44 a.m. with LVN 3, LVN 3 administered Resident 26's medication while privacy curtain was not closed and her roommate was in the next bed. During an interview on 1/24/24 at 7:54 a.m. with LVN 3, LVN 3 stated she should have closed Residents 147 and 26's privacy curtains. LVN 3 stated the residents were in the room together and did not have privacy while taking their medications. LVN 3 stated she had forgotten to close the curtains. During a concurrent observation and interview on 1/24/24 at 11:01 a.m. with LVN 2, LVN 2 walked into Resident 18's room and checked the residents blood sugar while the curtain and door were left open. LVN 2 stated she should have closed the curtain to give the resident privacy during the procedure. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated her expectations for medication pass was for the nurses to provide the residents' privacy. The DON stated the curtains should be closed to respect the residents' dignity. During a review of the facility's document titled, Licensed Practical/Vocational Nurse (LVN) Job Description, the job description indicated, . Using independent and interdependent judgment, the Licensed Vocational/Practical Nurse (LVN/LPN) maintains the delivery of quality care . Protect the privacy of patients . During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 8/2009, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . 5. During a review of Resident 18's Admission Record [AR], undated, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke-blockage in a blood vessel in the brain), Type 2 Diabetes Mellitus (disease in which blood glucose [sugar] is too high) and aphasia (disorder which affects ability to communicate). During a review of Residents 18's MDS assessment dated [DATE], indicated Resident 18's BIMS scored 99 The BIMS assessment indicated Resident 18 was unable to participate in the assessment. During a concurrent observation and interview on 1/24/24 at 11:01 a.m., with LVN 2, in Resident 18's doorway. LVN 2 gathered supplies to test Resident 18's blood sugar and placed the supplies with his insulin bottle into a plastic cup. LVN 2 took the cup into Resident 18's room and placed it on the bedside table. LVN 2 tested Resident 18's blood sugar, left the bottle of insulin on his bedside table and exited the room. Resident 18's insulin was left unattended and accessible. LVN 2 stated, The insulin was left in the room. I should not have left it there. LVN 2 stated Resident 18 had access to the insulin and could have contaminated it. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside because it was a safety issue. The DON stated her expectation was for the nurses to keep medication in their possession or in line of site. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2012, the P&P indicated, . Medications shall be administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse . No medications are kept on top of the cart . cart must be clearly visible to the personnel administering medications . must be inaccessible to residents or others passing by . 6. During a concurrent observation and interview on 1/22/24 at 9:45 a.m. in Resident 32's room, a plastic cup with a slightly translucent liquid and spoon was sitting on the bedside table. Resident 32 stated the cup had his medication to help him 'go' and rubbed his stomach. Resident 32 stated the nurse poured a powder into the water, mixed it and left it at bedside. During a review of Resident 32's Admission Record [AR], undated, the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (condition in which your blood does not have enough oxygen) and chronic obstructive pulmonary disease (COPD- group of diseases that block airflow and make it difficult to breathe). During a review of Residents 32's MDS assessment dated [DATE], indicated Resident 32's BIMS. The BIMS assessment indicated Resident 32 had a moderate cognitive impairment. During a concurrent observation and interview on 1/22/24 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1 at Resident 32's bedside, the plastic cup with the translucent liquid was observed. LVN 1 stated she had given Resident 32's [brand name for polyethylene glycol- a laxative for constipation] this morning and left it at bedside. LVN 1 stated the polyethylene glycol was a medication and should not have been left at bedside. LVN 1 stated she should have watched Resident 32 take the medication to verify he did. LVN 1 stated another resident could have access to the medication when left at bedside. LVN 1 stated if someone took the medication and it was not prescribed to them, they could have abdominal pain and diarrhea. During an interview on 1/25/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated medication should never be left at a resident's bedside. The DON stated her expectation was for the nurses stay with the residents and make sure the medication was taken. The DON stated it was a safety issue to leave the medication at bedside. During a review of a facility document titled, Back to the Basics Medication Administration and Storage, dated 2017, the document indicated, . oral medications . Residents should be observed swallowing all medication .

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There was one unwrapped frozen food item on the floor, under the food rack in the walk-in freezer. This failure had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Residents' meal trays were reheated by staff, who were not trained on the proper method to safely reheat food for residents whose meal trays were held to be consumed at a later time. This failure had the potential for growth of pathogenic bacteria and cause food born illness (illness caused by ingestion of contaminated food or beverages) to residents who consumed the improperly reheated food and placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During a concurrent observation and interview on [DATE] at 9:36 a.m. with the Certified Dietary Manager (CDM) in the walk-in freezer, a frozen item was observed under the food storage rack. The CDM stated it looked like an unwrapped hamburger patty. The CDM stated there should be no food under the storage rack. The CDM stated the area should be clean. During an interview on [DATE] at 11:12 a.m. with the CDM, the CDM stated his expectation was that the kitchen area was clean, and that staff was aware of cleaning in the kitchen. During a review of [facility] Daily Cleaning Schedule (Cleaning Schedule), dated week of ,d+[DATE] - [DATE], the Cleaning Schedule did not show staff initials for sweeping the freezer floor on ,d+[DATE] for the p.m. (afternoon) shift, and on ,d+[DATE] for the a.m. (morning) shift. During a review of the facility's policy and procedure titled, Sanitation Section 8 dated 2023, indicated, . The FNS (Food and Nutrition Services) Director will write the cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task . the kitchen staff is responsible for all the cleaning . During a review of professional reference titled, FDA Food Code 2022, section ,d+[DATE].13 Nonfood-Contact Surfaces, dated 2022, indicated, .Non FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. During a concurrent observation and interview on [DATE] at 9:36 a.m. with the CDM in the staff lounge, the resident nourishment refrigerator was observed with a resident meal tray inside the refrigerator. The CDM stated the meal tray was being held for a resident who left the facility for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment. The CDM stated they would hold the meal tray for the residents in the resident nourishment refrigerator and staff would reheat the meal tray when the residents returned from their appointments. During an interview on [DATE] at 10:36 a.m. with Resident 40, Resident 40 stated staff would warm her food if it was cold. During an interview on [DATE] at 9:32 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff would hold resident's meal tray if the resident was sleeping or if the resident was not there to eat the meal. LVN 3 stated, We would store the resident's meal tray in the resident nourishment refrigerator. LVN 3 stated the Certified Nursing Assistant (CNA) would warm up the resident's meal tray when the resident came back. LVN 3 stated there was no training for reheating resident's meal trays. During an interview on [DATE] at 10:38 a.m. with the Director of Staff Development (DSD), the DSD stated staff would hold a resident's meal tray if the resident was not there to eat their food. The DSD stated the CNAs would reheat the resident's meal tray when they returned from their appointments . The DSD stated the CNAs did not have a thermometer to check the food temperature. The DSD stated the CNAs would need to touch the resident's food to be sure it was warm. The DSD stated they had not done an in-service on reheating food. During an interview on [DATE] at 10:57 a.m. with the CDM, the CDM stated CNAs would need to reheat food to 165 degrees Fahrenheit (F). The CDM stated residents could get a food born illnesses if the food was undercooked or over-cooked. The CDM stated the resident's mouth could get burned if the reheated food was too hot. The CDM stated he did not feel it was appropriate for CNAs to reheat food. During an interview on [DATE] at 11:00 a.m. with the Registered Dietician (RD), the RD stated it was not appropriate for CNAs to reheat residents' meal trays. The RD stated the food could be outside of appropriate temperatures. The RD stated there should be better communication with the kitchen about holding residents' meal trays. The RD stated it was not appropriate for staff to touch the resident's food to see if it was warm. The RD stated staff touching the resident's food with their hands could cause cross-contamination. During an interview on [DATE] at 11:33 a.m. with CNA 3, CNA 3 stated she had put residents' food in the resident nourishment refrigerator if the residents were not at the facility during meal service. CNA 3 stated she had reheated meal trays in the microwave. CNA 3 stated to check the temperature she just asked the resident if the temperature was okay. During an interview on [DATE] at 1:11 p.m. with Resident 28, with LVN 1 translating, Resident 28 stated when he went to dialysis staff would save his food. Resident 28 stated he did not like it because when he came back from dialysis, the food tasted different. Resident 28 stated the food tasted like it was expired food. Resident 28 stated the CNA would reheat his food. Resident 28 stated when the CNA reheated his food it tasted dry. During a concurrent observation and interview on [DATE] at 1:41 p.m. with Resident 42, with LVN 1 translating, Resident 42 was observed eating food from a styrofoam container. Resident 42 stated when he would go to dialysis, the facility saved his meal tray. Resident 42 stated if he did not want what was on the tray, he would buy something else. Resident 42 stated it was the CNA that warmed his food. During a review of the Order Listing Report dated [DATE], the Order Listing Report indicated, . dialysis for [Resident 28] on Tuesday, Thursday, and Saturday at 6:15 a.m. During a review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, indicated, .Previously cooked PHF (Potentially Hazardous Foods) or TCS (Time/Temperature Safety) food . should be rapidly reheated to an internal temperature of 165 degrees F within two hours. Internal temperature must then register 165 degrees F for fifteen seconds. Be sure the food reaches a full 165 degrees F when reheating . During a review of professional reference titled, FDA Food Code 2022, section ,d+[DATE].11 Reheating for Hot Holding, dated 2022, indicated, . (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC [degree Celsius] (165oF) [degrees Fahrenheit] and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating .

Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of two sampled residents (Resident 98), when the staff failed to answer Resident 98's call light in a timely manner. This failure resulted in Resident 98 urinating on himself and sitting in his urine for approximately 21 minutes. Resident 98 verbalized feeling felt frustrated, embarrassed, and helpless. Findings During a review of Resident 98's Admission Record (AC), undated, the AC indicated, Resident 98 was admitted to the facility on [DATE] for rehabilitation after closed fracture of the lower end of left femur (broken upper bone of leg), with diagnosis of respiratory failure (a serious condition which makes it difficult to breathe), muscle weakness, chronic combined systolic and dystolic heart failure (heart does not pump enough blood for body's needs), left artificial hip joint, benign prostatic hyperplasia without lower urinary tract symptoms, (enlarged prostate). During a review of Residents 98's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 98's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 98's BIMS score was 15 cognitively intact. During an observation on 1/22/24 at 10:55 a.m. in the hall outside of Resident 98's room, the call light was flashing above the door, the call light was audible, and the resident was calling out for help to urinate. There were pounding sounds coming from the room. During an observation on 1/22/24 at 11:02 a.m. in the hall outside of Resident 98's room, the call light continued to flash and ring as it had not been answered. Certified Nursing Assistant (CNA) 2 was observed rolling a cart with snacks in and out of the rooms in the hall. CNA 2 entered Resident 98's room, turned off the call light and was heard asking the Resident 98 if he needed anything. Resident 98 stated, . it is too late now, I have already wet all over the bed and myself . I couldn't find the urinal . CNA 2 stated, .let me get your CNA to clean you up . During a concurrent observation and interview on 1/22/24 at 11:03 a.m. with CNA 2 in the hall outside of Resident 98's room, CNA 2 stated Resident 98 was not part of her group, and she was busy handing out passing snacks to the residents. CNA 2 continued to go down the hall and passing out snacks. CNA 2 did not inform anyone that Resident 98 needed assistance. During an interview on 1/22/24 at 11:15 a.m. with Resident 98 in his room, Resident 98 stated he pushed the call light because he could not find his urinal and he had to go to the bathroom. Resident 98 stated he was no longer able to get up without assistance. Resident 98 stated he was sitting in his own urine and felt frustrated, embarrassed, and helpless. During an observation on 1/22/24 at 11:16 a.m. in the hall outside of Resident 98's room, CNA 2 and CNA 8 were observed going into Resident 98's room. Resident 98 was heard telling the CNAs he did not want to urinate in his bed or himself, but he could not wait any longer. Resident 98 had been unassisted and sitting in his urine for greater than 21 minutes (from 10:55 a.m. to 11:16 a.m.). During an interview on 1/22/24 at 2:44 p.m. with CNA 2, CNA 2 stated .call lights should be answered within 15 minutes, sooner if the resident needed to go to the bathroom . CNA 2 stated she did not answer Resident 98's call light because Resident 98 was not part of her group, and she was busy passing out snacks to the other residents. CNA 2 stated, there were three CNAs working at the time of the incident. CNA 2 stated one of the CNAs was taking her lunch break and Resident 98's CNA was busy in another room. CNA 2 stated she did go into Resident 98's room, turned off his call light and offered him a snack. CNA 2 stated Resident 98 did inform her that he had urinated on himself and on the bed. CNA 2 stated she did not assist Resident 98 because she had to continue to pass out snacks to the other residents and she did not notify anyone that Resident 98 needed help because she did not want to leave the snack cart unattended. CNA 2 stated, she should have waited until there were three CNAs available before she passed out snacks. CNA 2 stated she should have assisted Resident 98 or sent someone in to help him. During an interview on 1/25/24 at 10:45 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 2 did not follow call light policy and did not meet the expectations of her position. DSD stated it was the expectation of the facility that call lights were answered within fifteen minutes regardless of whose group the Resident was in. DSD stated CNA 2 should not have been passing out snacks while there were only two CNA on the floor. CNA 2 left only one CNA to assist residents which resulted in Resident 98 urinating on himself and having to sit in soiled clothes. DSD stated leaving residents in soiled wet clothes puts them at risk for embarrassment and skin breakdown. During an interview on 1/25/24 at 10:45 a.m. with Director of Nursing (DON), the DON stated the CNA 2 did not follow call light policy resulting in Resident 98 feeling embarrassed and frustrated. DON stated, CNA 2 put other residents in danger when she decided to pass out snacks leaving only one CNA to care for the residents alone. DON stated CNA 2 did not work per expectations of the facility. During review of the facility's policy and procedure (P&P) Quality of Life - Dignity dated 8/2009, indicated .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . During a review of the facility's policy Answering the Call Light dated 10/2010, indicated .General Guidelines .8. Answer the resident's call as soon as possible .6. If assistance is needed when you enter the room, summon help by using the call signal . During a review of the facility's job description for Certified Nurses [undated] indicated, . Performs Patient Care Activities Appropriately .B. Answers patient lights and performs services in a timely manner that adds to the physical well-being of the patient .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Residents 114, 112, 108) of 16 sampled residents when: 1. Resident 114 experienced an 8.7% weight loss within the three-month period and a 12.2% weight loss within the five-month period and the care plan did not address this situation. This failure resulted in Resident 114 to have an on-going severe significant unplanned weight loss for five months since admission to the facility. 2. Resident 112 did not have a care plan to address the 15.6% weight loss within the three-month period and the 13.2% weight loss within the four-month period. This failure resulted in Resident 112 to have an on-going severe significant unplanned weight loss for four months since admission to the facility. 3. Resident 108's care plan for oral/dental health problems contained interventions that were not followed. This failure resulted in Resident 108's oral/dental health not being followed and had the potential for Resident 108 to have oral/dental infections. These findings placed Residents 114, 112 and 108 at risk for a decline in their health and safety and unable to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a review of Resident 114's Medical Record (MR), dated 10/8/21, the medical record indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) , and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 99 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive (ability to think and reason) Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and not on physician-prescribed weight-loss regimen. During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs. (pounds., unit of measurement) 5/9/21 120 lbs. 5/15/21 122.1 lbs. 5/23/21 118.8 lbs. [-3.3. lbs. in one week] 5/29/21 117.8 lbs. 6/2/21 116 lbs. 6/6/21 117 lbs. 7/1/21 116.4 lbs. 8/6/21 111.6 lbs. (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.]) 9/3/21 111.6 lbs. 10/1/21 109.6 lbs. (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5 lbs.]) During a review of Resident 114's Order Summary Report (OSR), dated 10/8/21, indicated, Resident 114 diet was ordered on 5/07/21 by the physician, indicating Regular diet, Regular texture, and Regular Liquids Consistency. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD (Registered Dietician) Admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. LVN 1 was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. LVN 1 stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed. During a concurrent interview and record review, on 10/07/21, at 3:07 p.m., with the DON, Resident 114's Progress Notes (PN), were reviewed. The DON was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. The DON stated Resident 114's care plan to notify the physician for significant weight loss was not followed. The DON stated Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review, on 10/07/21, at 12:55 p.m., with the DON, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Interventions/Tasks of the CP indicated, RD to evaluate and make diet change recommendations PRN. The DON was unable to confirm documentation the RD evaluated or make a diet change recommendation for Resident 114 after establishing the initial care plan on 5/11/21. The DON stated Resident 114's care plan for RD to evaluate and make diet change recommendations was not followed. During an interview on 10/8/21, at 3:48 p.m., with RD 1, RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable. During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated 9/2010, indicated, An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, .Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 2. During a review of Resident 112's Medical Record (MR), dated 10/5/21, indicated, Resident 112 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Anxiety Disorder, unspecified Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), Unspecified Urinary Incontinence, Wedge Compression Fracture of First Lumbar Vertebra (a fracture often caused by trauma such as sustaining a fall, occurs in front of the vertebra and resulting on a wedge shape), Vitamin D deficiency (lack of) and Muscle Wasting and Atrophy (decreased muscle tissues). The most recent Minimum Data Set (MDS) dated [DATE], Section C1000 indicated, Resident 112's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 112 has a swallowing disorder and complaints of difficulty or pain with swallowing. During a review of the facility's document titled, Weights and Vitals Summary (WVS), dated 10/8/21, the form indicated the following weights and comparisons for Resident 112: 5/25/21 107.4 lbs. (pounds., unit of measurement) 6/3/21 92.5 lbs. 6/20/21 92.0 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -14.3%, -10.6lbs.]) 7/1/21 95.3 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -11.3%, -12.1lbs.]) 8/1/21 96.4 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -10.2%, -11 lbs.]) 8/29/21 90.9 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.]) 