Every finding on record at Country Crest Post-Acute

Based on observation, interview, and record review, the facility failed to maintain food safety requirements regarding the preservation of a sanitary kitchen environment in addition to appropriate storage and labeling of foods when the main kitchen was observed to have a build up of grime and webbing on pipes under counters, mineral and corrosive (something that causes gradual harm due to a chemical reaction) buildup on pipes and draining apparatuses, dirt buildup on flooring and air gap drains, grease and grime on the hood over the stove, breadcrumb buildup in the toaster, dirt buildup on the filters and plastic of a portable cooler unit, a large unlabeled brisket thawing in the refrigeration unit, expired Yoplait yogurt in the refrigeration unit, a container of red gelatin dessert unlabeled in the refrigeration unit, and an inadequately covered cardboard box of sliced mushrooms in the refrigeration unit.This failure had the potential to result in disease transmission, increasing health complications and overall wellbeing issues to those residents' receiving their nutritional intake from the facility kitchen.During a review of the facility's policy and procedure titled, Sanitization, dated Revised October 2008, the policy indicated, The food service area shall be maintained in a clean and sanitary manner.During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated Revised October 2017, the policy indicated, Food Services, or other designated staff, will maintain clean food storage areas at all times .Dry foods that are stored in bins will be .labeled and dated (use by date) .All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).During an observation on 1/12/26 at 11:00 am, in the main kitchen, the following was observed: The hood above the stove had an accumulative buildup of grease and grime.The pipes and drain hoses under the counter by the dishwasher had an accumulative buildup of grime and webbing, and the pipes and drain hoses under the preparation counter across from the dry storage had an accumulative buildup of grime and webbing.The pipes to the air gap in the floor under the counter by the dishwasher appeared to be encrusted in corrosive material and the flooring under the counter had an accumulative buildup of dirt.The drainpipe used for condensation (collection of water droplets) removal out of the refrigerator exhibited the presence of corrosive material on the pipe and the wall it was attached to, and the air gap drain on the floor where the pipe terminated appeared dirty and grimy.The pipes on the outside of the dishwasher appeared to have mineral and corrosive material buildup.The face of the dishwasher appeared to have mineral buildup along the crevices.The toaster had a buildup of breadcrumbs on top and within the appliance.The Scale Inhibitor apparatus (descaler, system that prevents mineral buildup in water lines and appliances) on the wall attached to the steamer exhibited a buildup of minerals.The portable cooler unit had an accumulative buildup of dirt on the filters through the vent openings and on the plastic throughout the unit.The 18 quart dry rice container was not labeled nor dated.An unopen 32 ounce container of Yoplait yogurt with an expiration date 20 [DATE], remained on the shelf in the refrigerator for usage. A cardboard box occupied by sliced mushrooms was inadequately covered exposing the sliced mushrooms.A large brisket (cut of beef) in the refrigerator was not labeled nor dated.A container of red gelatin dessert which had been partially served was not labeled nor dated.During a concurrent observation and interview with Food Service Director (FSD) on 1/12/26 at 1:30 pm, in the main kitchen, all visual aspects of the kitchen was observed, FSD confirmed that the kitchen was not clean to acceptable standards, including the pipes and hoses throughout, the flooring and air gap drains, the portable cooling unit, the hood to the stove, the descaler for the steamer, and the toaster. Additionally the brisket, red gelatin dessert, and dry rice were not labeled nor dated, and the Yoplait yogurt was expired.During a concurrent observation and interview with Facility Dishwasher (FD) on 1/12/26 at 1:45 pm, in the main kitchen, the stove hood was observed to have a buildup of grease and grime. FD stated the hood to the stove is typically cleaned weekly but FD has not been able to clean it since December 2025 because there is too much work to do.During a concurrent observation and interview with Morning [NAME] (MC) on 1/12/26 at 2:00 pm, in the main kitchen, the stove hood was observed to have a buildup of grease and grime. MC stated it is usually cleaned weekly by FD but depending on what is going on it doesn't always get done.During a concurrent observation and interview with Certified Dietary Manager (CDM) on 1/13/26 at 08:30 am, in the main kitchen, all visual aspects of the kitchen was observed, CDM confirmed that the kitchen was not clean to acceptable standards, including the pipes and hoses throughout, the flooring and air gap drains, the portable cooling unit, the hood to the stove, the descaler for the steamer, and the toaster. Additionally, the brisket, red gelatin dessert, and dry rice were not labeled nor dated, and the Yoplait yogurt was expired.

Based on observation, interview, and record review the facility failed to maintain a clean homelike environment when two of three shower rooms were found to be less than adequately maintained when the laminate on counter tops was chipped, paint was chipped and not adhered to the walls above and around the shower stalls, flooring was in disrepair in front of the shower stalls, by the door, as well as within the shower stalls.This failure had the potential to result in disease transmission, with increasing health complications and overall wellbeing issues to those residents utilizing the common space.During a review of the facility's policy and procedure titled, Quality of Life - Homelike Environment, dated Revised May 2017, the policy indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment.During an observation on 1/12/26 at 4:00 pm, the resident shower rooms were observed for adherence to safety and overall cleanliness and sanitation. Shower room one was found to have chipped laminate along the counter tops, paint chipped and not adhering to the walls around the shower stall, and flooring in disrepair in front of the shower stallShower room two was found with water damage on the wall at floor level outside the shower room in between the shower room and supply storage, paint chipped and not adhering to the walls around the shower stall, and flooring in disrepair in front of the shower stall, by the door, and within the shower stall.During a concurrent observation and interview on 1/13/26 at 08:00 am, with Director of Nursing (DON), in shower room one and two, DON confirmed the shower rooms were in disrepair and did not represent a safe and aesthetic homelike environment for residents.

Based on observation, interview, and record review the facility failed to ensure that it remained free from (potential) accidents and hazards when two of three shower rooms were observed to have a hole in the floor of one shower room, and an open box on the wall appearing to be a temperature control apparatus with exposed wires and sharp edges in the second shower room.This failure had the potential to result in physical injury leading to psychological trauma and health decline for residents utilizing the common space.During a review of the facility's policy and procedure titled, Hazardous Areas, Devices and Equipment, dated Revised July 2017, the policy indicated, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards.A hazard is defined as anything in the environment that has the potential to cause injury.During an observation on 1/12/26 at 4:00 pm, the resident shower rooms were observed for adherence to safety requirements. Shower room one was observed with an open, uncovered hole in the floor across from the shower stall large enough for a pipe fitting.Shower room two was observed with what appeared to be a temperature control apparatus on the wall with the lid off exposing small wires and sharp edges.During a concurrent observation and interview on 1/13/26 at 08:00 am, with Director of Nursing (DON), in shower rooms one and two, DON confirmed the shower rooms were in disrepair and concurred the hole in the floor and open temperature apparatus could result in safety issues posing potential risk of injury to residents.

Based on interview and record review, the facility failed to provide physical therapy (PT) services as indicated on the evaluation for five out of five sampled residents (Resident 1, 9, 13, 34, and 41) when:Residents 1, 34, and 41 were not provided with PT five times a week.Residents 9 and 13 were not provided with PT three times a week.This had the potential to result in a decline in physical function and physical ability and prevented Resident 1, 9, 13, 34, and 41 from reaching their full potential and causing health complications and emotional dysfunction. A review of Resident 1's clinical record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included, muscle weakness, unsteady on feet, dementia (loss of memory), and anxiety (fear of unknown).During an interview on 1/12/26 at 11:00 a.m., with Resident 1, Resident 1 stated he did not think he was getting PT, as much as he is supposed to, last two weeks of December.A review of Resident 34's clinical record indicated, Resident 34 was admitted to the facility on [DATE], with diagnosis that included, Muscle weakness, unsteady on feet, and arthritis.During an interview on 1/12/26 at 11:45 a.m., with Resident 34, Resident 34 stated she did not get PT five times a week for the month of December and beginning of January.A review of Resident 41's clinical record indicated, Resident 41 was admitted to the facility on [DATE], with diagnosis that included, Fracture to lower back, muscle weakness, unsteady on feet, and lack of coordination.During an interview on 1/12/26 at 3:17 p.m., with Resident 41, Resident 41 stated that he only got PT three times the week of 12/21/25 and only two times the week of 12/28/25.During a concurrent interview and record review, on 1/14/26 at 3:00 p.m., with the Director of Rehabilitation (DR), Resident 1, 34, and 41's Physical therapy and Evaluation Plan of treatment (PT eval & TX,) was reviewed, the PT eval & TX indicated, Resident 1, 34, and 41 were to get PT five times a week. DR confirmed resident 1, 34, and 41 did not get PT five times a week for the week of 12/21/25 through 12/27/25 and for the week of 12/28/25 through 1/3/26.A review of Resident 9's clinical record indicated, Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included, muscle weakness, unsteady on feet, and dementia (loss of memory).During an interview on 1/12/26 at 12:30 p.m., with Resident 9, Resident 9 stated He never received PT for the week of 12/21/25 and the week of 12/28/25. Resident 9 said no one even showed up.A review of Resident13's clinical record indicated, Resident 13 was admitted to the facility on [DATE], with diagnosis that included, paralysis to right side of body, unsteady gait and walking, and high blood pressure.During an interview on 1/12/26 at 2:00 p.m., with Resident 13, Resident 13 stated she only got PT once for the week of 12/21/25 and none at all for the week of 12/28/25.During a concurrent interview and record review, on 1/14/26 at 3:00 p.m., with the Director of Rehabilitation (DR), Resident 9 and 13's PT eval & TX was reviewed, the PT eval & TX indicated, Resident 9 and 13 were to get PT three times a week. DR confirmed resident 9 and 13 did not get PT three times a week for the week of 12/21/25 through 12/27/25 and for the week of 12/28/25 through 1/3/26.During a concurrent interview and record review on 1/15/26 at 2:00 p.m., with the DR, the facility's policy and procedure (P&P) titled, Rehabilitation Services, dated January 2017 was reviewed. The P&P indicated, Purpose: To promote quality of care for all residents. To hold Rehabilitation Services staff accountable to the facility mission, objectives, and goals. Mission: Rehabilitation Services provides the highest quality standard of PT. Goals: To provide professional rehabilitation services when prescribed by physicians. To treat residents. The DR Confirmed the P&P was not followed due to a PTA quit the last week of December.

Based on interview and record review, the facility failed to implement an individualized patient-centered care plan for two of 15 sampled residents (Resident 9 and 41) when:Certified Nurse Assistant (CNA 3) transferred Resident 9 to bed without assistance and Resident 9 fell to the floor.CNA 3 ambulated Resident 41 without assistance and Resident 41 fell to the floor causing a skin tear.These failures resulted in Resident 9 and Resident 41 to fall had had the potential to cause broken bones. 1.A review of Resident 9's clinical record indicated, Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included, muscle weakness, unsteady on feet, and dementia (loss of memory).During an interview on 01/12/26 at 12:30 p.m., with Resident 9, Resident 9 said that last month CNA 3 was helping him get into his wheelchair by herself and he lost his balance and slipped to the floor. Resident 9 told CNA 3 that she needed another person to help but she ignored him. During a review of Resident 9's Progress Notes (PG), dated 12/31/25 at 4:07 p.m., the PG indicated, Resident 9 was being transferred from bed to wheelchair by CNA 3. CNA 3 tried to do a stand and pivot transfer, but Resident 9 was too weak to bear weight and Resident 9 was lowered to the floor.During a concurrent interview and record review, on 01/13/26 at 10:30 a.m., with the Director of Nursing (DON), Resident 9's Care Plan dated 12/26/25 was reviewed, the Care Plan indicated that Resident 9's Mobility Deficit as evidenced by: Requiring assistance or is dependent in: Mobility- Chair/Bed-to-Chair Transfer. Interventions: use of two persons during transfers. DON confirmed CNA 3 was supposed to get help when transferring Resident 9.During a concurrent interview and record review, on 1/14/26 at 11:00 a.m., with the Director of Rehabilitation (DR), Resident 9's Physical therapy and Evaluation Plan of treatment (PT eval & TX,) was reviewed, the PT eval & TX indicated, Resident 9 was a maximum assist with transfers. DR confirmed maximum assistance means there should always be two CNA's when transferring Resident 9.2. A review of Resident 41's clinical record indicated, Resident 41 was admitted to the facility on [DATE], with diagnosis that included, Fracture to lower back, muscle weakness, unsteady on feet, and lack of coordination.During an interview on 1/12/26 at 3:17 p.m., Resident 41 stated that last month CNA 3 was helping him walk to the bathroom by herself and he lost his balance and fell. When he fell CNA 3 grabbed his right arm and tore his skin.During an interview on 1/12/26 at 4:00 p.m., with confidential witness (CW), CW stated, I witnessed CNA 3 walking Resident 41 to the bathroom by herself, Resident 41 lost his balance and fell to the floor. When Resident 41 fell CNA 3 grabbed his right arm and caused a skin tear.During a review of Resident 41's PG dated 12/29/25 at 3:09 p.m., the PG indicated, Resident 41 was turning to put the front wheel walker aside and lost his balance. CNA 3 reached to help Resident 41 lower to the floor and caused a skin tear to Resident 41's right arm.During a concurrent interview and record review, on 01/13/26 at 10:30 a.m., with the Director of Nursing (DON), Resident 41's Care Plan dated 12/26/25 was reviewed, the Care Plan indicated that Resident 41's Mobility Deficit as evidenced by: Requiring assistance or is dependent in: Transfer- Walking- Wheelchair. Interventions: use of two persons during transfers. DON confirmed CNA 3 was supposed to get help when transferring or walking Resident 41.During a concurrent interview and record review, on 1/14/26 at 11:00 a.m., with DR, Resident 41's PT eval & TX, was reviewed, the PT eval & TX indicated, Resident 41 was a maximum assist with transfers and walking. DR confirmed maximum assistance means there should always be two CNA's when transferring Resident 41.During an interview on 1/12/26 at 4:30 p.m., with CNA 1, CNA 1 stated Resident 9 and Resident 41 are both two-person assistance when transferring or walking them.During an interview on 1/14/26 at 4:30 p.m., with CNA 2, CNA 2 stated Resident 9 and Resident 41 are both two-person assistance when transferring or walking them.During a concurrent interview and record review on 1/15/26 at 2:00 p.m., with the DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016 was reviewed. The P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. and will be consistent with the resident's rights to participate in the development and implementation of his or her care plan. The DON Confirmed the facility staff should have followed the P&P but didn't.