9/3/21 90.6 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -15.6%, -16.8 lbs.]) 10/1/21 93.2 lbs. (-10.0% change, [comparison weight 5/25/21, 107.4 lbs., -13.2%, -14.2 lbs.]) During a concurrent interview and record review, on 10/08/21 at 12:44 p.m., with the Director of Staff Development (DSD), Resident 112's WVS and Care Plan (CP), dated 10/8/2021 were reviewed. DSD stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The WVS indicated, on 7/1/21, Resident 112's weight was 95.3 lbs., a 12.1 lbs., 11.3% weight loss in one month since admission to the facility. On 8/29/21, Resident 112's weight was 90.9 lbs., a 16.8 lbs., 15.6% weight loss in three months. Resident 112's admission weight on 5/25/21 was 107.4 lbs. The DSD reviewed resident 112's care plans and stated there was no care plan developed to address the weight loss on 6/20/21, 7/21/21, 8/1/21, 8/29/21, 9/3/21, and 10/1/21. The DSD stated, Resident 112 should have a weight loss care plan and nutrition care plan as soon as the weight loss was identified. The DSD stated it was the responsibility of the licensed nurse or DON to initiate the care plan. During a review of the facility's policy and procedure, titled, Care Plans - Comprehensive dated September 2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly . During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 3. During a review of Resident 108's Face Sheet (document that contains residents name, date of birth, room number, resident representative, diagnoses, insurance information and more) titled, Admission and Records, dated 10/5/21 at 3:44 p.m., indicated, .Resident 108 was admitted on [DATE] for Apraxia (Difficulty with skilled movements even when a person has the ability and desire to do them) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood.) . Type 2 Diabetes (A chronic condition that affects the way the body processes blood sugar.) with Diabetic Nephropathy (deterioration of kidney function) . Conversion disorder (a medical condition in which the brain and body's nerves are unable to send and receive signals properly) with seizures (a sudden, uncontrolled electrical disturbance in the brain) . Essential hypertension (high blood pressure that has no clearly identifiable cause) . Vitamin B 12 Deficiency Anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12) . Muscle weakness (generalized) . Benign Prostatic Hyperplasia ( condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms (hesitancy, poor and/or intermittent stream, straining, feeling of incomplete bladder emptying, dribbling, etc.) . The admission record did not indicate Resident 108 had no teeth and had lost his dentures. During a review of Resident 108's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) - Version 3.0 Resident Assessment and Care Screening, dated 9/22/21, indicated, Resident 108 has the ability to express ideas and wants and had a Brief Interview of Mental Status (BIMS- The total possible BIMS score ranges from 00. to 15. 13 - 15: cognitively intact. 08 - 12: moderately impaired. 00 - 07: severe impairment) score of 10, indicating moderately impaired. During a concurrent observation and interview on 10/7/21, at 11:50 a.m., with Resident 108, in his room, Resident 108 had no teeth and no dentures at bed side. Resident 108 stated he does not have any teeth and does not have his dentures here, they (the facility staff) do not offer oral care to me nor have they since I have been here. During a review of Resident 108's Care Plan (CP) titled, [name of resident] has oral/dental health problems (missing teeth r/t (related to) Poor dentition), date initiated 9/18/21, the CP indicated, Goal The resident will be free of infection, pain or bleeding in the oral cavity by review date . interventions/Tasks Coordinate arrangements for dental care, transportation as needed/as ordered . [resident's name] requires mouth inspections q shift [every shift] during oral cares. Report changes to the nurse . Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions . Provide mouth care as per ADL [activities of daily living] personal hygiene . During an interview on 10/11/21, at 9:26 a.m., with the Director of Staff Development/ Infection Preventionist (DSD/IP), the DSD/IP stated, We [the facility] offer oral care to residents . the DON [Director of Nursing] does the bulk of the care planning, the nurses do some once in a while and I help occasionally too. DSD/IP was observed checking her three education binders and stated she was unable to locate any education she had provided to staff on oral care. DSD/IP stated it is important for residents to have oral care to prevent decay, sores, and infection; all these issues can affect the resident's ability to eat. During a concurrent observation and interview on 10/13/21, at 12:29 p.m., with Certified Nursing Assistant/Sitter (CNA/S) in Resident 108's room, CNA/S was seen helping Resident 108 with his lunch. Resident 108 was sitting up in bed and his hands were shaking. CNA/S stated she has been a sitter for Resident 108 on four different days, I assist him with eating and drinking, help him to the bathroom, get dressed and help keep him safe. CNA/S stated she does not look at the residents care plan and she has not looked in Resident 108's mouth, I was not aware that I should inspect the residents (Resident 108's) mouth at least once a shift and let the nurse know if there are any issues. CNA/S pulled out Resident 108's mouth wash from her pocket and stated, I have offered it to him and will offer it again. During a concurrent interview and record review on 10/13/21, at 1 p.m., with Licensed Vocational Nurse (LVN) 6, Resident 108's care plans were reviewed. LVN 6 stated she was not aware that Resident 108 had a care plan for his mouth. LVN 6 stated, I look at the care plans for residents at least once daily . I was not aware that we should be checking his (Resident 108's) mouth every shift. LVN 6 stated it is very important to monitor his mouth for signs and symptoms of infection. LVN 6 confirmed the care plan had not been followed. During a review of the facility's policy and procedure (P&P), titled, Mouth Care, dated 10/2010, the P&P indicated, .Purpose The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Preparation 1. Review the resident's care plan to assess for any special needs of the resident . During a professional reference review the Centers for Disease Control and Prevention, last updated 11/3/2020, article titled, Oral Health, was reviewed. The Oral Health article indicated, . Oral health is essential to general health and well-being. Oral disease can cause pain and infections that may lead to problems with eating, speaking, and learning. It can also affect social interaction . the three oral conditions that most affect overall health and quality of life are cavities, severe gum disease, and severe tooth loss . Tobacco use and diabetes are two risk factors for gum disease . During a review of the facility's P&P, titled, Care Plans - Comprehensive dated 9/2010, indicated, .An individualized comprehensive care plan that is measurable objective and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .1. Our facility's Care Planning .care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .f. Identify professional services that are responsible for each element of care .9. The Care Planning/Interdisciplinary Team (IDT) is responsible for the review and updating of the care plans: a. When there has been a significant change in resident's condition .d. At least quarterly .

Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 114) maintained acceptable parameters of nutritional status when: 1. Licensed nurses did not communicate two episodes of significant severe unplanned weight loss to the interdisciplinary team (IDT - members of the care team that include nurses, social workers, doctors, therapists, dietician and others). Licensed nurses documented Resident 114's weight loss of 8.6% between 5/7/21 and 8/6/21 and a weight loss of 10.2% between 5/7/21 and 10/1/21 and did not report this to the IDT and appropriate assessments and effective interventions were not implemented. 2. The Registered Dietician (RD) did not conduct a nutritional assessment to address the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 in accordance with the facility's policy and procedure. As a result of these failures, Resident 114's compromised nutritional status was not addressed which could lead to further medical complications. Findings: 1. A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen. A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs (pounds., unit of measurement) 5/9/21 120 lbs 5/15/21 122.1 lbs 5/23/21 118.8 lbs [-3.3. lbs in one week] 5/29/21 117.8 lbs 6/2/21 116 lbs 6/6/21 117 lbs 7/1/21 116.4 lbs 8/6/21 111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.] 9/3/21 111.6 lbs 10/1/21 109.6 lbs (-10% change [comparison weight 5/15/21, 122.1 lbs., -10.2%, -12.5lbs.] A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114. A review of the facility document titled, History and Physical (H&P), dated 5/9/21, 6/17/21, and 8/31/21 for Resident 114 completed by the Physician indicated the section titled, Physical Findings, WT [weight] was not documented. A review of the facility document titled, 30-day Evaluation - Monthly dated 7/13/21 and 9/1/21 for Resident 114 completed by the Physician indicated VS [Vital Signs] WNL [Within Normal Limits]. Exam unchanged. During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. On 10/1/21, Resident 114's weight was 109.6 lbs., a 12.5 lb., 10.2% weight loss in five months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months and when Resident 114 experienced a 10.2% significant severe unplanned weight loss in five months. During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD Admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN), were reviewed. The LVN 1 was unable to confirm documentation the physician was notified for s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. During a concurrent interview and record review, on 10/07/21 at 1:15 p.m., with the LVN 1, Resident 114's CP, initiated on 5/11/21, was reviewed. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The LVN 1 was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN, dated 10/7/21 for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21 and a significant severe unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. Resident 114's CP, initiated on 5/11/21 was reviewed with the DON. The CP indicated, Resident 114's has the potential nutritional problem related to Diet restrictions. The DON was unable to confirm Resident 114's care plan was updated to address the significant unplanned weight loss of 3.3 lbs. in a week on 5/23/21, 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs, 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, licensed nurses should update the care plan to address the weight loss or create a new care plan for new problems. The DON stated, Resident 114's significant unplanned weight loss could result in further medical complications including anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review, on 10/7/21, at 3:07 p.m., with the DON, the facility documents titled IDT Weight Management Assessment (IDT-WMAU), dated 5/25/21, 6/4/21, 6/9/21, and 6/15/21 for Resident 114, were reviewed. Section A of the IDT-WMAU dated 5/25/21 indicated, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 25% to 75%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/4/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 3.3# in a week. PO intake was 58%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by the DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/9/21 for Resident 114, indicated for Section A, Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.8# in a week. PO intake was 79%. She eats in her room and is able to feed herself. Continue to monitor weekly weights. Intake 75% to 100%. Section B of the IDT-WMAU indicated no changes needed. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON confirmed the IDT-WMAU. The IDT Weight Management Assessment (IDT-WMAU), dated 6/15/21 for Resident 114, indicated for Section A. Resident 114 was on a regular diet and tolerated well. Resident 114 lost 0.4# in a week. PO intake was 72%. She eats in her room and is able to feed herself. Weight was stable, continue to monitor weights monthly. Intake 50% to 100%. Section B of the IDT-WMAU indicated, Recommendations: Current Plan of Care remains appropriate, no changes needed at this time. The IDT-WMAU was completed by DM 1. The DM 1, SSD, AD, and DSD attended the IDT meeting. The DON was unable to confirm further IDT-WMAU meetings were conducted after 6/15/21. During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway. During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals. During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher. During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114. During an interview on 10/8/21 at 10:16 a.m., with the RD 1, the RD 1 stated, he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively. On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry. During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her. During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes. Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk. During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 was not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable. During an interview on 10/11/21 at 1:47 p.m., with the CNA 7, the CNA 7 stated, the diet ordered for Resident 114 had not changed since admission. The CNA 7 stated, Resident 114's weights were taken every month by the RNA (Restorative Nurse Assistant) or CNA and reported to the charge nurse. During a concurrent interview and record review on 10/12/21 at 1:25 p.m., with the DSD, Resident 114's Meal Percentage Report Documentation Survey Reports (MPR), dated 8/1/2021 through 10/7/21 were reviewed. The MPR indicated, of the 204 meals (breakfast, lunch, and dinner), served between 8/1/21 and 10/7/21, Resident 114 refused of her meals 9% of the time and consumed 50% or less 21% of the time. The DSD confirmed Residents 114's intake. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . Review of the facility's Policy and Procedure titled Care Planning- Interdisciplinary Team revised September 2010 showed, an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; f. Identify the professional services that are responsible for each element of care; .4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) .5.When possible, interventions address the underlying source(s) of the problem area (s) .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition. During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the Journal indicated, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . 2. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with LVN 1, Resident 114's PN was reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 for Resident 114. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), Resident 114's the WVS and the PN, dated 10/7/21 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 and a significant unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21. The DON stated, Resident 114's significant unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21, and the significant severe unplanned weight loss of 12.5 lbs., 10.2% in five months, from 5/15/21 through 10/1/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 and the significant severe unplanned weight loss of 10.2 % within a five-month timeframe from 5/7/21 to 10/1/21 for Resident 114 were not addressed by the RD. RD 1 further stated the weight loss for Resident 114 was not acceptable. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1 In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments .

Based on observation, interview and record review, the facility failed to provide outside services of Podiatry (DPM), Registered Dietician (RD), and Psychiatry for three (3) of sixteen (16) sampled residents and twenty-two (22) unsampled residents when: 1. A physician of podiatry was not contracted to provide services to the facility from 12/3/20 to 10/6/21. This failure resulted in podiatry services not being provided to Resident 117 and 109 as well as 22 other residents in need of podiatry physician evaluation. Resident 117 experienced pain, infection, and removal of the left great toenail and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown toenails, and infections. 2. A Registered Dietitian (RD) was not contracted to provide services to the facility from July 21, 2021 to August 19, 2021. This failure resulted in no RD assessments for Resident 114 and no effective interventions to address a significant severe weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 for Resident 114 to not be assessed or monitored by the RD. 3. A psychiatrist was not contracted to provide services to the facility from 12/3/20 to 10/14/21. This failure resulted in psychiatry services were not provided to Resident 114. This failure resulted in Resident 114 did not receive psychiatric assessments and placed Resident 114 at risk for decline in her mental health status. These failures place the residents at risk for a decline in their health and safety. Findings: 1. During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109's toenails were extremely long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109 stated he had not seen a podiatrist since admission to the facility 3/1/21. During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 109 and his toenails were long. LVN 2 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 2 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 2 stated the facility did not have a podiatrist. During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 2 had told her Resident 109 needed a podiatrist. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated Resident 109's toenails looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience sores from the nails pressing on his skin. During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke (bleeding in the brain), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that attacks the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking. During a review of Resident 109's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist. During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails taken 10/5/21. The RDO stated the facility did not have a contracted podiatrist. The RDO stated should have not waited to get a podiatrist. During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and looked infected and overgrown. Resident 117 stated he had not seen a podiatrist. During a review of Resident 117's clinical records there was no documentation of assessment of his toenails in the nursing progress notes, physician's notes, or Activities of Daily Living (ADL) or any other records to indicate he was seen by a podiatrist. During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicted Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking. During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated she was aware the facility needed a podiatrist. The SSD stated the RDO had found a podiatrist 10/5/21 and the podiatrist came to the facility 10/6/21 to treat 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here. During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed A photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109 and he had an active toenail fungus that caused the toenails to thicken and become discolored and an ingrown right great toenail. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of the toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months. The DPM stated she had assessed and treated 22 other residents, but Residents 109 and 117 toenails were in the worst condition. During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the Podiatrist (DPM), the DPM stated she was made aware 10/5/21 the facility needed podiatry services. The DPM stated she had been coming to the area but no one from the facility had contacted her until yesterday. The DPM stated she had seen Resident 117, had removed the left great toenail and treated him for infection. The DPM stated the toenail had purulent (Yellow fluid from a wound-sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she had ordered a betadine (disinfectant for skin) treatment daily to treat the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist but was not. During an interview, on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility had been unable to get the Podiatrist to come to the facility. The ADM stated there was no Podiatry services at the facility from 12/2/20 to 10/6/21. During an interview, on 10/13/21 at 8:37 a.m., with LVN 1, LVN 1 stated she had assessed Residents 109 and 117 about a month ago. LVN 1 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 1 stated the SSD told her she would follow up with a podiatrist but had not. LVN 1 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 1 stated the long toenails would most likely have been painful. LVN 1 stated the condition of Resident 109 and 117's toenails should not have gotten that bad. During a concurrent interview and record review, on 10/13/21 at 11:00 a.m., with the RDO, the contracts for outside services were reviewed. The RDO stated the facility had opened 12/3/20 and did not have a contracted podiatrist 12/3/20 to 10/6/21. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have podiatry care for the residents. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided. During a professional reference review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists' . 2. A review of an email provided by the facility from the Nutrition Consulting Company A, dated 7/23/21, at 4:55 p.m., indicated the last day of service for the Nutrition Consulting Company A was July 21, 2021. A review of the contract with the Nutrition Consulting Company B indicated the contract began on August 19, 2021. On 10/5/21 at 3:23 p.m. an interview was conducted with the Administrator (ADM). The ADM stated the RD 1 started consulting for the facility last week. A review of Resident 114's Medical Record (MR), dated 10/8/21, indicated, Resident 114 was admitted on [DATE], with diagnoses that included Unspecified Dementia with Behavioral Disturbance (diminished memory with episodes of agitation or restlessness), Bipolar Disorder (feeling very sad or very excited), Circadian Rhythm Sleep Disorder (unable to sleep), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hyperlipidemia (elevated fat levels in the body), Muscle Weakness, Muscle Wasting and Atrophy (decreased muscle tissues), Psychotic Disorder with Delusions (a disorder characterized by a disconnection from reality) and Essential Hypertension (abnormally high blood pressure). The most recent Minimum Data Set (MDS, a resident assessment tool) dated 8/18/21, indicated a BIMS (brief interview for mental status) score of 9 out of a possible 15, indicating Resident 114 was unable to complete the interview. Section C1000 of the MDS indicated, Resident 114's Cognitive Skills for Daily Decision Making was severely impaired. Section K of the MDS indicated, Resident 114 had a weigh loss of 5% or more in the last month and was not on a physician- prescribed weight-loss regimen. A review of the facility document titled, Weights and Vitals Summary (WVS), dated 10/8/21, indicated the following weights and comparisons for Resident 114: 5/7/21 121.2 lbs (pounds., unit of measurement) 5/9/21 120 lbs 5/15/21 122.1 lbs 5/23/21 118.8 lbs [-3.3. lbs in one week] 5/29/21 117.8 lbs 6/2/21 116 lbs 6/6/21 117 lbs 7/1/21 116.4 lbs 8/6/21 111.6 lbs (-7.5% change [comparison weight 5/15/21, 122.1 lbs., -8.6%, -10.5 lbs.] 9/3/21 111.6 lbs A review of the facility document titled Order Summary Report (OSR), dated 10/8/21, indicated, on 5/07/21 a Regular diet, Regular texture, and Regular Liquids Consistency