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed when nursing staff failed to wear appropriate personal protective equipment (PPE) while handling hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately).This failure had the potential to result in unwanted exposure to hazardous medications leading to health complications. Findings:During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/24, the P&P indicated, Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.A review of the Occupational Safety and Health Administration (OSHA) 's current recommendations for addressing the health and safety hazards faced by healthcare workers titled, Controlled Occupational Exposure to Hazardous Drugs, indicated, IV. Work Areas. B. Administration of Drugs to Patients: Administration of hazardous drugs (HDs) to patients is generally performed by nurses or physicians. The potential for occupational exposure exists for every route of drug administration. Drug Administration: HDs are administered through many different routes, in several types of settings, and for numerous disease states, Safe handling is required for all HDs no matter how they are used. (https://www.osha.gov/hazardous-drugs/controlling-occex; accessed 1/22/26)During a medication pass observation on 1/13/25 at approximately 8:30 am with Licensed Nurse 4 (LN 4), LN 4 was observed preparing three medications for Resident 23, including phenytoin (a medication to treat seizures) 100 milligrams (mg, a unit of measurement), 2 capsules. The pharmacy label affixed to the bubble pack indicated the medication was hazardous. LN 4 prepared the medications without wearing gloves or any other personal protective equipment.During an interview on 1/13/25 at 9:05 am with LN4, LN 4 stated the expectation is to use gloves when handling phenytoin and confirmed they did not wear any during the medication preparation or administration.During an interview on 1/13/25 at 2:43 pm with Director of Nursing (DON), DON stated that proper precautions, including the use of gloves, were expected during medication administration. DON stated nursing staff were expected to follow precautionary instructions listed on the pharmacy label.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for one out of four residents (Resident 16) did not reconcile. Two controlled medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not accurately documented on the Medication Administration Record (MAR) to indicate they were administered to the resident.This failure resulted in the facility being unable to ensure accurate accountability of controlled medications and had the potential for diversion or misuse, unavailability of emergency medications when needed, and failure to meet the resident's therapeutic needs, placing the resident at risk for worsening of their medical conditions.Findings:A review of Resident 16's medical record indicated Resident 16 was admitted on [DATE] with diagnoses that included anxiety, high blood pressure, and fracture of thoracic vertebra (a break in the bones of the middle back.)Resident 16 had a physician's order dated 7/1/24, for tramadol (a medication to treat pain) 50 milligrams (mg, a unit of measure), 1 tablet by mouth every 6 hours as needed for moderate to severe pain. The CDR indicated 1 tablet was signed out on 8/11/25 at 5 pm, 12/20/25 at 8:15 am, 12/24/25 at 7:30 am, and 12/31/25 at 7:30 am. The MAR did not indicate tramadol was administered to Resident 16 for these dates and times.Resident 16 had a physician's order dated 9/23/25, for Ativan (a medication to treat anxiety) 0.5 mg, 1 tablet by mouth every 12 hours as needed for anxiety. The CDR indicated 1 tablet was signed out on 10/1/25 at 5 am. The MAR did not indicate Ativan was administered to Resident 16 on this date.During a concurrent interview and record review on 1/13/26 at 2:43 pm with Director of Nursing (DON), DON confirmed the CDRs and MARs for Resident 16's tramadol and Ativan were not accurate. The DON stated that when a controlled medication is administered, it is signed out of CDR and the MAR, and the dates and times must reconcile between the two records.During a review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 01/24, indicated, the individual who administers the medication dose, records the administration of the residents MAR immediately following the medication being given. In no case should the individual who administered the medication report off duty without first recording the administration of any medications.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 9 and Resident 29) were free of significant medication errors when both residents received latanoprost eye drops (a medication to treat glaucoma and ocular hypertension) multiple times (doses) past the expiration date.This failure had the potential for ineffective use of the latanoprost eye drops, placing the residents at risk for worsening of their medical conditions.Findings: During a concurrent record review and inspection of Medication Cart 1 on 1/12/26 at 1:25 pm alongside Licensed Nurse 3 (LN 3), two bottles of latanoprost eye drops opened 11/14/25 for Resident 9 and 29, were identified. LN3 reviewed the manufacturer's labeling on the bottle which indicated, Opened bottle may be stored at room temperature for 6 weeks. LN 3 confirmed both eye drops had expired on 12/26/25. She stated nursing staff had continued to administer the eye drops to Resident 9 and 29 beyond their expiration date, and confirmed that medication can be less effective when used beyond the expiration date.A review of Resident 9's medical record indicated a physician's order for latanoprost ophthalmic solution 0.005%, instill 1 drop in both eyes at bedtime for glaucoma, dated 11/20/25.A review of Resident 9's December 2025 and January 2026 Medication Administration Record (MAR) indicated latanoprost was administered to Resident 9 sixteen times past the expiration date.A review of Resident 29's medical record indicated a physician's order for latanoprost ophthalmic solution 0.005%, instill 1 drop in both eyes at bedtime for glaucoma, dated 11/25/25.A review of Resident 29's December 2025 and January 2026 MAR indicated latanoprost was administered to Resident 29 sixteen times past the expiration date.During an interview on 1/13/26 at 2:43 pm with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration date of a medication prior to administration. He stated that if there was an earlier expiration date after first use, that was to be added to the medication label. The DON stated this was to ensure the effectiveness of the medication.During a review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 1/24, the policy indicated that nursing staff are required to place a date opened label on applicable medications and document the date opened. The policy further indicated that certain medications, including multidose vials and ophthalmic drops, have shortened beyond use dates once opened to ensure medication purity and potency, and the manufacturer recommendations for beyond use dating are to be followed.A review of the manufacturer's labeling for latanoprost, revised 8/2011, the labeling indicated, . Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks.According to an article dated 10/31/25 by the United States Food and Drug Administration, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. (https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines; accessed 1/22/26)

Based on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date, and expired medications were not available for resident use.This failure had the potential for residents to receive medications or biologicals with unsafe and reduced potency from being used past their discard date, and incorrect medications from inadequate labeling.Findings:During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/24, the P&P indicated, medication expiration dates must be checked, expired medication will not be administered to a resident, the nurse is to place a date opened label on applicable medications and document the date, and the manufacturer recommendations for beyond use dating are to be followed.During a review of the facility's P&P titled, Medication Storage - Storage of Medication, dated 1/24, the P&P indicated, Insulin vials and pens are to be labeled with the date when initially opened. Outdated medications are to be immediately removed from inventory, disposed of, and documented with the pharmacy when a current order exists.During a review of the facility's P&P titled, Medication Brought to the Facility by the Resident/Family, undated, the P&P indicated, when a medication brought from outside the facility is determined to be necessary for the resident, the DON and nursing staff, with support from the physician and pharmacist, are responsible for ensuring the medication is properly labeled in accordance with the facility policy and the contents have been verified by a licensed pharmacist.During an inspection of medication cart 3 on 1/12/26 at 12:50 pm alongside Licensed Nurse 5 (LN 5), one Trelegy (an inhaler used for the treatment of asthma) 100 micrograms (mcg, a unit of measurement) /62.5 mcg/25 mcg inhaler, and one Anoro (an inhaler used for the treatment of chronic obstructive pulmonary disease) 62.5 mcg/25 mcg inhaler both opened and unlabeled with an opened date were identified. Also, one Lantus Solostar (an insulin to treat diabetes) 100 units/milliliter (u/ml) insulin pen opened and unlabeled with an open date was identified. LN 5 confirmed the medications were available for use but lacked labels indicating the date opened. LN 5 confirmed the medications expire after a specified period once opened, which would be reflected by an open-date label, and stated they believed the insulin pen is stable for only 28 days at room temperature. During an inspection of Medication Cart 1 on 1/12/26 at 1:25 pm alongside Licensed Nurse 3 (LN 3), two bottles latanoprost (used to lower high fluid pressure within the eye) 0.005% eye drops, opened on 11/14/25 were identified. LN 3 reviewed the manufacturer's labeling on the package which indicated, Opened bottle may be stored at room temperature for 6 weeks. LN 3 confirmed both medications expired on 12/26/25. Also identified was one albuterol inhaler expired 1/2025. LN 3 confirmed the finding and stated it should not have been available in the medication cart for administration. During an interview on 1/13/26 at 2:43 pm with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration date of a medication prior to administration. He stated if there was a date that a medication should be disposed of before the expiration date, it should have been added to the medication label. DON stated the identified albuterol inhaler that expired 1/2025 may have been a medication the resident brought from home. The DON stated home medication was not permitted in the medication cart unless approved by the physician and labeled by the pharmacy. He stated an unlabeled medication brought from home was not permitted in the medication cart.

Based on interviews, and record review, the facility failed to provide needed care and service for one of three sampled residents (Resident 1), when:1. A change in condition was not recorded and reported to the Medical Director (MD) when Resident 1 experienced a decrease in the frequency of her daily brief (type of adult disposable underwear) changes, which was a significant indicator of decreased urine output. 2. A laboratory blood test (labs - the process of analyzing a blood sample to measure specific substances) order placed by the MD on [DATE], was not fulfilled, resulting in Resident 1's lab not being drawn as instructed.These failures led to Resident 1 not receiving appropriate medical assessments and treatment, ultimately resulting in her death on [DATE].Findings:During a review of the facility policy titled Change in a Resident's Condition or Status, revised 11/2015, the policy indicated that: The facility will promptly notify the resident, their attending physician, and their representative of any changes in the resident's medical or mental condition and/or status. The Charge Nurse (CN) will notify the resident's attending or on-call physician of significant changes in the resident's physical, emotional, or mental condition, or if there is a need to transfer the resident to a hospital or treatment center. A Significant Change is defined as a decline or improvement in the resident's status that will not resolve without staff intervention or standard clinical interventions and impacts more than one area of the resident's health. Before notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information, including using the SBAR communication tool (Situation, Background, Assessment, and Recommendation. It provides a structured, concise, and standardized way for healthcare professionals to communicate important patient information.) The CN will document changes in the resident's medical or mental condition in the resident's medical record. If a significant change occurs, a comprehensive assessment of the resident's condition will be conducted, and any changes will be reported to the Director of Nursing Services to ensure the resident's medical record is updated accordingly.During a review of Resident 1's admission record, the admission record indicated that Resident 1 was admitted on [DATE] with diagnoses that included type 2 diabetes (high blood sugar), unspecified dementia (a progressive state of decline in mental abilities), hypertensive chronic kidney disease (a condition where high blood pressure damages the kidneys, causing them to lose function over time), need for assistance with personal care. Resident 1 was not her healthcare decision maker. 1. During a review of Resident 1's record titled Bladder Elimination, dated [DATE] - [DATE], the record indicated Resident 1 had: Four brief changes on [DATE], One brief change on [DATE], Three brief changes on [DATE], Four brief changes on [DATE], Two brief changes on [DATE], Two brief changes on [DATE], Two brief changes on [DATE], Three brief changes on [DATE], Two brief changes on [DATE], One brief change on [DATE].During an interview with Certified Nursing Assistant (CNA) D on [DATE] at 9:40 am, CNA D stated Resident 1 was a heavy wetter and had a lot of brief changes. During an interview with CNA E on [DATE] at 9:50 am, CNA E stated [Resident 1] usually received 15-20 brief changes every 24 hours. CNA E confirmed Resident 1 was a Heavy wetter. CNA E stated that facility staff were generally aware that Resident 1 was Very incontinent. CNA E stated, It would be strange for [Resident 1] to receive only 2-4 brief changes in a 24-hour period. During an interview with CNA F on [DATE] at 10:03 am, CNA F confirmed she worked the Night shift for [DATE], [DATE], and [DATE]. CNA F confirmed Resident 1 was a Heavy wetter and 15-20 brief changes in a 24-hour period was Normal for her. During an interview with CNA G on [DATE] at 11:06 am, CNA G confirmed 2-4 brief changes in a 24-hour period for Resident 1 was Not enough. Because [Resident 1] was always incontinent.During an interview with Licensed Nurse (LN) H on [DATE] at 11:14 am, LN H stated [Resident 1] needed multiple brief changes a day, and 2-4 brief changes a day was not like her elimination baseline. During an interview with Director of Nursing (DON) on [DATE] at 12:19 pm, DON stated he was not aware there was a decrease in the number of brief changes for Resident 1. DON confirmed this was considered a change in condition and both MD and DON should have been notified of this, especially since Resident 1 had a history of Urinary tract infection (UTI - an infection in any part of the urinary system). 2. During a review of Resident 1's clinical record titled Blood Sugar Summary, dated [DATE] - [DATE], indicated Resident 1's average blood sugar levels were between 250 - 300 milligrams per deciliter (mg/dL, a unit of measurement) and Resident 1's Blood Sugar level elevated to above 320 to 430 mg/dL from [DATE] to [DATE]. (blood sugar level above 400 was very dangerous and could lead to a life-threatening condition) [DATE] 7:49 am - Blood Sugar level of 268 mg/dL[DATE] 7:40 am - Blood Sugar level of 265 mg/dL[DATE] 7:53 am - Blood Sugar level of 238 mg/dL[DATE] 8:23 am - Blood Sugar level of 274 mg/dL[DATE] 7:47 am - Blood Sugar level of 345 mg/dL[DATE] 6:44 am - Blood Sugar level of 320 mg/dL[DATE] 7:39 am - Blood Sugar level of 356 mg/dL[DATE] 7:35 am - Blood Sugar level of 434 mg/dL[DATE] 7:54 am - Blood Sugar level of 408 mg/dLDuring a review of Resident 1's clinical record titled SBAR, dated [DATE] at 12:44 pm, indicated LN H notified MD, Nurse called MD for Resident 1 having high fasting blood glucose (FBG - the level of glucose (sugar) in the blood after fasting for at least 8 hours) before breakfast 434 mg/dL and before lunch 353 mg/dL. New order received for Complete Blood Count (CBC- a common blood test that measures various components of the blood to assess overall health and detect potential medical conditions)/ Comprehensive Metabolic Panel (CMP- a routine blood test that provides an overview of the body's chemical balance and metabolism)/ Hemoglobin A1C (Hb A1C - a blood test that measures the average blood sugar levels over the past two to three months) one time only for one day. MD recommendation was to Monitor and new order for labs.During a review of Resident 1's physician orders, dated [DATE] at 12:30 pm, indicated CBC/CMP/HbA1C one time only for one day During a review of Resident 1's clinical record titled Laboratory Result, dated [DATE] at 12:54 pm, indicated LN A documented Notified by lab that Resident 1 refused ordered labs today. MD notified and gave order to try again tomorrow. Lab slip placed in lab book per policy. Lab will attempt again tomorrow morning.During a review of the facility's lab requisition binder, a local phlebotomist (a healthcare professional who specializes in drawing blood from residents) documented no labs on the lab draw log on [DATE], the date Resident 1's lab draw was ordered to be done. During a review of Resident 1's progress notes, dated [DATE] at 7:09 am, by LN H, indicated LN H received a report from night shift staff that [Resident 1] was calling out all night. [Resident 1] had FBG 258 mg/dL and pulse 40 (normal range 60-100 beats per minute) thready (a weak pulse), and SPO2 (Oxygen levels) was 87% on room air. [Resident] 1 was transferred to the emergency room on [DATE]. During an interview with DON on [DATE] at 1:56 pm, DON stated if a lab order is refused by a resident, the lab slip would be placed back into the lab requisition binder for the next day and notify the MD. DON stated he could not remember if LN H told him about Resident 1's change in condition on [DATE]. During a concurrent interview with LN A on [DATE] at 2:10 pm, the facility's lab requisition binder was reviewed. LN A confirmed that if the phlebotomist wrote no labs in the lab requisition binder, then there were no lab slips for the phlebotomist to reference for that day. LN A confirmed phlebotomist wrote no labs in lab requisition binder on [DATE]. LN A stated that she could not remember if she put a lab slip in the binder for [DATE] and confirmed that there was not one in the binder. LN A stated after Resident 1 refused the lab draw for [DATE], she forgot to enter the verbal lab order received from MD for [DATE]. LN A stated that a new lab order was needed in order for Resident 1 to successfully receive a lab draw on [DATE].During an interview with the supervisor of a local lab company (S LAB) on [DATE] at 3:30 pm, S LAB stated that no labs written on the lab requisition log indicated no lab slips were in the binder for the phlebotomist to reference. S LAB stated if a resident refused a lab draw, the phlebotomist would document on the lab draw log in the lab requisition binder with the resident's name, type of lab ordered, and write refused. S LAB confirmed no labs was documented in the lab draw log for [DATE], and Resident 1's name was not on the log. During an interview with CNA D on [DATE] at 9:40 am, CNA D stated that Resident 1 was not someone who routinely refused medications or care.During an interview with CNA E on [DATE] at 9:50 am, CNA E stated Resident 1 only refused care to new staff but accepted care if new staff took their time and spoke with her.During an interview with CNA F on [DATE] at 10:03 am, CNA F confirmed she worked the night shift for [DATE], [DATE], and [DATE]. CNA F stated [Resident 1] screamed out Help me! Lord, help me! Help me! during her shift all three nights. CNA F stated Resident 1's roommate pressed the call light one night to get staff to help calm Resident 1. CNA F stated she reported Resident 1's calling out to LN C on [DATE], [DATE], and [DATE] during their shift. CNA F stated that she did not see LN C leaving nurse's station to assess Resident 1 during the shifts when she reported Resident 1 screaming. During an interview with MD on [DATE] at 10:42 am, MD stated he was notified by staff on [DATE] that Resident 1 refused the lab draw and he gave a verbal order for the lab to attempt the lab draw on [DATE]. MD stated he was not notified that the labs were never drawn. MD stated he would have expected to be notified that labs were not drawn as ordered. MD stated he expected the facility to follow up to ensure the labs were drawn if the first attempt was not successful. MD stated he was not notified that Resident 1 cried out for help on [DATE], [DATE] or [DATE]. MD stated this would be considered a change in condition for Resident 1 and that facility should have notified him because he would have sent Resident 1 Out immediately for evaluation.During an interview with CNA G on [DATE] at 11:06 am, CNA G stated [Resident 1] would not scream out or cry out for help at her baseline. CNA G stated Resident 1 was Generally a quiet person. During an interview with LN H on [DATE] at 11:14 am, LN H stated she was told by night shift nurse LN A that Resident 1 refused lab draw on [DATE]. LN H stated it was not the nurse's job to ask a resident if they wanted lab work. LN H stated it was the job of the phlebotomist to ask the resident. LN H stated after she notified MD of Resident 1's high blood glucose levels on [DATE], and he gave her a verbal order for labs to be drawn on [DATE]. LN H stated she entered the order electronically and filled out a lab slip. LN H stated she placed the lab slip into the facility lab binder. LN H stated she did not work on [DATE] and did not follow up to ensure Resident 1's lab order was fulfilled as ordered. During an interview with DON on [DATE] at 12:19 pm, DON confirmed that an increase in blood glucose levels would be considered a change in condition that the MD and the DON should be notified of immediately. DON confirmed LN A should have entered a new lab order electronically for [DATE]. DON confirmed it was his job to follow up on lab work for residents and ensure it was completed as ordered. DON confirmed he did not follow up on Resident 1's lab work.During an interview with LN C on [DATE] at 2:20 pm, LN C confirmed he worked the night shift for [DATE], [DATE] and [DATE]. LN C stated he couldn't recall whether Resident 1 called out for help. LN C confirmed he did not assess Resident 1 for a change in condition. LN C stated Resident 1 appeared more Confused on [DATE], and he called MD, but MD did not answer. LN C confirmed he did not call MD again, nor notify DON or Administrator (Admin) of change in condition. During a review of Resident 1's clinical record titled Hospitalist: History and Physical, dated [DATE], at 9:56 AM, by Hospital MD, Resident 1 was admitted to the hospital with the following diagnoses: Septic shock: A life-threatening condition that occurs when an infection spreads throughout the body and causes a severe drop in blood pressure. Acute respiratory failure with hypoxia: A life-threatening condition where the lungs cannot adequately provide oxygen to the body. Profound hyperkalemia: A life-threatening condition where blood potassium levels are dangerously high, potentially causing fatal abnormal heart rhythm. Acute kidney injury with anuric renal failure: A condition where the kidneys suddenly lose their ability to function properly, no urine output whatsoever. Resident 1's BUN profoundly elevated at 287, emergent hemodialysis (a life-saving treatment for acute kidney failure) was performed. Hypovolemic Hypernatremia: a condition where there is a loss of both water and sodium, but more water is lost than sodium, resulting in a higher concentration of sodium in the blood and a decrease in overall body fluid volume Metabolic acidosis/Lactic acidosis: a condition where there is too much acid in the blood, occurring when the body either produces too much acid or the kidneys cannot remove enough of it. Lactic acidosis is a specific type of metabolic acidosis caused by an excess buildup of lactic acid in the blood, often due to insufficient oxygen delivery to the body's tissues.Hospital MD also indicated in the assessment and plan, Septic shock, admit to intensive care unit (ICU - a special hospital area for patients with life-threatening illnesses who require constant monitoring and advanced life support), will be a miracle if this patient survives.During a review of Resident 1's physician order, Resident 1 was placed on hospice care, returned to the facility on [DATE] and passed away on [DATE].

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received wound preventative measures as ordered to prevent skin breakdown, promote circulation, and provide pressure relief. This failure resulted in Resident 1 sustaining a stage 2 pressure ulcer (partial-thickness skin loss, where the epidermis (outer layer) and part of the dermis (second layer) are damaged caused by prolonged pressure) to their coccyx (tailbone), which had the potential to lead to complications including pain, discomfort, and infection. Findings: During a record review of the facility policy titled Skin Integrity Management Protocol dated 1/2019, it was indicated that staff were to relieve the underlying cause, addressing pressure, shear, other physical friction, and maceration/moisture factors. The facility policy indicated to keep local areas clean, dry, and free of body wastes such as urine, feces, perspiration, and wound drainage. The policy indicated to inspect skin frequently for indications of hyperemia (redness, swelling, and warmth), non-blanchable erythema (redness of the skin or mucous membranes), or disruption of skin integrity .sacrum/coccyx, and buttocks and to apply skin A&D ointment (zinc oxide) as indicated for skin maintenance. During a record review of the facility job description for Certified Nursing Assistants (CNAs) undated, it was indicated that facility CNAs were to observe and report the presence of pressure areas and skin breakdowns to prevent bedsores. A record review of Resident 1's admission record indicated they were admitted to the facility on [DATE] with diagnoses that included an intertrochanteric fracture of the right femur (a break in the upper part of the thigh bone) after a fall at home with Open Reduction Internal Fixation (ORIF - a surgical procedure used to repair broken bones, particularly in cases where the bone is displaced or comminuted), protein-calorie malnutrition (nutritional status with reduced availability of nutrients leads to changes in body composition and function), panic disorder (frequent and unexpected panic attacks), and hypokalemia (a low potassium level in blood). Resident 1 was their own responsible party (made their own financial and medical decisions). During a record review of Resident 1's Minimum Data Set (MDS - a standard assessment tool used in nursing homes and other long-term care facilities to collect data on residents' health and functional status) Section H Bowel and Bladder dated 9/26/24, Resident 1 was assessed as occasionally incontinent for urine and always incontinent for bowel. During a record review of Resident 1's MDS Section M Skin Conditions dated 9/26/24, Resident 1 was assessed as at risk for developing pressure ulcers. During a record review of Interdisciplinary Team (IDT - team of professionals from different disciplines to work collaboratively towards a resident's treatment plan) Notes dated 11/4/24, the Director of Nursing (DON) indicated that Resident 1 had a Braden score (a tool used to predict the risk of developing pressure ulcers) risk of 14 (a score of 18 or less indicates at-risk status) and indicated they were a moderate risk. During a record review of Resident 1's admission Baseline Care Plan dated 9/26/24, Resident 1's skin was assessed with surgical staples to the right hip and scattered purple discoloration to bilateral upper extremities, and moisture-associated skin damage (MASD - skin inflammation and erosion caused by prolonged exposure to moisture, like urine, stool, perspiration, or wound drainage) to buttocks and groin. During a record review of Resident 1's care plan dated 9/27/24, staff were to observe for skin redness and report accordingly. Resident 1 was at risk for skin breakdown or pressure ulcer formation. The care plan further indicated that staff were to observe for the presence of skin breakdown during care. During a record review of Resident 1's Physician Orders dated 9/26/24, it was indicated that zinc oxide was to be applied to the buttocks and groin as needed for skin maintenance. During a record review of the Situation-Background-Assessment-Recommendation (SBAR - a structured communication tool used to improve communication between healthcare professionals, especially when discussing critical patient information) dated 10/28/24, Resident 1 had a wound to their coccyx evaluated by nursing staff. Nursing staff concluded that Resident 1 had a stage 2 pressure ulcer (a partial-thickness skin loss due to unrelieved pressure) to their coccyx, and Resident 1 verbalized pain. During a record review of Resident 1's Physician Orders dated 10/28/24, it was indicated that the coccyx area was to be cleaned with normal saline, zinc oxide applied and covered with comfort foam dressing every shift for wound care. During a record review of Resident 1's shower sheets dated 10/1/24, 10/5/24, 10/8/24, 10/12/24, 10/15/24, 10/19/24, 10/22/24, 10/26/24, 11/2/24, 11/5/24, 11/9/24, 11/12/24, 11/15/24, and 11/16/24, CNAs did not indicate any reddened areas or rashes on Resident 1. During a record review of Skilled Services Documentation dated 9/29/24 through 10/27/24, nursing staff documented no skin issues for Resident 1 every day. During an interview with Licensed Vocational Nurse (LVN) A on 6/10/25 at 9:54 am, LVN A stated that the facility expectation was for CNAs to document on shower sheets when they noted skin issues. LVN A stated that CNAs should have documented rash for Resident 1's coccyx area and notified facility nursing staff. LVN A stated that it was difficult to get CNAs to complete skin assessments on facility residents. LVN A stated that they had voiced their concerns to the Director of Staff Development (DSD) but did not receive feedback. During an interview with the DSD on 6/10/25 at 10:21 am, the DSD stated that they faced challenges with newer CNAs and resident skin assessments. The DSD stated that CNAs did not know how to assess residents' skin and how to determine if a change had occurred. The DSD stated that they were aware that nursing staff complained about CNAs and how they did not know how to properly document skin assessments. The DSD confirmed that staff did not follow the facility skin assessment policy for Resident 1. During an interview with the Administrator (Admin) on 6/10/25 at 11:30 am, the Admin confirmed that CNAs and nursing staff did not assess and document per facility policy to prevent and treat Resident 1's pressure ulcer. The Admin confirmed that the lack of assessment and documentation contributed to the breakdown of communication and care that could have prevented a stage 2 pressure ulcer for Resident 1.

Based on interview and record review, the facility failed to notify the Medical Director (MD) for one of three sampled residents (Resident 1), when there was a need to alter Resident 1's healthcare decision maker as Resident 1 was still listed as the decision maker. Resident 1 had a St. Louis University Mental Status (SLUMS) examination (a cognitive screening test designed to detect the early signs of mild cognitive impairment and dementia) done on 7/22/24, and had a score of 3 out of 30, indicating that Resident 1 was cognitively impaired. This failure resulted in the facility continuing indicating that Resident 1 Has the capacity to make and understand decisions , and only notified Resident 1 when there was an alleged abuse allegation. Findings: During a review of the facility's policy titled, Change in a Resident's Condition or Status , revised 5/2027, indicated: 1. Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 2. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly 3. A significant change of condition is a major decline or improvement in the resident's status that .Will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting ); 4. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of Resident 1's admission record, indicated that Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), left hip fracture, muscle weakness (generalized), and abnormalities of gait and mobility. Resident 1 was listed as her Responsible Party (RP - an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications). During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), the MDS indicated that Resident 1's cognition level had changed from moderately impaired to severely impaired since early 2024: 1. On 1/16/24, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 11 out of 15, indicating her cognition was moderately impaired. 2. On 4/12/24, the MDS indicated that Resident 1 had a BIMS score of 3 out of 15, indicating her cognition was severely impaired. 3. On 6/14/24, the MDS indicated that Resident 1 had a BIMS score of 3 out of 15, indicating her cognition was severely impaired. 4. On 2/2/25, the most recent MDS indicated that Resident 1 had a BIMS score of 3 out of 15, indicating her cognition was severely impaired. During a review of Resident 1's record titled, SLUMS Examination , dated 7/22/24, indicated Resident 1 had a score of 3 out of 30, suggesting Resident 1 had dementia. During a review of Resident 1's Speech Therapy (ST) Evaluation record, dated 7/22/24, completed by the Speech-Language Pathologist ([SLP] - the healthcare professionals who work to prevent, identify, diagnose, and treat disorders related to speech, language, social communication, cognitive communication, and swallowing in people of all ages), the ST evaluation record indicated that Resident 1 was referred to the ST services for assessing any changes in her status. In the Impressions section, the record indicated: - Patient [Resident 1] completed SLUMS assessment with a score of 3/30, deficits noted across all cognitive-linguistic domains (a way of studying language as a mental phenomenon). - Patient [Resident 1] presented with decreased orientation on this date with patient [Resident 1] oriented to state and mixed orientation to self. - Patient [Resident 1] was able to provide first name and date of birth but was unable to provide last name and age. - Patient [Resident 1] presented with difficulty with memory recall both in structured assessment tasks as well as in conversational tasks requiring memory recall. - She [Resident 1] presented with deficits in basic problem solving such as using call light. Also noted was decreased awareness of deficits as patient [Resident 1] stated she was safe to get out of bed. During a concurrent interview and record review on 2/5/25 at 11:20 am with the ADMIN in the ADMIN's office, Resident 1's grievance resolution form, dated 10/26/24, was reviewed. The ADMIN stated he did not recall he filed the alleged abuse report to the proper authorities, and he believed the SSD was the one investigating the allegation. The ADMIN stated he was the facility abuse coordinator, and he and the SSD would be the one investigating any alleged abuse event. When asked as a mandated reporter and the facility abuse coordinator, why he did not report to the authorities, the ADMIN said, We did our own review, and it was unsubstantiated. Even We did our own investigation, do we still need to report it? She [Resident 1] had Alzheimer's, dementia, and often made false accusation, we did not have a staff look like that, and she was her own RP, so I didn't think we had to report it. During a concurrent interview and record review on 2/5/25 at 11:28 am with the ADMIN in the ADMIN's office, Resident 1's current physician order and the most current MDS, dated [DATE], were reviewed. The order indicated that Resident 1, Has the capacity to make and understand decisions , and it was ordered on 5/28/23 and had never been revised or updated based on Resident 1's status. When asked why Resident 1 who had Alzheimer's disease, with a BIMS score of 3, and was still listed as the RP, the ADMIN agreed that Resident 1 shouldn't be listed as the RP, and stated, We will ask the doctor to update it. During an interview on 2/5/25 at 11:50 am, with the Certified Nursing Assistant (CNA) D, in the dining area, the CNA D stated she took care of Resident 1 this month, she said, Resident 1 had dementia, she was not accurate, and often confused. During an interview on 2/5/25 at 2 pm with Licensed Nurse (LN) A, in the hallway, LN A stated, Resident 1 has Sundowning syndrome (a set of symptoms that can occur in people with dementia in the late afternoon and evening. Symptoms include confusion, anxiety, agitation, and difficulty sleeping), especially in the afternoon, she would be very agitated, try to walk out of the room on her own, and refuse any help. Resident 1 could not walk on her own . During a concurrent interview and record review on 2/7/25 at 10:37 am, with the ADMIN in the ADMIN 's office, Resident 1's SLUMS examination report, dated 7/22/24, was reviewed. The ADMIN stated that he wasn't sure whether the MD was notified about the report, the ADMIN said, Once we received the result, we would notify the physician, the nurse probably would be the one who notifies the MD. The ADMIN stated the Director of Nursing (DON) should have more information about whether the MD was notified. During an interview on 2/7/25 at 11:10 am with CNA B in Resident 1's room, the CNA B stated that she took care of Resident 1 very often, so she knew her. The CNA B said, Resident 1 has dementia, her mood swings a lot. She is very confused and forgetful. She would ask to go to the bathroom, then in seconds, when I tried to help her, she would refuse to go, and say she did not have to go . During a concurrent interview and record review on 2/7/25 at 10:55 am with the DON in the ADMIN's office, Resident 1's medical record was review. When asked whether the MD was notified about Resident 1' SLUMS examination report, the DON stated, I believed the MD was notified. At 12:10 pm in the ADMIN'S office, the DON admitted that he could not locate such note that indicating the MD was notified in Resident 1's medical record, and he stated, First of all, someone had to be made aware of. The medical record received the report and scanned it into the resident's PointClickCare (PCC - a cloud-based healthcare software platform that helps manage care, services, and finances.) They did not come to me, so I was not made aware of it . The MDS nurse did the cognition assessment, found her BIMS was 3, she should mention it during the Interdisciplinary care team (IDT - a group of health care professionals from different disciplines who work together to provide care) meeting when we were discussing Resident 1's capacity of signing treatment consent. Then Resident 1's SLUMS report, BIMS, and her capacity would be brought to the attention during the meeting, and the MD would be eventually notified. The DON agreed that the above process did not occur for Resident 1.