was ordered by the Physician for Resident 114. During a concurrent interview and record review, on 10/07/21 at 12:44 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 114's Weights and Vitals Summary (WVS), dated [DATE] was reviewed. The LVN 1 stated, all newly admitted residents were weighed every week for four weeks and if stable, then weighted monthly. The LVN 1 stated, she would ask the Certified Nurse Assistant (CNA) to reweigh the resident for any weight loss. The LVN 1 stated, she would notify the doctor, the RD, the dietary department, and the responsible party (RP) for any significant or severe weight loss. The WVS indicated, on 5/15/21, Resident 114's weight was 122.1 lbs. On 8/6/21, Resident 114 weight was 111.6 lbs., a 10.5 lb., 8.6% weight loss in three months. The LVN 1 was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced an 8.6% significant severe unplanned weight loss in three months. During a concurrent interview and record review, on 10/07/21 at 12:55 p.m., with LVN 1, Resident 114's Care Plan (CP), initiated on 5/11/21, was reviewed. The Focus Section of the CP indicated, the RD Admission Assessment was completed on 5/13/21. The interventions/tasks section of the CP indicated, monitor/record/report to MD PRN signs and symptoms (s/s) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in one week, >5% in one month, >7.5% in three months, >10% in six months. Provide, serve diet as ordered. Monitor intake and record every meal. During a concurrent interview and record review, on 10/07/21 at 1:00 p.m., with the LVN 1, Resident 114's Progress Notes (PN) were reviewed. The LVN 1 was unable to confirm documentation the RD was notified of the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21. During a concurrent interview and record review on 10/7/21 at 3:07 p.m., with the Director of Nursing (DON), the WVS and the PN for Resident 114 were reviewed. The DON stated, all newly admitted residents were weighed every week for four weeks and if stable, were weighed monthly. The DON confirmed Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21. The DON stated, Resident 114's significant severe unplanned weight loss could result in anemia, electrolyte imbalance, dehydration, kidney failure, and further weight loss. The DON was unable to confirm nursing documentation in Resident 114's medical record which indicated the Physician, the RD, the dietary department, and the RP were notified when Resident 114 experienced a significant severe unplanned weight loss of 10.5 lbs, 8.6% in three months, from 5/15/21 through 8/16/21. During a concurrent interview and record review on 10/7/21 at 3:15 p.m., with the Director of Nursing (DON), Resident 114's Dietician Nutritional Assessment (DNA), dated 5/13/21 was reviewed. The DON stated, the DNA for Resident 114 was completed by the Registered Dietician (RD) 2. Section B of the DNA indicated, Resident 114's caloric needs were between 1,230 and 1,420 calories. Section D of the DNA indicated, Resident 114's fluid needs were between 1,230 and 1,420 ml (unit of measurement). Section F of the DNA indicated the goal for Resident 114 was Resident will not have a significant weight change. Section G of the DNA indicated interventions for Resident 114's was diet is liberalized. Continue POC (Plan of Care). RD to monitor weights and follow up as needed. The DON was unable to validate a DNA addressing the significant severe unplanned weight loss of 10.5 lbs., 8.6% in three months, from 5/15/21 through 8/16/21 was completed by the RD. The DON confirmed Resident 114 did not receive the appropriate follow-up assessment required by the RD according to the facility's policy. During an interview on 10/7/21, at 5:24 p.m., with the LVN 3, the LVN 3 stated, Resident 114 fed herself, refused help, and frequently paced the hallway. During a concurrent observation and interview inside Resident 114's room, on 10/7/21, at 5:30 p.m., with the CNA 3, the CNA 3 stated, Resident 114 fed herself, had good and bad days. The CNA 3 stated, she would offer a sandwich or something else if Resident 114 consumed 25% or less of her meals. During an observation of the dinner meal service on 10/7/21, at 5:35 p.m., in Resident 114's room, Resident 114 was observed struggling to cut the chicken meat with a fork. Resident 114 used her hands to eat the chicken meat. Resident 114 consumed 90% of chicken, 75% of rice, 75% of vegetable and 100% of dessert. Resident 114 did not drink the milk. Resident 114 attempted to remove the water pitcher cover to drink water, however she was unable to remove the water pitcher cover. The CNA 3 assisted Resident 114 to remove the water pitcher cover and Resident 114 drank water directly from the pitcher. During an interview on 10/7/21, at 5:51 p.m., with the LVN 1, the LVN 1 stated, she was not notified or aware of any change in intake or weight loss for Resident 114. On 10/8/21 at 10:16 a.m., an interview was conducted with the RD 1. The RD 1 stated he started working at the facility two weeks ago. The RD 1 stated the facility had a loose system for monitoring weights. The RD 1 stated, there was not much communication between nursing and the RD or dietary department. The RD 1 stated, the CNAs were responsible for weighing residents weekly and monthly. The CNAs notified the licensed nurses of the weekly and monthly weights. The licensed nurses were responsible to enter the resident's weights in the electronic medical record. The RD 1 stated, the licensed nurses were responsible to notify the RD of any significant weight change. The RD 1 further stated the facility's goal was to manage resident's weight loss proactively. On 10/8/21, at 11:55 a.m., an observation of Resident 114 was conducted. Resident 114 was observed walking slowly with a steady gait, wearing a loose blue upper garment, loose pants, and a pair of slippers. When Resident 114 was asked in her native language how she was doing, Resident 114 stated she was hungry. During a concurrent observation and interview on 10/8/21, at 12:05 p.m., with the CNA 4 outside Resident 114's room, the CNA 4 stated, Resident 114's upper and lower garments were loose and looked too big for her. During a concurrent observation and interview on 10/8/21, at 12:33 p.m., with the CNA 5 inside Resident 114's room, the CNA 5 stated, Resident 114 was on a regular diet and needed assistance with tray set-up. The CNA 5 set-up Resident 114's meal tray and Resident 114 begin eating her meal vigorously. CNA 5 stated, Resident 114 liked to be left alone during mealtimes. Upon completion of Resident 114's lunch meal, on 10/8/21, at 12:51 p.m., Resident 114 consumed 100% of the fish, gelatin, and dinner roll. Resident 114 consumed 75% of the french fries and 25% of the cabbage salad. Resident 114 drank 100% (240 ml) of milk. During a concurrent observation and interview on 10/8/21, at 1:19 p.m., with the CNA 6, the CNA 6 stated, Resident 114 consumed 100% of her lunch meal and drank 100% of her milk. CNA 6 validated Resident 114 didn't eat 100% of her cabbage salad. During an interview on 10/8/21, at 3:48 p.m., with the RD 1, the RD 1 confirmed the significant severe unplanned weight loss of 8.6% within a three-month timeframe from 5/7/21 to 8/6/21 for Resident 114 were not addressed by the RD. The RD 1 further stated the weight loss for Resident 114 was not acceptable. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated September 2020, the P&P indicated, Weight Assessment .1. The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe .Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacist, and the resident on resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During a professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014, the journal indicated, .Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Consultant services may be uses in the following areas .Dietary Services .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments . 3. During a concurrent interview and record review, on 10/11/21 at 8:51 a.m., with the Director of Nurses (DON), the Physician's Orders (PO) for Resident 114 was reviewed. The DON stated Resident 114 had diagnosis of Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there). The DON stated Resident 114 received two medications for mental illness, Olanzapine (medication for psychosis (hallucinations) 10 milligrams (mg-weight measurement) daily and Valproic acid (mood stabilizer) 125 mg twice a day since admission 5/7/21. The DON stated Resident 114 had behaviors of screaming, hitting herself, hallucinations and elopement. The DON confirmed there was no psychological evaluation for Resident 114. The DON stated the facility did not have a Psychiatrist to evaluate residents with mental illness. The DON stated the facility should have had psychiatric consultation for Resident 114 but did not. During a concurrent interview and record review, on 10/11/21 at 11:32 a.m., with the Social Services Director (SSD), the SSD reviewed Resident 114's clinical records. The SSD confirmed Resident 114 was diagnosed with Psychosis and Bipolar Disorder and had not been evaluated by a psychiatrist. The SSD stated the facility did not have a psychiatrist since opening 12/3/20 to present. The SSD stated when she had asked corporate Regional Director of Operations (RDO) about psychiatric services, the RDO had told them the main hospital had taken too long to obtain the psychiatrist's credentials and psychiatric services were never started. The SSD stated corporate was responsible for contracting outside services for the facility but had not done it. During an interview on 10/11/21 at 9:09 a.m., with the Administrator (ADM), the ADM stated the facility originally had contracts but were unable to get the Psychiatrist to come to the facility. The ADM stated there was no psychiatric services at the facility since opening 12/3/20. The ADM stated the facility should have had Resident 114 evaluated by a psychiatrist but did not. During a review of Resident 114's Face Sheet dated 10/7/21, the Face Sheet indicated the admitted was 5/7/21. The Face Sheet indicated Resident 114 had diagnosis of Dementia (memory impairment), Bipolar Disorder (mental condition marked by periods of elation and depression), Major Depressive Disorder (chronic loss of interest/sadness), Psychotic Disorder (chemical imbalance in the brain marked by seeing or hearing things that are not there), Circadian Sleep Disorder (unable to sleep at regular times), Muscle Wasting (weakness and shrinking in the muscles), and Hypertension (higher than normal pressure in the blood vessels). During a review of the facility's policy and procedure titled, Antipsychotic Medication Use dated 3/15, the policy indicated, .Antipsychotic medication may be considered for residents .Only after .Psychological, emotional psychiatric evaluations . During a review of the facility's policy and procedure titled, CONSULTANTS dated 12/2009, the policy indicated, .Our facility uses outside resources to furnish specific services provided by the facility .To furnish specific services .On a consultant basis .Written, signed, dated agreements are maintained for each consultant .Each agreement contains .The responsibility of the consultant .The responsibility of the facility .The minimum number of hours to be provided by the consultant .Consultants provide the Administrator with written, dated, signed reports .Recommendations .Plans for implementation .Findings .Plans for continued assessments .The facility retains the professional and administrative responsibility for all services provided by consultants .Consultants serve on various committees of the facility .

Based on observation, interview and record review, the facility failed to provide foot care and make necessary podiatry appointments for two of sixteen sampled residents (Resident 109 and Resident 117) diagnosed with Type 2 Diabetes Mellitus (disease with impaired response to insulin, elevated blood sugar, decreased blood circulation in the feet), who had ingrown toenails (condition in which the side of the toenail grows into the flesh), and infected (disease caused by bacteria with swelling, redness and pus) toenails, and twenty-two unsampled residents that required podiatry assessments and treatments. This failure resulted in the incision, drainage of pus, and removal of the left great toenail, pain, and infection for Resident 117, and pain, and ingrown right great toenail for Resident 109 and placed the other twenty-two (22) residents at risk for pain, ingrown nails, and infections which had the potential to affect the mobility of all residents. Findings: During a concurrent observation and interview, on 10/5/21 at 9:00 a.m., with Resident 109, Resident 109 was lying in his bed, on top of the blankets, with no shoes or socks on. Resident 109's toenails were long, sharp, with brownish yellow discoloration on both feet. Resident 109's right great toenail was grown around the end of the toe in a circle and was pressing on his skin under the toe. Resident 109's skin on his feet was dry with a large amount white peeling flakes. The Licensed Vocational Nurse (LVN) 2 was present at the door of the room and stated Resident 109 can be quiet and likes to be left alone. Resident 109 was alert, pleasant, articulate, and spoke Spanish. Resident 109 stated he had not seen a podiatrist and he trimmed his own nails. Resident 109 stated, He had lived on the streets before coming to the facility and took care of himself. During a review of Resident 109's Face Sheet dated 3/1/21, the Face Sheet indicated Resident 109 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 109 had diagnosis of Type 2 Diabetes Mellitus, Hemiparesis Following Intracerebral Hemorrhage Left Side (weakness following a stroke [bleeding in the brain]), Congestive Heart Failure (weakness in the heart where fluid accumulates in the lungs), Hepatitis C (infection caused by virus that affects the liver), Chronic Kidney Disease (impaired kidney function that worsens over time), and Difficulty Walking. During an interview on 10/5/21 at 9:11 a.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 109 and was aware his toenails were very long. LVN 1 stated nurses were responsible for cutting the nails for residents with diabetes. LVN 1 stated she had told the Social Services Director Resident 109 needed to see a Podiatrist. LVN 1 stated the SSD was responsible for getting appointments for podiatry but had not made Resident 109 an appointment for podiatrist. LVN 1 stated the long toenails could cause skin breakdown (Sores from pressure) or problems with infection if they were not taken care of. During an interview, on 10/5/21 at 9:38 a.m., with Certified Nursing Assistant 1 (CNA), CNA 1 stated Resident 109 had told her his toenails were too long. CNA 1 stated Resident 109's shoes probably rubbed the long toenails and hurt. CNA 1stated the LVN's were responsible for cutting the toenails of residents diagnosed with diabetes. CNA 1 stated the CNA's were allowed to file the residents toenails but she had not filed Resident 109's toenails because they were too long. CNA 1 stated Resident 109's long toenails could cause pain, infection, and that would be very bad for a diabetic resident. During an interview, on 10/5/21 at 9:47 a.m., with the Social Services Director (SSD), the SSD stated LVN 1 had told her about Resident 109's toenails and the need for a podiatry appointment. The SSD stated she had not made Resident 109 an appointment but should have. The SSD stated the Regional Director of Operations (RDO) was working on getting a podiatry contract for the facility but had not done it. The SSD stated she did not know when the facility would get a podiatrist. The SSD stated they would have to get an appointment for podiatry in another town. The SSD stated she could have made an appointment for Resident 109 but had not. The SSD stated she was aware Resident 109 was diabetic. The SSD stated Resident 109's toenails were long and looked like talons. The SSD stated when the toenails were that thick and tough only a podiatrist could cut them. The SSD stated Resident 109 could experience pressure sores from the nails pressing on his skin. During an interview, on 10/5/21 at 11:05 a.m. with the RDO, the RDO viewed a photograph of Resident 109's toenails. The RDO stated the facility should have made Resident 109 a podiatry appointment and not waited for the facility to get a contract. During a concurrent observation and interview, on 10/6/21 at 9:03 a.m., with Resident 117, Resident 117 was lying in his bed without socks or shoes. Resident 117's toenails were long, jagged, thick, and brownish yellow colored. Resident 117's fingernails were long and had yellow substance under the nails. Resident 117's skin on his feet had patches of thick, yellow colored, peeling skin. The tissue around the nails was dry and had peeling skin. Resident 117 pointed to his left great toenail and stated he was worried about, The bad one. The left great toenail had dark blackish coloration and was jagged and overgrown. Resident 117 stated he had not seen a podiatrist. During a review of Resident 117's Face Sheet dated 4/30/21, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 117 had diagnosis of Idiopathic peripheral Autonomic Neuropathy (decreased feeling in the arms and legs), Osteomyelitis Multiple sites (infection in the bones), Type 2 Diabetes Mellitus, Ingrown Nail, Fracture of the Cervical, Thoracic and Lumbar Region (broken bones of the back), Chronic Obstructive Pulmonary Disease (constriction of the airway with difficult breathing), and Difficulty Walking. During an interview, on 10/6/21 at 9:15 a.m., with the SSD, the SSD stated the facility had contracted a podiatrist to come to the facility on [DATE]. The SSD stated the podiatrist had been at the facility since 6:00 a.m. The SSD stated the podiatrist planned to see about 24 residents. When asked why the facility had not gotten a podiatrist before, the SSD stated, We couldn't find one to come out here. During a concurrent observation and interview, on 10/6/21 at 12:45 p.m., with the Podiatrist (DPM), the DPM stated she was informed 10/5/21 the facility needed her services. The DPM viewed a photograph of Resident 109's toenails and stated the toenails appeared not to have been trimmed in about six (6) months. The DPM stated she had treated Resident 109, and he had an active toenail fungus that caused the toenails to thicken and become discolored. The DPM stated she was very careful to not injure Resident 109 because he was diabetic. The DPM stated Resident 109 was high risk if the overgrown toenails grew into his skin and caused pressure sores. The DPM stated due to the condition of his toenails, Resident 109 should have seen a podiatrist and had his nails trimmed every two months by a podiatrist. The DPM stated she ordered A&D ointment (petroleum-based skin moisturizer) every other day to relieve the dry skin on his feet. The DPM stated she had assessed and treated 22 other residents at the facility, but Residents 109 and 117 toenails were in the worst condition. During a concurrent interview and record review, on 10/6/21 at 2:38 p.m., with the DPM, the DPM stated she had seen Resident 117. The DPM's notes for Resident 117 indicated she had removed the left great toenail. The DPM stated she had to remove Resident 117's left great toenail due to infection. The DPM stated the toenail had purulent (yellow fluid from a wound-which indicated a sign of infection) drainage under the toenail which caused redness and pain. The DPM stated the blackish color on the left great toenail was due to a previous injury where the nailbed bled and became blackened. The DPM stated she ordered antibiotics for Resident 117. The DPM stated she ordered a betadine (disinfectant for skin) treatment daily to the left great toe. The DPM stated she did not know how long Resident 117's toe was infected. The DPM stated Resident 117 should have been treated by a podiatrist every two months but was not. During a review of the DPM notes, dated 10/6/21, the notes indicated .Skin .Dry .Nails .Hypertrophic (overgrown) .Yellow .Thick .Subungual Debris (thickened discolored nails) .L [Left] Hallux (big toe) Paronychia (infection of tissue under nail) TNA (total nail avulsion (removal) Mod [moderate] Drainage & Pain .Absent right third toe nail .Comp History +Physical Exam High Complexity .Nail Debridement (removal of diseased nail bed tissue .Trimming of dystrophic (misshaped, thickened) nails .Rx (prescription) (L) Hallux Beta (betadine (antiseptic solution for injuries) x 21 days, Paronychia [with] infection ingrown .Rx Keflex (antibiotic used to treat infection) 500 mg 1 [by mouth] [twice a day] x7 days . During a concurrent interview and record review, on 10/12/21 at 4:01 p.m., with the Director of Nursing (DON), the DON was not able to find any documentation of nail care provided for Residents 109 or 117. The DON stated the LVN's were responsible for diabetic residents' foot care. The DON stated she did not monitor the nail care documentation of the LVN's. The DON stated she was responsible for supervision of the LVN's. The DON stated medical records monitored and told her when there were omissions. The DON stated she had not assessed Resident 109 or 117's feet because the LVN's had not told her there was a problem. The DON stated the LVN's had not told her about these two resident's nail care needs and they should have. During a concurrent interview and record review, on 10/12/21 at 4:10 p.m., with the Director of Staff Development (DSD), the nail care records for Residents' 109 and 117 were reviewed. The DSD stated she was not sure how to run a report for nail care documentation. The DSD stated she did not monitor when the LVN's performed nail care for diabetic residents. The DSD stated the LVN's did weekly assessment and when they had concerns, they should report it to the DON. The DSD stated the condition of Residents' 109 and 117's toenails were concerning and should have been reported. The DSD stated she had not been informed of the condition of the residents' toenails. The DSD stated