Based on interview and record review, the facility failed to report an abuse allegation for one of three sampled residents (Resident 1) when Resident 1 informed Certified Nursing Assistant (CNA) A that a male staff was Really rough when getting her [Resident 1] in & out of bed, grabbed her really hard, and wanted to hurt her on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse. Findings: During a review of the facility's policy titled, Abuse Prevention Program , revised 12/1/22, indicated this policy is to, Promote and environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and /or mistreatment. The policy also indicated that: 1. The facility shall thoroughly investigate allegation of abuse by identifying and interviewing all involved, including the alleged victim, alleged perpetrator, witness (es) and others who might have seen, heard or have knowledge of the allegations, and with documented evidence that support the investigation. 2. The facility's Abuse Prevention Coordinator shall initiate the investigation process immediately within the required time frame in accordance with the regulation after the alleged incident occurred - focusing on determining if allegations have occurred, the cause and its extent and by providing complete and through documentation of the investigation and exercising caution in handling possible evidence(s). 3. The facility shall respond to abuse allegation(s) immediately by protecting the alleged victim and integrity of the investigation. 4. The facility shall report any and all allegation of abuse to the District California Department of Public Health (CDPH), Local Ombudsman, and/or Local Law enforcement, either by phone, email or facsimile, within 2-hour timeframe. During a review of Resident 1's admission record, indicated that Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included Alzheimer's disease ((a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), left hip fracture, and need for assistance with personal care. Resident 1 was her Responsible Party (RP - an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications). During a review of Resident 1's most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 2/2/25, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating her cognition was severely impaired. During a review of Resident 1's medical record titled, St. Louis University Mental Status (SLUMS) Examination (an assessment tool for dementia and mild cognitive impairment), dated 7/22/24, indicated Resident 1 had a score of 3 out of 30, suggesting Resident 1 had dementia. During a review of the facility's document titled, Grievance Resolution Form , dated 10/26/24, indicated that Resident 1 reported to CNA A on 10/24/24, stating, A tall, male, attractive, light-colored hair, on 10/24/24, really rough when getting in & out of bed. Grabbed her [Resident 1] really hard. He wanted to hurt her. He does not like her or women. He helped her twice on the same day. The person listed as the investigator was the Social Service Director (SSD). The SSD and the administrator (ADMIN) both signed the form and dated 10/28/24. The statement for the Resolution on the form indicated, No one of that description worked that shift. Name [Resident 1] has diagnose of Alzheimer's. During a concurrent interview and record review on 2/5/25 at 11:20 am with the ADMIN in the ADMIN's office, Resident 1's grievance resolution form, dated 10/26/24, was reviewed. The ADMIN stated he did not recall he filed the alleged abuse report to the proper authorities, and he believed the SSD was the one investigating the allegation. The ADMIN stated he was the facility abuse coordinator, and he and the SSD would be the one investigating any alleged abuse event. When asked as a mandated reporter and the facility abuse coordinator, why he did not report to the authorities, the ADMIN said, We did our own review, and it was unsubstantiated. Even We did our own investigation, do we still need to report it? She [Resident 1] had Alzheimer's, dementia, and often made false accusation, we did not have a staff look like that, and she was her own RP, so I didn't think we had to report it. During a concurrent interview and record review on 2/5/25 at 12 pm, with the ADMIN in the ADMIN's office, Resident 1's most recent MDS, dated [DATE], progress note, social service note, and care plan were reviewed. The ADMIN agreed that Resident 1's BIMS was 3, and Resident 1 shouldn't be listed as the RP, the ADMIN said, Family B was the main contacted person, we would ask the doctor to update it. The ADMIN admitted that he could not locate any documentation from the social service department regarding the investigation for the alleged abuse allegation. The ADMIN stated, There should have been an interdisciplinary care team (IDT - a team of health care professionals from different disciplines that work together to provide care) meeting, a documentation of investigation, and it should be care planned. When asked whether Family B was contacted for this alleged abuse allegation, the ADMIN stated, I am not sure. During an interview on 2/5/25 at 1:40 pm with the SSD in the SSD's office, when asked for the record of Resident 1's alleged abuse allegation investigation, the SSD stated, I did not do the investigation. The SSD said, It's been too long, I don't remember. When asked if she was to investigate an abuse incident, would she document the investigation process in the resident's record, the SSD stated, Probably, but I am not sure. When asked whether she would report the abuse incident to CDPH, and local authorities, the SSD stated that she wouldn't, and she would only report it to the ADMIN.

Based on interview and record review, the facility failed to ensure social services met the needs for two of three residents (Resident 1, 2) when: 1. The Social Service Director did not investigate and reported to the authorities after Resident 1 informed the Certified Nursing Assistant (CNA) B of an allegation of abuse on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse. 2. The Social Service Director failed to ensure the Behavior Management Committee address the appropriateness of the use of the psychotropic medication when Resident 2 was prescribed with PRN Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. This failure could contribute to unsafe use of psychotropic medications that could have placed residents at risk for adverse consequences. Findings: A review of a facility policy titled, Social Services Assessment, revised 11/22/16, indicated the purpose was to identify information to help staff develop a personalized plan of care that utilizes the individual's existing needs, strengths, functional deficits, and optimizes function and quality of life and meets individual's goal and preferences. When a resident is admitted a discharge plan is discussed, documented in the social services assessment, and updated in the record to reflect changes to the initial discharge plan. 1. A review of a facility job description for Social Service Director (SSD), no revised date provided, indicated The primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator (ADMIN), to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The duties and responsibilities of the SSD were to: Administrative Functions - Perform administrative requirements, such as completing necessary forms, reports, etc., and submitting such to the ADMIN as required. Committee Functions - Serve on, participate in, and attend various committees of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Budget, Quality Assessment, and Assurance, etc.) as required, and as appointed by the ADMIN; Evaluate and implement recommendations from established committees as they may pertain to social services. Resident Rights - Review complaints and grievances made by the resident and make a written/oral report to the ADMIN indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures; Maintain a written record of the resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint. Specific Requirements - Must be knowledgeable of the rules, regulations, and guidelines that govern nursing care facilities. During a review of Resident 1's admission record, indicated that Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included Alzheimer's disease ((a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), left hip fracture, and need for assistance with personal care. Resident 1 was listed as her health care decision maker (Refer to F 580). During a review of Resident 1's most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 2/2/25, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating her cognition was severely impaired. During a review of Resident 1's medical record titled, St. Louis University Mental Status (SLUMS) Examination (an assessment tool for dementia and mild cognitive impairment), dated 7/22/24, indicated Resident 1 had a score of 3 out of 30, suggesting Resident 1 had dementia. During a review of the facility's document titled, Grievance Resolution Form , dated 10/26/24, indicated that Resident 1 reported to CNA A on 10/24/24, stating, A tall, male, attractive, light-colored hair, on 10/24/24, really rough when getting in & out of bed. Grabbed her [Resident 1] really hard. He wanted to hurt her. He does not like her or women. He helped her twice on the same day. The person listed as the investigator was the Social Service Director (SSD). The SSD and the administrator (ADMIN) both signed the form and dated 10/28/24. The statement for the Resolution on the form indicated, No one of that description worked that shift. Name [Resident 1] has diagnose of Alzheimer's. During a concurrent interview and record review on 2/5/25 at 11:20 am with the ADMIN in the ADMIN's office, Resident 1's grievance resolution form, dated 10/26/24, was reviewed. The ADMIN stated he did not recall he filed the alleged abuse report to the proper authorities, and he believed the SSD was the one investigating the allegation. The ADMIN stated he was the facility abuse coordinator, and he and the SSD would be the one investigating any alleged abuse event. During a concurrent interview and record review on 2/5/25 at 11:40 am with the Director of Staff Development (DSD) in the ADMIN's office, the facility's abuse training record was reviewed. The DSD confirmed that the SSD had abuse training titled, titled, Mandated Reporter, Elder and Dependent Adult Abuse , on 2/12/24, 7/31/24, and 1/30/25. During a concurrent interview and record review on 2/5/25 at 12 pm, with the ADMIN in the ADMIN's office, Resident 1's most recent MDS, dated [DATE], social service progress note, and care plan were reviewed. The ADMIN agreed that Resident 1's BIMS was 3, and Resident 1 shouldn't be listed as the RP, the ADMIN said, Family B was the main contacted person, we would ask the doctor to update it. The ADMIN admitted that he could not locate any documentation from the social service department regarding the investigation for the alleged abuse allegation. The ADMIN stated, There should have been an interdisciplinary care team (IDT - a team of health care professionals from different disciplines that work together to provide care) meeting, a documentation of investigation, and it should be care planned. When asked whether Family B was contacted for this alleged abuse allegation, the ADMIN stated, I am not sure. During an interview on 2/5/25 at 1:40 pm with the SSD in the SSD's office, when asked for the record of Resident 1's alleged abuse allegation investigation, the SSD stated, I did not do the investigation. The SSD said, It's been too long, I don't remember. When asked if she was to investigate an abuse incident, would she document the investigation process in the resident's record, the SSD stated, Probably, but I am not sure. When asked whether she would report the abuse incident to CDPH, and local authorities, the SSD stated that she wouldn't, and she would only report it to the ADMIN. 2. During a review of the facility policy titled, Behavior Management Committee , revised 9/2025, indicated, It is the policy of this facility that the residents exhibiting behavior problem will be assessed thoroughly and less restrictive interventions will be offered prior to the administration of the psychoactive medications. The Social Services: Will meet with residents and attempt to identify possible psychosocial issues that may be causing the behaviors. In collaboration with the Director of Nursing Services/designated Licensed Nurse will oversee the Behavior Management Committee. Decide further intervention in collaboration with the Attending Physician and Psychiatrist to support the need of psychotropic medication not to exclude gradual dose reduction. Will ensure that the Behavior Management Committee will address the appropriateness of the use of the psychotropic medication and the need for gradual dose reduction. Will document in the Social Service note information discussed during the Behavior Management Committee Meeting which includes the intervention, psychological or psychiatric referral and gradual dose reduction. Will ensure that the Behavior Management Committee address the appropriate use of the psychotropic medication. During a review of Resident 2's admission record, indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and need for assistance with personal care. Resident 2 was not her healthcare decision maker. During a review of Resident 2's most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 12/18/24, the MDS indicated that Resident 2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating her cognition was moderately impaired. During a concurrent interview and record review on 2/7/25 at 1:55 pm, with the administrator (ADMIN) in the admin's office, SOM - the guidance for PRN order for psychotropic and antipsychotic medication, and Resident 2's Medication Administration Record (MAR), dated from 4/1/24 to 4/30/24, were reviewed. The MAR record indicated Resident 2 was prescribed with Lorazepam tablet 0.5 mg, and was to Give 1 tablet by month every 8 hours as needed for Anxiety for 30 days as exhibited by yelling out even when all needs are met, start date-4/2/24 . The ADMIN stated he was aware that the PRN psychotropic drugs were limited to 14 days, unless the provider indicated the need for the extended time period in the resident's record. The ADMIN confirmed that he couldn't locate such note in Resident 2's medical record. During a concurrent interview and record review on 2/7/25 at 2:28 pm with the Director of Nursing, in the admin's office, Resident 2's medical record titled, Psychotherapeutic review interdisciplinary care team (IDT- a team of health care professionals from different disciplines that work together to provide care) v.2 , dated 4/10/24, was reviewed. The DON stated residents who were prescribed with psychotropic and antipsychotic medication, their status, indication of using the medication, and reaction to the medication, etc., would be discussed in the monthly Psychotherapeutic review IDT meeting, and Resident 2's rationale for needing PRN Ativan for 30 days should be discussed and documented in the Psychotherapeutic review IDT meeting. The DON confirmed that he could not locate such note in Resident 2's medical record.

Based on interview and record review, the facility failed to ensure safe use of psychotropic medications (medication that alters mood, behavior, and cognition) for one of three sampled residents (Resident 2) when Resident 2 was prescribed with Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. This failure could contribute to unsafe use of psychotropic medications that could have placed residents at risk for adverse consequences. Findings: During a review of the State Operations Manual (SOM -contains guidance on certification and survey activities, a federal document from the Centers for Medicare & Medicaid Services), revised 8/8/24, indicated, 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. 2. As needed (PRN) for psychotropic drugs are limited to 14 days. 3. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. The Attending physician or prescribing practitioner should document the rationale for the extended time period in the medial record and indicate a specific duration. During a review of Resident 2's admission record, indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and need for assistance with personal care. Resident 2 was not her healthcare decision maker. During a review of Resident 2's most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 12/18/24, the MDS indicated that Resident 2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating her cognition was moderately impaired. During a concurrent interview and record review on 2/7/25 at 1:55 pm, with the administrator (ADMIN) in the ADMIN's office, the SOM - in the guidance for PRN order for psychotropic and antipsychotic medication, and Resident 2's Medication Administration Record (MAR), dated from 4/1/24 to 4/30/24, were reviewed. The MAR record indicated Resident 2 was prescribed with Lorazepam tablet 0.5 mg, and was to Give 1 tablet by month every 8 hours as needed for Anxiety for 30 days as exhibited by yelling out even when all needs are met, start date-4/2/24 . The ADMIN stated he was aware that the PRN psychotropic drugs were limited to 14 days, unless the provider indicated the need for the extended time period in the resident's record. The ADMIN confirmed that he couldn't locate such note in Resident 2's medical record. During a concurrent interview and record review on 2/7/25 at 2:28 pm with the Director of Nursing (DON) in the ADMIN's office, Resident 2's medical record titled, Psychotherapeutic review interdisciplinary care team (IDT- a team of health care professionals from different disciplines that work together to provide care) v.2 , dated 4/10/24, was reviewed. The DON stated residents who were prescribed with psychotropic and antipsychotic medication, their status, indication of using the medication, and reaction to the medication, etc. would be discussed in the monthly Psychotherapeutic review IDT meeting, and Resident 2's rationale for needing PRN Ativan for 30 days should be discussed and documented in the Psychotherapeutic review IDT meeting. The DON confirmed that he could not locate such note in Resident 2's medical record.

Based on observation, interview, and facility policy review, the facility failed to ensure sanitary preparation and service of meals. Specifically, the facility failed to practice proper hand hygiene and glove use during food preparation, and the facility failed to hold foods at safe temperatures during meal service. This had the potential to affect all residents who received meals from the facility's kitchen. Findings included: 1. During an observation on 09/24/2024 at 11:23 AM, the temperature of pizza's being served to residents was at 136 degrees Fahrenheit (F). The temperature of the pizza's was measured again at 12:17 PM, and was at 122 degrees F. It was also observed that there were three stacked pizza pans underneath the pizza, separating it from the heat source. There were four pizza slices that remained, and they were served to two unidentified residents. During an interview on 09/25/2024 at 1:47 PM, the Food Services Director (FSD) stated that the facility staff should have discarded the four slices of pizza that were served and instead served the pizza that remained in the food warmer. The FSD stated there was no facility policy specific to safe holding temperature for foods. 2. A facility policy titled, Glove Use Policy, dated 2018, indicated that gloves needed to be changed Before beginning a different task. The policy revealed gloves needed to be changed As soon as they become soiled such as when doing housekeeping duties - including mopping, removing garbage, using the phone, cleaning. During an observation on 09/25/2024 at 10:40 AM, [NAME] #7 mixed iceberg lettuce with gloved hands. He opened the walk-in refrigerator door, touching the handle, to get more lettuce of a different variety. He opened the bag and mixed in the new lettuce with the iceberg lettuce with both of his hands. At no point between touching the refrigerator and mixing the lettuce did he wash his hands or change his gloves. During an interview on 09/25/2024 at 10:43 AM, [NAME] #7 stated that the salad was for dinner for the residents. During an interview on 09/25/2024 at 11:00 AM, the Food Services Director (FSD) stated that the residents were having salad for dinner. During an interview on 09/25/2024 at 11:43 AM, the Culinary Director stated that [NAME] #7 was his newest hire. He stated that [NAME] #7 was often being written up for infractions similar to what was observed, and he often forgot to wash his hands between certain tasks. He stated that it was his expectation that staff change gloves and wash their hands after touching a high-contact surface, before touching food. During a follow-up interview on 09/25/2024 at 1:47 PM, the FSD stated that she was not part of the hiring or training staff for the kitchen the food was prepared in. She stated that she had not worked with [NAME] #7. The FSD stated that if she saw [NAME] #7 touch lettuce after touching a high-contact surface, she would expect that the food be discarded, and the staff member retrained on glove use. During an interview on 09/26/2024 at 11:05 AM, the Director of Nursing (DON) deferred to dietary staff on questions regarding all kitchen related concerns. During an interview on 09/26/2024 at 1:38 PM, the Administrator deferred to dietary staff on questions regarding food temperatures and handwashing during food preparation.

Based on observation, interview, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1 of 1 dumpster was closed to prevent the potential for vermin and pest attraction. This had the potential to affect all 56 residents that resided in the facility. Findings included: The U.S. FDA 2022 Food Code, dated 01/18/2023, revealed Chapter 5. Water, Plumbing, and Waste, section 5-5 Refuse, Recyclables, and Returnables, included, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. A facility policy titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated, 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. The policy also indicated, 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. An observation on 09/25/2024 at 12:10 PM, revealed the dumpster behind the building was open. During a concurrent interview, the Food Services Director (FSD) confirmed the dumpster should be closed. An observation on 09/26/2024 at 8:22 AM, revealed the dumpster behind the building was open. During a concurrent interview, the FSD stated that for as long as she had been with the facility the dumpster had always been open. The FSD stated the only things discarded in the dumpsters were paper and containers from the kitchen as well as nursing materials. During an interview on 09/26/2024 at 11:05 AM, the Director of Nursing (DON) stated the regulation required the dumpster lids to be closed. During an interview on 09/26/2024 at 1:38 PM, the Administrator stated he did not really know the expectation, but he wanted the dumpster to be closed when it could be.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen was administered appropriately for 3 (Residents #204, #17, and #11) of 4 residents reviewed for respiratory care. Specifically, the facility failed to ensure Resident #204 and Resident #17 received oxygen at their prescribed flow rates and failed to ensure the humidifier bottle on Resident #11's oxygen concentrator was functioning properly. Findings included: A facility policy titled, Oxygen Administration (Mask, Cannula, Catheter), revised 12/2016, revealed, The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. The policy also indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The facility policy procedures revealed, 9. Attach the oxygen delivery device to the oxygen unit. 10. Turn the unit on to the desired flow rate and assess equipment for proper functioning. A. Airflow should be felt through the oxygen delivery device. B. Bubbles should be seen diffusing through the humidifier bottle. 11. If no evidence of oxygen flow, check connections and tubing for leaks. The policy revealed, 13. Reassess oxygen flowmeter for correct liter flow. 1. An Admission Record indicated the facility most recently admitted Resident #204 on 09/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease with acute exacerbation and acute respiratory failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #204 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy on admission and while a resident of the facility. Resident #204's care plan, last reviewed on 09/23/2024, included a focus area, initiated on 09/10/2024, that indicated the resident was at risk for complications related to the use of oxygen. Resident #204's Order Summary Report included an active order, dated 09/24/2024, to administer oxygen at 2 liters per minute via nasal cannula as needed (PRN). An observation on 09/23/2024 at 9:32 AM revealed Resident #204 was receiving oxygen via nasal cannula at a flow rate of 2.5 liters per minute. Observations on 09/24/2024 at 8:30 AM and 09/25/2024 at 11:54 AM revealed Resident #204 was receiving oxygen via a nasal cannula at a flow rate of 3 liters per minute. During an interview on 09/25/2024 at 2:14 PM, Licensed Vocational Nurse (LVN) #1 confirmed the resident's oxygen was set at flow rate of 3 liters per minute but should be set at 2 liters per minute. 2. An Admission Record indicated the facility most recently admitted Resident #17 on 09/15/2020. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic respiratory failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #17's Order Summary Report included active orders, dated 01/30/2023, to administer oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or to maintain an oxygen saturation above 88 percent (%). Observations on 09/23/2024 at 10:16 AM and 09/25/2024 at 10:50 AM revealed Resident #17 was receiving oxygen via nasal cannula at a flow rate of less than 0.5 liters a minute. During an interview on 09/25/2024 at 12:24 PM, Licensed Vocational Nurse (LVN) #1 confirmed that Resident #17's oxygen was set at a flow rate of 0.5 liters per minute but should be set at 2 liters per minute. She stated it was her responsibility to ensure the oxygen was set to the correct flow rate according to the orders. 3. An Admission Record indicated the facility most recently admitted Resident #11 on 07/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified dementia with behavioral disturbance, anxiety disorder, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident received oxygen therapy. Resident #11's care plan included a focus area, initiated on 02/17/2022, that indicated the resident received oxygen therapy related to ineffective gas exchange. An intervention dated 02/17/2022 specified the resident's oxygen setting was to be set at 2 liters per minute. Resident #11's Order Summary Report included active orders, dated 09/27/2024, to administer oxygen at 2 liters per minute as needed to maintain an oxygen saturation at 90 percent (%) or greater. An observation on 09/24/2024 at 8:32 AM revealed Resident #11 was receiving oxygen at 2 liters per minute; however, the humidifier bottle on the resident's oxygen concentrator was not producing bubbles. During a concurrent observation and interview on 09/25/2024 at 9:44 AM, Resident #11 was receiving oxygen at 2 liters per minute; however, the humidifier bottle on the resident's oxygen concentrator was not producing bubbles. Licensed Vocational Nurse (LVN) #1 stated the humidifier bottle was not screwed on completely, so it was possible the resident was not getting the proper amount of oxygen. During an interview on 09/26/2024 at 10:08 AM, LVN #2 stated it was everyone's responsibility to ensure the oxygen was set accurately and indicated the certified nursing assistants (CNAs) should ask the nurse what the oxygen setting should be. LVN #2 stated the oxygen would not work properly if the humidifier bottle was not screwed on completely and could cause increased condensation in the tubing. During an interview on 09/26/2024 at 10:29 AM, the Director of Nursing (DON) stated the licensed nurse was responsible for ensuring oxygen was set according to the physician's orders. The DON stated if a humidifier bottle was not screwed on correctly, then there would be no seal, which could cause oxygen to leak and an incorrect amount of oxygen would be administered. During an interview on 09/26/2024 at 10:54 AM, the Administrator stated the staff should make sure the settings for oxygen were according to the orders and the equipment was functioning properly.