she expected the LVN's would have informed the doctor so he could have looked at it. The DSD stated Residents 109 and 117 could have experienced pain, infection, loss of the nail, inflammation and drainage. The DSD stated the DON was responsible for the nursing department. The DSD stated the last documentation for nail care for Residents 109 and 117 was 5/21. The DSD stated there was no nail care documentation by the LVN's for 6/21, 7/21, 8/21, 9/21, or 10/21. During a concurrent interview and record review, on 10/13/21, at 8:11 a.m., the Interim Medical Records (IMR) reviewed the Activities of Daily Living (ADL) and the weekly nursing assessments done by the LVN's for Residents 109 and 117. The IMR stated the last nail care documented on the ADL's for Resident 109 was 5/1/21 and for Resident 117 was 5/1/21. The LVN documentation for diabetic nail care dated 6/21, 7/21, 8/21, 9/21 and 10/21 for Residents 109 and 117 indicated there was no nail care. The IMR stated LVN's should have done more frequent nail care and referred them to a podiatrist. The IMR stated the DON was responsible for monitoring the LVN's work. The IMR stated the LVN's should have told the DON about the residents' nail care and incorporated her help. During a concurrent interview and record review, on 10/13/21, at 8:37 a.m., with LVN 2, the nursing assessments 5/21-10/21 were reviewed. LVN 2 stated she had assessed Residents 109 and 117 about a month ago. LVN 2 stated she told SSD Residents 109 and 117 needed a podiatrist because she was unable to trim their toenails. LVN 2 stated the SSD told her she would follow up with a podiatrist but had not. LVN 2 stated she did not know if the facility had gotten podiatrist. LVN 2 stated long toenail could cause cuts, get caught on something or cause an infection. LVN 2 stated the long toenails would most likely have been painful. LVN 2 stated she believed the DON did assessments on the residents but didn't know how often. LVN 2 stated the condition of Resident 109 and 117's toenails should not have gotten that bad. During an interview on 10/13/21, at 11:00 a.m., with the RDO, the RDO stated the facility had opened 12/3/21. The RDO stated it was difficult to get physician contracted services due to the distance. The RDO stated the facility had contracts when they opened but the podiatrist had not come to the facility since opening. The RDO stated it was his job to get physician contracted services for the facility. The RDO stated it was his expectation the facility would have sent Residents 109 and 117 to the podiatrist for treatment. The RDO stated the residents could have been harmed in many ways, especially since they were both diabetic. The RDO stated if he had been informed of the situation with Residents' 109 and 117's toenails, he would have acted but he was blindsided. During a review of the facility's undated document titled, Licensed Practical/Vocational Nurse-SNF Job Description, the document indicated, .This job description is a record of the essential functions of the listed job .This position involves direct patient care .The Licensed Vocational Nurse provides .Medical treatment and personal care services to .Persons in a skilled nursing facility setting by performing the following duties .Be dedicated to the provision of quality care, and use sound judgement in decision making .Responsibilities to the Patient .Observes patients and reports .To medical personnel in charge .Communicates the plan of nursing care for each patient through reports .Provides a level of competency to treat patients .Involves them with care planning by meeting any needs identified during assessment .Communication .Timely follow up . During a review of the facility's policy and procedure titled, Care Area Assessments dated 5/2011, the policy indicated, .Care Area Assessments (CAAs) will be used to .Develop individualized care plans .CAAs are the link between assessment and care planning .Identify areas of concern .Review by .doing an in-depth, resident specific assessment of the triggered condition .History .Physical assessment .The IDT will employ tools and resources .Factors that should be considered in developing the care plan .Any need for further evaluation by the physician or other healthcare provider . During a review of the facility's policy and procedure titled, Care of Fingernails/Toenails dated 2010, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the residents from accidentally scratching and injuring his or her skin .Watch for and report changes .Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if the nails are too hard or too thick to cut .DOCUMENTATION .The following information should be recorded in the resident's medical record .The condition of the resident's nails .Bluish or dark color of nail beds .ingrown nails .Pain .Any difficulties in cutting the resident's nails .Interventions taken . During a review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet .While foot problems can occur in all age groups, their prevalence increases with age. It is estimated that 80% of older people have foot problems . The prevalence of serious foot problems, such as peripheral arterial disease, does increase with age .Common foot problems in older people .Toenail disorders including hardened or ingrown nails .Toe deformities such as overlapping toes .Corns and calluses .Bunions .Fungal infections .If unattended such problems can lead to more serious issues .Those who are unable to perform this essential task for themselves need regular assessment and care to help prevent adverse effects from occurring .Dryness that is associated with reduced blood flow may cause the skin to split, resulting in painful fissures, while poor circulation may lead to a higher risk of infection .Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists . Referrals should be made to podiatrists, GPs, or pharmacists (for medication review) if patients have .Medical complications that put feet at risk, such as diabetes with peripheral vascular disease, significant peripheral arterial disease .Painful foot lesions, including severe deformities and toenails that are excessively thickened and cause pain, prevent mobility or are a risk to surrounding skin .Loss of sensation .Patients with diabetes who have an increased risk must have an expert assessment carried out by health professionals with specialist experience in the management of the foot in diabetes. Registered nurses should know who to refer and should ensure a timely referral is made and response given .

Based on interview and record review, the facility failed to: 1. Ensure one of 15 sampled resident's (2) right to refuse showers was honored when facility staff assigned two to a maximum of four certified nursing assistants (CNAs) to complete her shower after she had refused and behaved aggressively during the showers. 2. Offer Resident 2 an alternate method in caring for her personal hygiene other than showers when she had a known history of aggressively refusing them, and by giving her a medication to control her behavior during showers. These failures resulted in the facility staff physically controlling Resident 2 during showers after she had refused them, and medicating her to control the resistive, combative and aggressive behaviors she displayed when she refused the showers so that the staff were able to perform the scheduled showers. Findings: During a review of Resident 2's clinical record, the Face Sheet, dated 9/7/17, indicated Resident 2 was diagnosed with [REDACTED]. The social Service Notes for Resident 2 dated 4/10/17, indicated Resident 2 was alert, recognized people, knew where she was, and was able to tell her needs to the staff. The social service notes indicated the staff monitored Resident 2 for verbal aggression and episodes of resistive combative behaviors. The physician orders [REDACTED]. During an interview with CNA 1, on 9/6/17, at 12:25 PM, she stated Resident 2 was always given a pill ([MEDICATION NAME]) before her scheduled showers to try to help her relax during the shower. CNA 1 stated Resident 2 required two staff to shower her because she gets very aggressive and combative. At 3:09 PM, CNA 1 stated sometimes the pill does not work, and if Resident 2 did not want to shower, they would get three to four CNAs to shower her. CNA 1 stated three to four CNAs would shower Resident 2 because she fought the staff by kicking, scratching, and grabbing their hair. During an interview with the Social Service Designee, on 9/6/17, at 2:40 PM, she stated the [MEDICATION NAME] was given to Resident 2 whenever they were going to attempt to shower her but most of the time the medication did not work. During a review of the clinical record for Resident 2, the nurses notes dated 6/25/17, at 1:31 PM, indicated Resident 2 was scheduled to have a shower and she was given an [MEDICATION NAME] one hour prior. The nurse's notes indicated Resident 2 had a long history of combativeness and aggressive actions against staff assisting her with showers and according to the staff, Resident 2 had refused showers for the last several weeks. On 6/25/17, the nurse's notes also indicated the resident was Assisted by 4 staff to shower for safety .Resident attempted to strike staff a few times but behavior subsisted (sic) after she began washing herself but she remains with verbally aggressive statements. During an interview with Licensed Vocational Nurse (LVN) 2, on 9/7/17, at 12:45 PM, she stated, (It) takes so much effort to get her (Resident 2) to shower. LVN 2 confirmed that in the past, the facility had not offered Resident 2 alternate methods such as a bed bath. During an interview with the Director of Nursing (DON), on 9/8/17, at 10:15 AM, the DON stated, Residents can refuse showers because it is their (residents) right. The DON stated she was unaware of a resident in the facility who was not given the right to refuse their shower. The DON stated the staff was supposed to attempt to offer the shower at another time when the resident refused. She stated the licensed staff was supposed to document the interventions, and other alternate methods they had attempted and offered to the resident for her personal hygiene. The facility policy and procedure titled Refusal of Treatment dated 5/1/17, indicated the facility Shall honor a resident's request not to receive medical treatment as prescribed by his/her physician as well as care routines outlined on the resident's assessment and plan of care.