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure an effective infection prevention and control program was followed and maintained for 1 (Resident #38) of 1 resident reviewed for urinary catheters and 3 (Residents #37, #17, and #204) of 4 residents reviewed for respiratory care. Specifically, Resident #38's urinary catheter bag was observed on the ground or floor, and respiratory equipment was inappropriately stored to prevent infections for Residents #37, #17, and #204. Findings included: 1. A facility policy titled, Urinary Catheter Care, revised 03/2021, under the section, Infection Control, revealed b. Be sure the catheter tubing and drainage bag are kept off the floor. An Admission Record revealed the facility originally admitted Resident #38 on 01/19/2023 and readmitted the resident on 07/11/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of obstructive and reflux uropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required partial/moderate assistance with all activities of daily living (ADLs). The MDS indicated Resident #38 had an indwelling catheter. Resident #38's care plan, included a focus area initiated 01/20/2023, that indicated the resident was at an elevated risk for developing complications, including urinary tract infections (UTI), due to the presence of a suprapubic catheter related to obstructive uropathy. Interventions directed staff to observe and notify the physician of signs and symptoms of a UTI, provide catheter care daily and as needed, and keep the drainage bag below the level of the bladder (initiated 01/22/2023). An observation on 09/23/2024 from 11:03 AM through 11:08 AM, revealed Resident #38 propelling their wheelchair with their catheter drainage bag dragging across the floor. No facility staff were observed present. An observation on 09/24/2024 from 9:35 AM through 9:43 AM, revealed Resident #38 propelling themself in a wheelchair while their urine catheter drainage bag dragged across the floor of the facility. No facility staff were observed present. During an observation on 09/24/2024 at 11:07 AM, Resident #38 was observed outside of the facility propelling themself in a wheelchair while their catheter drainage bag dragged against the ground. No facility staff were observed present. An observation on 09/25/2024 from 8:47 AM through 8:57 AM, revealed Resident #38 propelling themself in a wheelchair while their urine catheter drainage bag dragged across the floor of the facility. No facility staff were observed present. Licensed Vocational Nurse (LVN) #2 was interviewed on 09/25/2024 at 9:18 AM and stated Resident #38's catheter drainage bag should not touch the floor. LVN # 2 stated she had seen Resident #38's drainage bag on the floor before and would find a better way to hang the bag so it would not touch the floor. During an interview on 09/25/2024 at 9:25 AM, LVN #1 revealed Resident #38's catheter drainage bag should never touch the floor or ground because of bacteria. During an interview on 09/26/2024 at 9:42 AM, the Director of Nursing (DON) revealed Resident #38's catheter drainage bag should never touch the floor. The DON stated having the drainage bag on the floor could increase the risk of infection. During an interview on 09/26/2024 at 10:38 AM, the Administrator revealed he expected the facility staff to raise the catheter drainage bag so that it did not contact the floor or ground. 45555 2. A facility policy titled, Oxygen/Nebulizer Equipment, revised 06/2021, indicated Purpose To prevent respiratory infection from oxygen or nebulizer equipment. The policy indicated 2. Prevent cannula, mask, or tubing from falling to the floor when not in use. An Admission Record indicated the facility admitted Resident #204 on 09/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation and acute respiratory failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #204 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy. Resident #204's Care Plan included a focus area initiated 09/10/2024, that indicated the resident was at risk for complications related to the use of oxygen. Interventions directed staff to observe for signs and symptoms of respiratory distress. Resident #204's Order Summary Report revealed the following active orders: - 09/10/2024 - An order to change the black microfiber oxygen tubing storage bag every month. - 09/12/2024 - An order to administer ipratropium-albuterol inhalation solution via nebulizer every four hours as needed for wheezing/shortness of breath. - 09/14/2024 - An order to administer Pulmicort suspension via nebulizer every twelve hours for severe COPD Observation on 09/23/2024 at 9:32 AM, revealed a nebulizer machine was on Resident #204's nightstand with tubing lying on top of the nightstand next to the machine. Observation on 09/25/2024 at 11:54 AM, revealed the nebulizer machine was on Resident #204's nightstand and the tubing was lying on top of the over-the-bed table with a small amount of fluid noted in the cannister. Resident #204 stated they used the machine several times a day and the staff changed out the equipment weekly, but stated staff did not rinse out the nebulizer medication cup. 3. An Admission Record indicated the facility admitted Resident #17 on 09/15/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic respiratory failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS did not indicate the resident received oxygen therapy. Resident #17's Order Summary Report indicated an order dated 01/30/2023, to administer supplemental oxygen at 2 liters via nasal cannula as needed for shortness of breath or to maintain saturations above 88% and an order dated 11/18/2023 to change a black microfiber oxygen tubing storage bag every month on night shift. During an observation on 09/24/2024 at 8:28 AM, Resident #17's oxygen tubing was stored on top of the oxygen concentrator with the cannula touching the surface of the machine. 4. An Admission Record indicated the facility readmitted Resident #37 on 09/17/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease with acute exacerbation and acute respiratory failure with hypercapnia (elevated levels of carbon dioxide in the bloodstream). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy. Resident #37's Care Plan initiated 09/17/2024, indicated the resident was at risk for altered respiratory status/difficulty breathing and complication related to supplemental oxygen use such as skin irritation or tripping over the oxygen tubing. Interventions directed staff to provide extension tubing or a portable oxygen apparatus, keep oxygen tubing away from the resident's feet to minimize being tangled, and observe for signs and symptoms of respiratory distress. Resident #37's Order Summary Report revealed an ordered dated 09/17/2024 to change the black microfiber oxygen storage bag every month on night shift and an order dated 09/18/2024, to change the tubing/mask for the nebulizer machine every week and as needed. Observation on 09/23/2024 at 10:19 AM and on 09/24/2024 at 8:29 AM, revealed a nebulizer machine was on Resident #37's nightstand with the mask, medication cannister, and tubing still connected to the machine, and stored on top of the machine. The observation revealed a small amount of fluid in the medication cup of the tubing. Observation on 09/25/2024 at 10:52 AM, revealed Resident #37's nebulizer machine was on the nightstand with the mask, medication, and tubing still attached and lying next to the machine. The observation revealed a small amount of fluid in the medication cup and dried debris inside the mask. There was no bag available to store the equipment. During an interview on 09/26/2024 at 10:08 AM, Licensed Vocational Nurse (LVN) #2 stated oxygen tubing should be stored in a bag when not in use. She stated nebulizer equipment should be rinsed out and also stored in a bag when not in use. She stated the items should be replaced weekly or as needed for infection control reasons. During an interview on 09/26/2024 at 10:29 AM, the Director of Nursing (DON) stated that when supplemental oxygen was not in use, tubing should be stored in a black mesh bag to keep it from getting contaminated. He stated nebulizer equipment should also be stored in a mesh bag when not in use. He stated the staff would only rinse out a nebulizer medication cup if the resident had not taken in the entire amount of the medication. During an interview on 09/26/2024 at 10:54 AM, the Administrator stated respiratory equipment should be stored appropriately.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure oxygen use was accurately coded on the Minimum Data Set (MDS) assessment for 2 (Resident #17 and Resident #11) of 4 residents reviewed for respiratory services. Findings included: The Centers for Medicare and Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, Version 1.19.1, dated 10/2024, Section O: Special Treatments, Procedures, and Programs revealed, Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. The user's manual further revealed, O0110C1, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc. [et cetera, and other similar things] delivered to a resident to relieve hypoxia in this item. The user's manual specified to check O0110C2, Continuous if oxygen therapy was continuously delivered for 14 hours or greater per day and to check O0110C3, Intermittent if oxygen therapy was intermittent (i.e. [id est, that is], not delivered continuously for at least 14 hours per day). 1. An Admission Record indicated the facility admitted Resident #17 on 09/15/2020. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic respiratory failure. Resident #17's Order Summary Report for all active, completed, and discontinued orders, contained orders started on 01/30/2023, to administer oxygen at 2 liters via nasal cannula as needed for shortness of breath or to maintain an oxygen saturation above 88 percent (%). The orders specified to monitor the resident's oxygen saturation every shift. Resident #17's September 2024 Medication Administration Record (MAR) revealed staff documented that oxygen was administered at 2 liters via nasal canula every shift on 09/01/2024, 09/02/2024, and 09/03/2024. The MAR also revealed staff documented that the resident's oxygen cannula tubing, oxygen tubing storage bag, and oxygen humidifier bottle were changed on 09/01/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident did not receive continuous or intermittent oxygen therapy while a resident of the facility and within the last 14 days. During an interview on 09/26/2024 at 10:11 AM, the MDS Resource Staff stated the MDS Coordinator was responsible for the accuracy of the MDS. She stated the information used to complete the assessment came from resident interviews, records, and physician information. She stated if a resident utilized supplemental oxygen during the MDS lookback period, then it should be reflected on the MDS. The MDS Resource stated Resident #17 was using oxygen during the lookback period; therefore, oxygen use should have been coded on the MDS. During an interview on 09/26/2024 at 10:29 AM, the Director of Nursing (DON) stated he was ultimately responsible for the MDS. He stated he signed that they were complete, but the MDS Coordinator was responsible for the accuracy. He stated Resident #17's oxygen use should have been coded on the MDS. During an interview on 09/26/2024 at 10:54 AM, the Administrator stated the accuracy of the MDS was the responsibility of the MDS nurse. He stated the MDS should be coded accurately and if oxygen was used, it should be coded. 2. An Admission Record indicated the facility admitted Resident #11 on 07/10/2024. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified dementia with other behavioral disturbance, anxiety disorder, and depression. Resident #11's Order Summary Report for all active, completed, and discontinued orders, contained orders started on 09/27/2022, to administer oxygen at 2 liters as needed to maintain an oxygen saturation at 90 percent (%) or greater. The orders specified to monitor the resident's oxygen saturation every shift. Resident #11's August 2024 Medication Administration Record (MAR) revealed staff documented that oxygen was being administered at 2 liters every shift on 08/01/2024 through 08/06/2024. The MAR also revealed staff documented that the resident's oxygen cannula tubing and oxygen humidifier bottle were changed on 08/04/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS did not indicate that the resident received continuous or intermittent oxygen therapy while a resident of the facility and within the last 14 days. During an interview on 09/26/2024 at 10:11 AM, the MDS Resource Staff stated the MDS Coordinator was responsible for the accuracy of the MDS. She stated the information used to complete the assessment came from resident interviews, records, and physician information. She stated if a resident utilized supplemental oxygen during the MDS lookback period, then it should be captured on the MDS. The MDS Resource stated Resident #11 was using oxygen during the lookback period; therefore, oxygen use should have been coded on the MDS. During an interview on 09/26/2024 at 10:29 AM, the Director of Nursing (DON) stated he was ultimately responsible for the MDS. He stated he signed that they were complete, but the MDS Coordinator was responsible for the accuracy. He stated Resident #11's oxygen use should have been coded on the MDS. During an interview on 09/26/2024 at 10:54 AM, the Administrator stated the accuracy of the MDS was the responsibility of the MDS nurse. He stated the MDS should be coded accurately and if oxygen was used, it should be coded.

Based on observation, interview, record review, and policy review, the facility failed to ensure a safe and sanitary environment which promoted the prevention of the spread of infection for 11 of 12 sampled residents (Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 11 and 12) when: 1. Resident 3 and Resident 4 had Clostridium difficile infections (C-Diff, a highly contagious bacteria in their intestines that causes severe diarrhea, inflammation of the colon, abdominal discomfort, lack of appetite, weight loss, isolation, extended hospital stays, and death); and a. Housekeeping Staff (HSK) had not disinfected Resident 3 and Resident 4's rooms which were contaminated with C-diff, with a disinfectant that was approved to kill C-diff. (According to the Centers for Disease Control (CDC), C-diff bacteria produces spores that can live on surfaces for months and years), and continued to clean 21 other resident rooms on 2 of 3 facility units; and b. Licensed Nurse (LN) C used a glucometer (a machine used to check blood sugar levels in diabetics), on Resident 4 and did not have a disinfectant approved to kill C-diff available to clean the glucometer after she used it. LN C then placed the contaminated glucometer back in her medication cart, where medications were kept for 17 other residents, and the glucometer was available to be used on other residents; and c. Certified Nursing Assistant (CNA) E, used a thermometer and a pulse oximeter (a device placed on a finger that checks oxygen levels), on Resident 4, and had not disinfected the equipment and then used that same equipment on 9 other residents. These failures had the likelihood to spread C-Diff infections to all 27 residents who resided on 2 of the 3 units of the facility and spread C-diff infections to staff and visitors with the likelihood to negatively impact their health, safety and welfare by serious illness, harm, impairment and death. Due to the facility's likelihood to cause injury, harm, impairment, and death by spreading C-Diff infections to 27 of 27 residents who resided on 2 of 3 units where there were C-diff infections, an Immediate Jeopardy situation was identified on 1/27/23 at 4:45 pm, in the presence of the Director of Nursing (DON) and by phone to the Corporate Nurse Consultant (NC) and an immediate corrective action plan was requested. On 2/1/23 at 12:00 pm, an immediate corrective action plan was accepted from the DON. On 2/2/23 at 10:30 am, the California Department of Public Health (CDPH) conducted an on-site visit to the facility and verified that the facility had implemented their immediate corrective action plan and ensured that there was no longer any immediate threats to the health, safety, and welfare of their residents, staff and visitors by means of spreading C-Diff infections. 2. Resident 3 was suspected of having C-diff and was not placed on Contact Isolation (precautions and the use of personal protective equipment to prevent the spread of infection by touching the resident and surfaces in th room), for 2 days. 3. Personal laundry for 5 of 10 residents (Residents 2, 3, 10, 11, and 12) that was contaminated with urine and feces, was lying on the floor of a cabinet in their rooms and not contained in a closed bag to prevent the spread of germs. 4. Two of 5 dining room tables on the Cottage unit had nicks and dents, 2 of 3 resident dining room counter tops on the Villa and Cottage units were pitted, dented, chipped and cracked, and 1 of 3 cloth chairs in the Villa dining room was torn. 5. Five of 8 resident's rooms (Residents 1, 2, 3, 5, and 7) had brown substances and gray dust balls on their floors and under their beds, corn chips and other food crumbs on the floors, and 2 of 4 bathrooms observed had brown smears of feces on the toilet and walls. 6. Two of 2 resident's (Resident 8 and 9) oxygen concentrators (a machine that provides oxygen to a resident), were observed to have thick brown dust on their filters. Findings: The facility's policy titled, Clostridium Difficile dated October 2018, was reviewed The policy indicated, Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. C-difficile is transmitted via the fecal-oral route. Therefore, any resident-care activity that involves contact with the resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission Residents with diarrhea associated with C. difficile are placed on Contact Precautions: A category of transmission-based precautions when transmission of a germ can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care item in the resident ' s environment. Precautions include, isolating the resident by a private room or other means, staff and visitors wear gloves and gowns when entering room and dispose of gloves and gowns when leaving room and washing hands with soap and water. Environmental cleaning in rooms of residents with CDI is done with a disinfecting agent recommended for C. difficile (e.g., household bleach and water solution or an EPA [Environmental Protection Agency, an agency that is responsible for the protection of human health and the environment], registered germicidal [a substance or other agent that destroys harmful germs] agent effective against C. difficile spores. The facility's policy titled, Isolation -Categories of Transmission-Based Precautions dated October 2018, was reviewed and indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection When transmission-based precautions are in effect, non-critical resident-care equipment (thermometers, pulse oxygen machines, and glucometers) will be dedicated to a single resident when possible. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. The facility's policy titled, Cleaning and Disinfecting Residents' Rooms dated August 2013, was reviewed and indicated, 1. Housekeeping surfaces (floors and tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected on a regular basis .and when surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 1. A review of Resident 3's admission record dated 1/6/23, indicated that Resident 3 was admitted on [DATE] with diagnoses that included, COVID-19 (Coronavirus disease, a respiratory infection), urinary tract infection, and dementia (a loss of memory, language, problem-solving and other thinking abilities). A review of Resident 3's lab results for C.diff testing indicated that Resident 3 had tested positive for C-Diff on 1/14/23. On 1/24/23 at 11:59 pm, a sign was observed on Resident 3's door that indicated, Contact Enteric [vomiting or diarrhea] Precautions, Everyone Must: Clean hands with sanitizer when entering room, wash with soap and water upon leaving room. Gown and glove when entering the room. Doctors and staff must: Use patient dedicated or disposable equipment. Clean and disinfect shared equipment before leaving room. A review of Resident 4's admission record dated 1/13/23, indicated that Resident 4 was admitted on [DATE] with diagnoses that included diabetes, muscle weakness and the need for assistance with personal care. A review of Resident 4's lab results dated 1/17/23, indicated that Resident 4 had tested positive for C-Diff. During an observation and interview on 1/27/23 at 12:08 pm, with CNA F, Resident 4's door was observed to have a sign posted titled, Contact Enteric Precautions . CNA F confirmed that Resident 4 was on isolation for C-Diff and had been for about a week. a. On 1/24/23 at 1:47 pm, an interview was conducted with HSK C. HSK C indicated that she was assigned to clean Resident 3's room, but did not know why the resident was on isolation. HSK C indicated that she was not aware of any special cleaning products that needed to be used in Resident 3's room, and continued to clean 10 other rooms after that. On 1/24/23 at 2:18 pm, an interview was conducted with the Housekeeping Supervisor (HSKS). HSKS indicated that he was not aware of any residents in the facility who had C-diff, or that rooms with C-diff contamination required any special cleaning solutions. On 1/27/23 at 1:07 pm, an observation and interview was conducted with HSK D. HSK D indicated that he cleaned Resident 4's room, and 11 other rooms after that. HSK D indicated that he was not aware that Resident 4 had C-diff or that rooms contaminated with C-diff required disinfectants that killed C-diff spores. HSK D indicated that he had cleaned Resident 4's room earlier in the day with, Room Sense 200 Disinfectant and Neutral Multi-Purpose Floor Cleaner. An observation with HSK D of the labels on the Room Sense and Neutral Multi-Purpose cleaners indicated that they would not kill C-diff. HSK D confirmed the cleaning solutions he had used to clean Resident 4's room would not kill C-diff. On 1/27/23 at 1:30 pm, an inteview and concurrent observation was conducted with the DON and HSKS. The Environmental Protection Agency (EPA registered cleaning products, their uses, and protection of the environment and humans), List K: Antimicrobial products Registered with EPA for Claims Against Clostridium Diffficile dated June 15, 2016, was reviewed with the DON and HSKS and both confirmed that Room Sense and Neutral Multi-Purpose floor cleaner were not listed as cleaners on the EPA's list that would kill C-diff. The DON indicated that a bleach product or EPA registered product specifically to kill C-diff should have been used and was not. The HSKS confirmed the facilty was out of bleach and bleach containing products. b. On 1/27/23 at 12:59 pm, an observation and interview was conducted with LN C. LN C indicated that she had checked Resident 4's blood sugar earlier that day with a glucometer that she was not able to disinfect afterwards because she did not have any disinfecting supplies available. LN C confirmed that her medication cart held medications for 17 other residents, and that she had put the contaminated glucometer back into her medication cart after checking Resident 4's blood sugar, without disinfecting it. LN C indicated that she did not know what disinfectant should have been used to kill C-Diff. On 1/27/23 at 1:27 pm, the HSKS and DON were interviewed. The HSKS indicated that the glucometers could be disinfected with Purell Food Service Surface Sanitation wipes (alcohol) and/or Health Care Clorox (Bleach) wipes, but confirmed that the facility did not have the Health Care Clorox wipes available, they are on backorder. The DON indicated that Purell Food Service Surface Sanitation wipes would not kill C-diff, because they are alcohol based and alcohol does not kill C-diff. The DON indicated that the Clorox bleach wipes would have been the appropriate disinfectant to use to disinfect the glucometer in order to kill C-diff, I expect my nurses to know this. The DON confirmed that LN C should not have put the contaminated glucometer back into her medication cart after she used the device on Resident 4. The DON indicated that he was not aware that the facility had ran out of Clorox wipes. c. On 1/27/23 at 12:54 pm, CNA E was interviewed. CNA E confirmed that she was aware that Resident 4 had C-diff. CNA E indicated that she had used a thermometer and pulse oximeter on Resident 4 that day and several days before that, and had used alcohol to wipe off the equipment. CNA E confirmed that she continued to use the same thermometer and pulse oximeter on the rest of her 9 residents. CNA E indicated that she did not know that alcohol would not kill C-diff and stated, we should have adequate cleaning stuff and this patient should have dedicated equipment and they should have provided us with that, they should have told us. 2. The facility's policy titled, Clostridium Difficile dated October 2018, was reviewed and indicated, Residents with diarrhea and suspected CDI [C-Diff Infections], are placed on Contact Precautions while awaiting laboratory results. The facility's policy titled, Isolation-Categories of Transmission-Based Precautions dated October 2018, was reviewed and indicated, The individual on contact precautions will be placed in a private room . During a review of Resident 3's nursing progress notes dated 1/12/23 at 10:07 am, LN L documented, Resident is having more than three loose stools per day for the third day .send a stool specimen to the lab to check for C-Diff. During a review of Resident 3's lab results for C-Diff dated 1/14/23, the results revealed that Resident 3 was positive for C-diff from the stool sample that was collected on 1/12/23. During a review of Resident 3's nursing progress notes dated 1/14/23 at 1:04 pm, the DON documented, Results of stool testing show C-Diff. Resident moved to a private room for contact precautions. On 2/10/23 at 3 pm, an interview and concurrent review of Resident 3's record was conducted with the Infection Prevention nurse (IP). The IP confirmed that Resident 3 was having symptoms of C-diff (diarrhea) and was therefore, suspected to have C-diff on 1/12/23, but was not placed in a private room with Contact Precautions until 1/14/23. The IP indicated that Resident 3 should have been placed in a private room and on Contact Precautions on 1/12/23, when she was first suspected to have C-diff, to avoid spreading the infection to others and that was not done. On 2/10/23 at 4:15 pm, the DON confirmed during an interview that Resident 3 should have been moved to a private room and placed on Contact Precautions on 1/12/23 instead of on 1/14/23, and that the facility had not followed their infection prevention policies. 3. The facility's policy titled, Appendix D-Linen and laundry management dated March 27, 2020, was reviewed and indicated, Always place it [soiled laundry] in the designated container. Carefully rollup soiled linen to prevent contamination of the air, surfaces, and cleaning staff. Place soiled linen into a clearly labeled, leak proof container (e.g., bag, bucket). The facility's policy titled, Appendix G-Laundry and Bedding dated November 5, 2015, was reviewed and indicated, The contaminated textiles and fabrics are placed into bags or other appropriate containment .these bags are then securely tied or otherwise closed to prevent leakage. On 1/24/23 at 11:13 am, an interview and observation was conducted with Resident 2. A pair of wet pants were observed laying on the floor of a cabinet under the TV in Resident 2's bedroom and not contained in a bag or laundry basket. Resident 2 indicated that the cabinet was where his dirty laundry was kept and indicated that his pants were wet with urine from that morning and his CNA threw the wet pants in the cabinet. On 1/24/23 at 11:52 am, during an interview and observation, CNA E confirmed that she had put those urine soaked pants of Resident 2 on the floor of the cabinet in his bedroom. CNA E confirmed that there was no laundry basket in the cabinet and indicated that she should have put them in a bag. On 1/24/23 at 11:59 am, an observation and interview was conducted with Resident 3. A pair of wet flannel pants were observed on the floor of the cabinet under her TV, and were not contained in a plastic bag and there was no laundry basket in the cabinet. Resident 3 indicated that those flannel pants were soaked with urine from the night before and her CNA threw them in the cabinet. On 1/24/23 at 2:18 pm, during an interview with HSKS, he indicated that dirty, wet or soiled laundry should be put into plastic bags before going into the cabinet. On 1/27/23 at 12:54 pm, an observation and interview was conducted with Resident 10. A wet blanket was observed in the cabinet under the TV in Resident 10's bedroom. Resident 10 indicated that his blanket was wet with urine and thrown into the cabinet without being put into a plastic bag. On 1/27/23 at 3:51 pm, an inteview was conducted with the IP. The IP indicated that the residents' dirty laundry should be put in a plastic bag before being placed in their cabinets to contain germs. The IP indicated she had been doing monitoring of this and confirmed that this practice was not being done. The IP explained that the facility did not have laundry facilities and that residents' personal laundry was being done every other day at another skilled nursing facility. She indicated the cabinet was considered a dirty area and should be disinfected by housekeeping. On 1/31/23 at 2:30 pm, an observation was conducted in Resident 11 and 12's bedroom. Soiled laundry was observed on the floor of their cabinets where the facility was also keeping their slippers, foot pedals to their wheelchairs, clean briefs (adult diapers), wash basins, and a coloring book. On 1/31/23 at 3:05 pm, an interview and concurrent observation was conducted with CNA J. CNA J confirmed that the cabinet in Resident 3's bedroom had dirty laundry, clean briefs and wheelchair foot pedals all stored together. CNA J indicated that none of those clean items should be stored with dirty laundry. 4. The facility's policy titled, Cleaning and Disinfection of Environmental Surfaces dated June 2009, was reviewed and indicated that, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standards. The CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities dated 2008, was reviewed and indicated, 2.f. Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned and disinfected or sterilized. On 1/27/23 at 12:59 pm, an observation was conducted in the Cottage unit. A counter that was measured to be 9 feet long in the resident's dining room, was pitted, dented, cracked and chipped on over half of the surface. On 1/27/23 at 1:05 pm, an observation and interview was conducted on the Cottage unit with CNA E. Two of 5 resident dining room tables were observed covered with pits and dents. CNA E confirmed that the resident dining room table surfaces contained pits and dents and could not be disinfected in that condition. On 1/27/23 at 2:50 pm, an observation and interview was conducted on the Villa unit with LN H. One cloth swivel chair in the dining room was observed to be torn and stained. LN H confirmed that the material on the swivel chair was ripped up and was filthy and could not be cleaned or disinfected in that condition. On 1/27/23 at 4:37 pm, during an interview and observation with the DON, he confirmed that the damaged countertop and resident dining room tables on the Cottage unit could not be disinfected in their current condition and needed to be replaced. On 1/31/23 at 2:45 pm, an observation and interview on the Villa unit was conducted with LN H. A counter that measured 9 feet in the resident's dining rooming was observed to be pitted, dented, cracked and chipped. LN H indicated that the countertop was not sealed anymore and confirmed there were many pits and dents on it. LN H indicated that the counter could not be disinfected anymore and was, filthy and gross. 5. The facility's policy titled, Cleaning and Disinfecting Residents Rooms dated August 2013, was reviewed and indicated, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. On 1/24/23 at 11:13 am, an observation and interview was conducted with Resident 2. Resident 2's bedroom had a large amount of corn chips, gray balls of dust, brown spots, and papers on his floor. His bathroom had a brown smear on the toilet seat. Resident 2 indicated that his room had not been cleaned for a couple of days. He indicated that he had dropped corn chips on his floor a couple of days ago and had asked a housekeeper to clean it up, but it had not been done yet. On 1/24/23 at 11:33 am, an interview was conducted with Resident 5 who indicated that her room was not cleaned every day and that there was dust and food on her floor. On 1/24/23 at 11:36 am, an interview was conducted with HSK C. HSK C indicated that there was no daily cleaning schedule for resident rooms and indicated that she was unable to clean all of the resident's rooms during her shift therefore, some rooms did not get done. On 1/24/23 at 11:47 am, Resident 7's room was observed to have balls of dust on his floor and under his bed. On 1/24/23 at 11:52 am, during an interview and observation with CNA I, she confirmed that there was corn chips, balls of dust, and brown spots on Resident 2's bedroom floor. CNA I confirmed that Resident 2's toilet had a dried smear of a brown substance on the seat. CNA I indicated that she did not know when Resident 2's room had been last cleaned. On 1/24/23 at 1:33 pm, an interview and observation was conducted with CNA E. Resident 3's bathroom was observed to have a dried brown substance on her toilet and bathroom wall. CNA E confirmed that Resident 3's toilet and bathroom wall had a dried brown substance smeared on them and indicated she did not know when Resident 3's bathroom was last cleaned. On 1/24/23 at 2:07 pm, an interview and record review was conducted with the HSKS. The HSKS indicated that he had not been monitoring if resident rooms were getting cleaned daily and that there was not a daily room cleaning schedule. A review of the HSKS, room cleaning check off list showed that the last entry was 1 year and 1 month ago. HSKS stated that he, had not been able to get to this yet. On 1/24/23 at 2:35 pm, an interview was conducted with the DON. The DON confirmed that Resident 3 was on Contact Isolation for C-Diff and indicated that her room and bathroom should have been disinfected with bleach or an EPA approved C-Diff killing disinfectant, and that the housekeeping staff should have known this. On 1/27/23 at 11:02 am, Resident 1's Family Member (FM) 2 was interviewed. FM 2 stated that Resident 1's room was, filthy, with food on the floor and the counters and tables were always dirty. On 1/27/23 at 12:17 pm, an observation and interveiw was conducted with Resident 1. Potato chips were observed on his floor and Resident 1 stated, they clean the room about every three to four days. 6. The facility's policy titled, Concentrator Maintenance dated 8/5/09, was reviewed and indicated, clean the gross particle filter when visibly dirty. On 1/27/23 at 11:28 am, an observation of Resident 9 and Resident 10's oxygen concentrator filters (filters prevent dust, pollen, hair, mites and other contaminants from getting into the machine and infecting the resident). Resident 9 and 10's oxygen concentrator filters were observed covered in a thick brown dust. On 1/31/23 at 2:45 pm, an observation and interview was conducted with LN H. LN H confirmed that Resident 9 and 10's oxygen concentrator filters were covered in a thick brown dust and indicated that it was up to the housekeeping staff to clean them. On 1/31/23 at 4:00 pm, an observation and interview was conducted with the HSKS. The HSKS confirmed that the oxygen concentrator filters for Resident's 9 and 10 were covered with a thick brown dust and stated, they need to be cleaned. HSKS indicated that the concentrator could malfunction if too much dust got into the machine. The HSKS indicated that the nurses were responsible for keeping the filters clean and that his department did not have a policy for this procedure. On 2/10/23 at 4:15 pm, during an interview the DON indicated that the oxygen concentrator filters were to be cleaned by the housekeeping staff.