Based on interview and record review, the facility failed to: 1. Ensure one of 15 sampled resident's (2) right to refuse showers were honored when facility staff assigned two to a maximum of four certified nursing assistants (CNAs) to complete her shower, after she had refused and behaved aggressively during the showers. 2. Offer Resident 2 an alternate method in caring for her personal hygiene other than showers when she had a known history of aggressively refusing them, and by giving her a medication to control her behavior during showers. These failures resulted in the facility staff physically controlling Resident 2 during showers after she had refused them, and medicating her to control the resistive, combative and aggressive behaviors she displayed when she refused the showers so that the staff were able to perform the scheduled showers. Findings: During a review of Resident 2's clinical record, the Face Sheet, dated 9/7/17, indicated Resident 2 was diagnosed with [REDACTED]. The social Service Notes for Resident 2 dated 4/10/17, indicated Resident 2 was alert, recognized people, knew where she was, and was able to tell her needs to the staff. The social service notes indicated the staff monitored Resident 2 for verbal aggression and episodes of resistive combative behaviors. The physician orders [REDACTED]. During an interview with CNA 1, on 9/6/17, at 12:25 PM, she stated Resident 2 was always given a pill ([MEDICATION NAME]) before her scheduled showers to try to help her relax during the shower. CNA 1 stated Resident 2 required two staff to shower her because she gets very aggressive and combative. At 3:09 PM, CNA 1 stated sometimes the pill does not work, and if Resident 2 did not want to shower, they would get three to four CNAs to shower her. CNA 1 stated three to four CNAs would shower Resident 2 because she fought the staff by kicking, scratching, and grabbing their hair. During an interview with the Social Service Designee, on 9/6/17, at 2:40 PM, she stated the [MEDICATION NAME] was given to Resident 2 whenever they were going to attempt to shower her but most of the time the medication did not work. During a review of the clinical record for Resident 2, the nurses notes dated 6/25/17, at 1:31 PM, indicated Resident 2 was scheduled to have a shower and she was given an [MEDICATION NAME] one hour prior. The nurse's notes indicated Resident 2 had a long history of combativeness and aggressive actions against staff assisting her with showers and according to the staff, Resident 2 had refused showers for the last several weeks. On 6/25/17, the nurse's notes also indicated the resident was Assisted by 4 staff to shower for safety .Resident attempted to strike staff a few times but behavior subsisted (sic) after she began washing herself but she remains with verbally aggressive statements. During an interview with Licensed Vocational Nurse (LVN) 2, on 9/7/17, at 12:45 PM, she stated, (It) takes so much effort to get her (Resident 2) to shower. LVN 2 confirmed that in the past, the facility had not offered Resident 2 alternate methods such as a bed bath. During an interview with the Director of Nursing (DON), on 9/8/17, at 10:15 AM, the DON stated, Residents can refuse showers because it is their (residents) right. The DON stated she was unaware of a resident in the facility who was not given the right to refuse their shower. The DON stated the staff was supposed to attempt to offer the shower at another time when the resident refused. She stated the licensed staff was supposed to document the interventions, and other alternate methods they had attempted and offered to the resident for her personal hygiene. The facility policy and procedure titled Refusal of Treatment dated 5/1/17, indicated the facility Shall honor a resident's request not to receive medical treatment as prescribed by his/her physician as well as care routines outlined on the resident's assessment and plan of care.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of 15 sampled resident's (2) reports of pain were addressed when her pain medication was not given as ordered, which resulted in Resident 2's pain not being managed; and, 2. Maintain one random resident's (19) optimal well-being by providing physician prescribed continuous oxygen, which resulted in the resident experiencing anxiety and shortness of breath. Findings: 1. During a concurrent observation in the smoking area and interview with Certified Nursing Assistant (CNA) 1, on 9/7/17, at 12:38 PM, Resident 2 was observed telling CNA 1 she was having pain to her fingers on her right hand. CNA 1 brought Resident 2 inside the building and stated Resident 2 had a history of [REDACTED]. CNA 1 stated, It is a lot of pain, and when Resident 2 complained of pain, she would start getting aggressive with staff. During a concurrent observation of Resident 2 in the hallway across from the nurses' station and interview with Licensed Vocational Nurse (LVN) 2, on 9/7/17, at 12:45 PM, Resident 2 was observed jerking abruptly, grabbing her right shoulder and leaning forward in her wheelchair. LVN 2 stated Resident 2 was able to tell the staff whenever she was in pain. LVN 2 stated in the past, even after her pain medication was given, Resident 2 continued to complain of pain to her head, back, hands, legs and everywhere. LVN 2 reviewed Resident 2's Medication Administration Record [REDACTED]. LVN 2 stated Resident 2 received her pain pill yesterday and that it Was a good day. During an interview with CNA 2 on, 9/7/17, at 1:01 PM, she stated Resident 2 complained of pain to her head, right shoulder and hand All the time. During a review of the clinical record for Resident 2, the right shoulder three view x-ray, dated 1/6/17, at 3:52 PM, indicated a high-riding humeral head (shoulder bone) consistent with (a) rotator cuff tear (A high-riding shoulder refers to the superior displacement/subluxation (partial or incomplete dislocation) of the humeral head). A review of the Nurses Notes dated 1/8/17, at 8:34 PM, (approximately 2 days after the x-ray result) indicated the physician ordered for the resident to consult with an orthopedic physician (a specialist trained in dealing with disorders of the musculoskeletal system) due to the right shoulder pain. During an interview with the Social Service Designee (SSD), on 9/7/17, at 4:35 PM, she reviewed Resident 2's clinical record and was unable to find documentation of the orthopedic consultation. During a concurrent interview with LVN 2 and LVN 4, on 9/7/17, at 5 PM, both stated when residents leave for a consultation visit, the licensed nurses were responsible to follow-up with the results of the consultation. Both LVN 2 and LVN 4 stated they were not aware Resident 2 had an orthopedic consultation due to her right shoulder pain and there was no communication among the licensed nurses of the need to follow-up on the report. During a review of the clinical record for Resident 2, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON), on 9/8/17, at 10:15 AM, she stated the pain scale was used to evaluate the resident's pain level, and when a resident complained of pain, I would expect them (nurses) to give (the pain) medication. The DON stated if the pain medication was not effective, the licensed nurses were supposed to call the physician for further instructions. The facility policy and procedure titled Pain Management revised 8/1/16, indicated It is the policy of this facility to ensure that all attempts are made to keep residents as pain free as possible. Attempts to control pain will be employed until the resident reaches an acceptable comfort level. 2. During an observation on 9/6/17, at 9:30 AM, in unit 2 hallway, Resident 19 was observed leaving the dining room toward the hallway yelling out for her nurse. Resident 19 was short of breath, anxious, and shouted, I need air. I told them (staff). Staff were informed and immediately brought Resident 19 her oxygen concentrator (a machine that supplies oxygen to residents). During an observation and concurrent interview with CNA 8, on 9/6/17, at 9:35 AM, in unit two hallway, CNA 8 was observed rushing an oxygen concentrator to Resident 19 and providing her with oxygen. CNA 8 stated she had just found out Resident 19 needed continuous oxygen from the nurses, after Resident 19 was heard shouting for air. During an interview and concurrent clinical record review of Resident 19's chart, with LVN 2, on 9/6/17, at 9:38 AM, she stated Resident 19 was to be on oxygen only when in her room, and if her oxygen saturation (measurement of the concentration of oxygen a person has normal is 96 percent to 100 percent) goes below 95 percent. The physician orders [REDACTED]. The physician orders [REDACTED]. LVN 2 stated She (Resident 19) always goes to the dining room without it (oxygen). LVN 2 reviewed the clinical record and confirmed Resident 19 was to be on oxygen continuously at all times. During a review of the clinical record for Resident 19, the oxygen Care Plan dated 6/1/17, indicated Resident 19 is to be on oxygen, as ordered .continuously. Monitor compliance . The facility policy and procedure titled OXYGEN ADMIN. & SAFETY dated 1/1/10, indicated It is the policy of Coalinga Regional Medical Center to assure the Resident receives the safest and most effective treatment of [REDACTED]. To restore and maintain the resident to optimal well being . To prevent exacerbation (make worse) if possible, of disease process.