Based on observation, interview, and record review the facility failed to ensure safe smoking for 3 of 3 sampled residents, prevent avoidable harmful falls with injuries for two of two sampled residents, and did not provide a fully functioning essential call light system when: 1. Smoking residents (Resident 3, 4, and 5) were smoking on the facility grounds, without smoking assessments, supervision, and necessary safety equipment. This had the potential for fire related injuries and hazards for all residents. 2.a Resident 1 had a significant change in condition that contributed to an avoidable unwitnessed fall while gardening without supervision. This resulted in a right broken ankle and pain. b. Resident 2 had a significant change in condition that contributed to two unwitnessed avoidable falls. This resulted in an injury to her left knee that required emergent surgery to repair. 3. An essential communication call light system did not function for all residents since July 2019. This had the potential to put all residents at risk for accidents and hazards and neglect. An Immediate Jeopardy (IJ) that was declared on 3/6/2020 at 2 pm, for failure to provide a system to prevent smoking hazards, prevent falls, and ensure a working call light system. An immediate corrective action plan to address unsafe smoking, prevent falls and interventions to ensure residents were able to call for assistance until call lights system functioning was provided by the facility's administrator on 3/6/2020 at 6:03 pm. The IJ was abated on 3/12/2020 at 11:50 am, after verification systems were in place to ensure residents were free from accidents and hazards. Refer to F 580, F 622 and F 919. Findings: 1. A review of a facility policy titled, Smoke Free Campus Policy, revised 3/18/2016, indicated smoking is dangerous, poses serious risks to residents' health and safety. The facility is a 17 acre smoke free environment. Skilled nursing residents' and visitors are to remain smoke free during their stay on our campus. Smoking by residents is permissible only through authorized leaves of absence off the 17 acre campus. A resident or visitor shall not cause or aid another resident to violate any of the terms of the smoke free campus policy. A review of a facility policy titled, Smoking, revised August 2017, indicated ashtrays of safe design shall be provided in areas where smoking is permitted. Residents who smoke will be assessed initially when they voice their interest to smoke, then quarterly and when there is a significant change. Residents will not be permitted to keep smoking materials in their possession unless interdisciplinary team (IDT- group of different health care disciplines who discuss resident care needs) determines they can manage them, if resident keeps smoking materials they must be locked in a box or drawer. A resident who poses a risk to themselves or others as a result of their non compliant smoking behavior will be given a thirty day notice of transfer or discharge. The assessment will be documented on the interdisciplinary team Smoking Assessment. The resident physician will be notified and an order will be obtained. Resident will have a smoking care plan which includes restrictions, special equipment, and instructions. Smoking safety aprons, ashtrays, fire blanket, fire extinguisher will be available in the designated smoking area. The physician will be notified of any unsafe smoking behavior occurs. This will be documented in the medical record. A thirty day notice or transfer or discharge will be issued if the unsafe practice or behavior cannot be resolved. 1. a. Resident 5's admission record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 5 was unable to make his own health care decisions. A review of a hospital discharge progress note dated 1/9/2020 at 10:57 am, the [DIAGNOSES REDACTED]. This was sent via fax to the facility on [DATE] at 11:02 am. A review of a comprehensive resident admission assessment dated [DATE], indicated there was no response marked under the section that addressed resident smoked, it was blank. The assessment indicated Resident 5 was forgetful and confused. A review of a baseline care plan dated 1/9/2020, indicated no documentation in the section for smoking concerns. A review of a smoking assessment undated, indicated Resident did not smoke. A review of a facility smoking policy in Resident 5's record, indicated facility was a smoke free environment, physician can order a nicotine patch, resident given choice to transfer to another facility to smoke, and violation of this policy would result in a discharge or they will no longer be allowed to smoke. This form had a line drawn through the information, no signature or dates. A review of a Smoke Free Campus Consent form dated 1/12/2020, three days after admission, indicated it was signed by a Family Member (FM) 1. The consent form indicated facility was a smoke free facility, if violated they may take corrective action up to immediate eviction. A review of social services notes dated, 1/15/2020 and 1/21/2020, indicated family members wanted hospice and the question does resident smoke, Social Services (SS) documented no. A review of a care plan conference summary note dated 1/15/2020, with family members, and facility staff which included social services, activities, nursing, and therapy. The note discussed need for ongoing hospice and no mention of smoking. A review of the IDT notes from 1/9/2020 through 2/26/2020, indicated Resident 5 had fallen on 2/11/2020, going to the bathroom. There were no IDT notes found in the record that documented Resident 5 was smoking and this may be a reason for getting up without assistance. A review of a nurses note dated 2/5/2020,with no time, indicated Resident 5 was found in his bathroom smoking a cigarette. Resident 5 was educated and will continue to monitor. A review of the nursing notes, social service, IDT notes, and physician progress notes [REDACTED]. During an interview on 3/6/2020 at 9 am, FM 2 stated when Resident 5 wanted to smoke, she asked the charge nurse at the time and was informed he could smoke off property. FM 2 stated she was not sure where this was and took Resident 5 where she had seen other people smoke. During an interview on 3/12/2020 at 11 am, Certified Nursing Assistant (CNA) L stated Resident 5 smoked in his bathroom and had his smoking supplies at times. 1.b. A review of Resident 4's admission record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 4 was her own health care decision maker. A review of a comprehensive resident admission assessment dated [DATE], indicated Resident 4 smoked. A review of a smoking assessment undated and unsigned, indicated Resident 4 did not smoke. A review of a social service admission assessment dated [DATE], indicated Resident 4 did not smoke. A review of a psychiatric progress note dated 1/13/2020, faxed to the facility same day at 10:23 am, indicated Resident 4 smoked a half a pack of cigarettes a day. A review of a licensed nurses daily skilled charting dated 2/7/2020, indicated Resident 4 was seen right outside the facility with Resident 3, reminded residents it was a non smoking facility. A review of a licensed nurses daily skilled charting dated 2/18/2020, indicated Administrator was aware of Resident 4 going out to smoke and needed to sign out of the facility when doing so. A review of a licensed nurses daily skilled charting dated 2/23/2020, indicated Resident 4 continued to smoke outside and very mobile around the facility. A review of a social service note dated 2/24/2020, indicated Resident 4 tried to quit smoking and did not. A review of a smoking care plan dated 2/25/2020, indicated Resident 4 signed herself out of the facility to smoke and frequently forgot to sign out. The care plan indicated the facility smoking policy was explained to Resident 4. A review of a social service note dated 2/26/2020, indicated Resident 4 was aware facility was a non smoking and if she continued to smoke she needed to sign herself out and go off facility grounds. During a concurrent observation and interview on 2/28/2020 at 2:15 pm, Resident 4 and Resident 3 were smoking in an area outside the facility, at the edge of the parking lot near the fire lane. Resident 4 and Resident 3 both required wheelchairs for mobility. Resident 4 stated it was very difficult to get to the area to smoke, the staff were not willing to assist her due to being a non smoking facility. Resdident 4 stated although they knew she smoked before she was admitted . Resident 4 stated there was no outside lights and difficult to see in the dark. During a concurrent observation and interview on 3/5/2020 at 12:46 pm, Resident 4 smoked just outside the facility parking lot in the fire lane, near an open area with dry grass, oak leaves and many oak trees. Resident 4 confirmed there were a lot of cigarette butts all over the dry ground and had witnessed Resident 3 threw some on the ground. There were no cigarette trash receptacles in the area nor any safety equipment available. Resident 4 stated she had been smoking at the facility within one week of admission, over two months ago. Resident 4 stated she smoked on a patio behind her room at times and facility staff were aware of her smoking. Resident 4 had possession of all of her smoking supplies. Resident 4 further explained she did not feel safe in this area. Resident 4 stated the residents who smoke out in this area were Resident 3 and Resident 5 with his family, and staff from the facility across the parking lot. Resident 4 stated CNA M who worked night shift was aware she was smoking on the back patio near her room, unsupervised. During an interview on 3/5/2020 at 1:30 pm, CNA L stated she was aware that Resident 4 was smoking, she could see her when she drove through the parking lot. CNA L stated Resident 4 was smoking since she had been admitted to the facility. CNA L stated she did not inform anyone that Resident 4 was smoking. During an interview on 3/5/2020 at 1:25 pm, CNA N stated Resident 4 had been smoking at the facility for a couple of months and she never told anyone about it. CNA N stated she saw Resident 4 in the parking lot in an area that was not safe. 1.c. A review of Resident 3's admission record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 3 was able to make his own health care decisions. A review of a history and physical hospital note dated 1/17/2020, and faxed to the admitting facility on same day at 11:47 am, indicated Resident 3 was dependent on tobacco. A review of a comprehensive resident admission assessment dated [DATE], indicated Resident 3 smoked. A review of a smoking policy undated, indicated Resident 3 signed and reviewed the rules of the facility was a smoke free environment, physician can order a nicotine patch, resident given choice to transfer to another facility to smoke, and violation of this policy would result in a discharge or they will no longer be allowed to smoke. This form had a line drawn through the information, no signature or dates. A review of a social service assessment dated [DATE], SS documented that Resident 5 smoked and next to the question was there a smoking safety plan in place SS marked not applicable, nicotine patch. A review of a smoke free campus policy and consent form dated and signed by Resident 3 on 1/26/2020, indicated the facility was a smoke free facility, if violated they may take corrective action up to immediate eviction. A third smoking assessment not signed and undated, indicated Resident 3 could not walk independently, not free of sedative medications, had decline in the last three months of the ability to perform activities of daily living, could not move fast to obtain help if needed and had smoked successfully in the past without prior incident, the rest of the form was incomplete. There was no decision made based on the smoking assessment if Resident 3 could smoke independently. A review of a licensed nurse progress note dated 2/14/2020, with no time, indicated Resident 3 smoked. A review of a smoking care plan dated 2/15/2020, indicated Resident 3 required frequent reminder to sign out to smoke and been counseled many times. A licensed nurse daily skilled note dated 2/18/2020 at 3 pm, indicated Administratorwas aware of Resident 3 smoking, he needed constant reminders to sign out before going on smoke break. A review of a nurses note dated 2/24/2020 at 4:30 pm, Licensed Nurse (LN) informed Resident 3 because he drank caffeine and smoked often that this can made his blood pressure run high. A review of an IDT progress note dated 2/24/2020 at 2 pm, indicated Resident 3 checked out of the facility frequently to go off campus and smoked. The IDT members present were the DON, SS, AD, and TD. A review of a smoking care plan dated 2/25/2020, indicated Resident 3 will sign himself out of the facility and smoke off campus. A note indicated Resident 3 was advised the facility was a no smoking policy. A licensed nurse daily skilled note dated 2/25/2020 at 3 pm, indicated staff had to constantly remind Resident 3 to sign out to go out smoking. A review of a social service progress note dated 2/27/2020, indicated Resident 3 was seen outside smoking with Resident 4. During an interview on 3/5/2020 at 1:25 pm, the Director of Staff Development (DSD) stated the facility was a non smoking and was unsure which smoking policy the facility was using, there were two different ones provided, one which allowed smoking and one that did not. DSD stated nursing staff did not have access to the policies. DSD was aware that Resident 4 was smoking due to catching her once. DSD further explained residents who smoked must sign out and go off campus to smoke, and could not describe what off campus meant or where it was located. DSD stated the area where Resident 4 was smoking was not safe. DSD was aware Resident 3 was signing out to smoke and he kept his smoking supplies in his pocket. DSD stated the facility was not enforcing the no smoking policy. During an interview on 3/6/2020 at 1 pm, Admissions Assistant (AA) stated we are a smoke free facility and when we admit someone who smokes, we offer a nicotine patch. AA stated residents needed to sign the policy upon admission. AA was unsure which policy was currently being used. AA stated they admit smoking residents and was not instructed not to admit smoking residents. During an interview on 3/11/2020 at 11:45 am, SS and Director of Nursing (DON) confirmed the smoking policy was unclear, there were two policies. SS and DON stated when residents are interviewed upon admission, if they answer yes to smoking, they offered a nicotine patch. SS and DON stated they did not ask if they plan to smoke, how long they have smoked, when was the last time they smoked or if they have any smoking supplies with them. DON stated the area where all three residents (Resident 3,4,5) smoked was not safe. SS and DON confirmed once they were aware the residents were smoking, that none of the care conferences or IDT meetings discussed the issue of three smokers at the facility. The IDT did not follow the smoking policy when they did not offer or coordinate a transfer/discharge to another facility that allowed smoking when residents did not follow the rules. During an interview on 3/6/2020 at 1:30 pm, the Adminstrator (Admin) stated the facility was non-smoking. Admin stated the admission staff are not to admit any smokers and this should be assessed with [REDACTED]. Admin explained off campus was just past the front entry of the facility. Admin was unable to define the smoking policy statement of 17 acres and where the facility boundaries were which defined off campus. Admin was unaware that employees from the other facility across the parking lot were smoking in the parking lot near the fire lane and that there were many cigarette butts on the dirt and brush. Admin was unaware that the smoking trash receptacles had been moved to the staff smoking area in back of the facility. Admin was aware there were three smokers currently at the facility and explained they were instructed to sign themselves out and smoke off campus. Admin confirmed there were two policies, and was unaware which policy the facility staff were using. Admin confirmed no safety equipment in the areas residents were smoking, such as trash receptacle, fire extinguisher, fire blankets and smoking aprons due to being a non smoking facility. Admin confirmed that discharges/transfers were not offered or other facilities contacted to better accommodate smoking residents. 2. a. A review of Resident 1's admission record indicated she was admitted [DATE], with [DIAGNOSES REDACTED]. Resident 1 was able to make her own health care decisions. A review of a Minimum Data Set (MDS, an assessment tool) dated 1/13/2020, indicated Resident 1 required limited assistance, and nursing staff to provide assistance for walking on and off and around the unit. A review of a nurses note dated 1/13/2020 at 3:30 pm, Resident 1's blood sugar was too high for blood sugar machine to give a reading at 11:30 am. LN A rechecked still too high. LN A notified Medical Director (MD) who ordered [MEDICATION NAME] 100 units per milliliter (u/ml) one time for blood sugar machine reading HI, recheck in two hours. At 3:30 pm, machine still read HI, MD notified Resident 1 received another 15u/ml of [MEDICATION NAME]. A review of Resident 1's record indicated she was in the hospital for high blood sugars from 1/13/2020 to 1/19/2020. A review of a care plan dated 1/20/2020, noted that Resident 1 had poor balance, lack of awareness, intermittent confusion, impulsive behavior, and loves to work in garden which has uneven surfaces. A review of Resident 1's second hospital admission, an emergency room note dated 1/20/20 5:45 pm, indicated Resident 1 presented with confusion, nausea and vomiting, abdominal pain, and extremely high blood sugar of 995. Resident 1 presented with confusion, nausea and abdominal pain (symptoms of high blood sugar). Resident 1 was diagnosed with [REDACTED]. A safety assessment on,1/20/20 at 5:45 pm, identified Resident 1 as a fall risk and implemented interventions, including being placed close to the nurses' station for close monitoring, and frequent reorientation for confusion with standby assist with ambulation (walking). A review a hospitalist progress note dated 1/21/2020 at 1:16 pm, the physician indicated Resident 1 was a brittle diabetic (hard to control blood sugar very low to very high). A review of a admission assessment dated [DATE], indicated Resident 1 was confused. A review of a fall risk assessment dated [DATE], 1/23/2020, and 1/27/2020 indicated Resident 1 was a high fall risk. A review of Resident 1's fall care plan dated 1/23/2020, indicated Resident 1 had an actual fall 3 months ago in the garden. Physical therapy (PT) and Occupational Therapy (OT) were ordered to work with Resident 1 on goals. A review of Resident 1's activity progress note dated 1/24 /2020, indicated she liked to garden daily. A review of PT and OT progress notes for Resident 1, there were no activities related to gardening. A review of the CNA Activity Daily Living (ADL) Tracking Form ranging in dates 1/01/2020 to 1/31/2020 for morning, evening and night (NOC) shifts, indicated Resident 1 required one person assistance for walking and moving about the facility during every shift. A review of a nurses note dated 1/25/2020 at 3:00 pm, LN A documented Resident 1 had an unwitnessed fall, and was found by OT sitting on her low garden bench. Resident 1 informed OT she had fallen from the bench and into the wooden fence behind her. Resident 1 stated she lost her balance when sitting on the bench and twisted her right ankle trying to get up. Resident stated to have complained of mild discomfort to her right ankle. LN A and OT walked Resident 1 from the garden area back to her room and applied ice. A review of a OT treatment note 1/25/20 no time noted, OT indicated she found Resident 1 in the back yard (garden area) and she had swelling and bruising on the outside of the right ankle. Resident 1 reported mild pain in her right ankle with weight bearing and while at rest. A review of a nurses note dated 1/25/2020 at 3 pm, LN A documented Resident 1 presented with a finger stick blood sugar of 508 at 7:30 am, (blood sugar target 80 - 130, high level of 508 requires notification of physician), 15 u/ml was given as per physician orders, blood sugar checked again 11:30 am, it was 250. A review of a care plan dated 1/25/2020, noted that Resident 1 had increased weakness, with with delayed thoughts and word finding after recent hospitalization for unstable blood sugars. Resident 1 now restricted from garden area following her discharge until cleared by therapy. A review of an x-ray report dated 1/27/2020, indicated Resident 1 had a right broken ankle. During an interview on 2/10/2020, at 12:45 pm, the Admin stated Resident 1 was informed that she was not to go outside to the garden area without assistance, due to being more confused lately, and often did not follow instructions. During an interview on 2/10/2020, at 2:15 pm, LN A stated when she assessed Resident 1 post fall, she stated initially she was not making sense. LN A stated Resident 1's fall was related to the elevated blood sugars that day prior to the fall. LN A did not recheck blood sugar after the fall. The Medical Doctor (MD) was notified and ordered staff to monitor the resident. Resident 1 was known to spend time gardening in the garden areas, and though restricted per care plan, was allowed to continue gardening without assistance. LN A stated she worried about Resident 1's DM and labile (unstable up and down) blood sugars along with her confusion and weakness but allowed Resident 1 to go to the garden because it is what she loves to do. LN A stated she told Resident 1 that she could go to the garden that day but needed to check in with her on occasion. During an interview on 2/10/2020, at 2:40 pm, OT stated she found Resident 1 in the garden sitting on a low gardening bench. OT stated Resident 1 was not assessed to determine Resident 1's ability to utilize the extremely low gardening bench prior to its use. OT stated Resident 1 informed her that she had fallen off her gardening bench backwards into the fence. Resident 1 stated she twisted her ankle trying to get up as she slipped in the wet grass. OT and LN A walked Resident 1 back to her room which was on another wing of the facility. During a interview on 2/12/2020 at 3 pm, the Activity Director confirmed Resident 1 loved to garden, and this supervised activity had not been provided. During an interview 2/12/2020 at 3:50 pm, the DON stated Resident 1 was different when she was readmitted , significant mental change. DON expected nursing staff to notify physician for changes in condition related to pain. 2.b. A review of Resident 2's admission records indicated she was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 2 was able to make her own health care decisions. Resident 2 was admitted to room [ROOM NUMBER] which did not have a working call light and a bell was provided Resident 2. A review of a record of admissions, indicated Resident 2 was originally admitted [DATE], discharged [DATE] to home, readmitted [DATE], then discharged [DATE]. A review of a fall risk assessment dated [DATE], indicated Resident 2 at a high risk for falls. A review of a physician's orders [REDACTED]. A review of a nurses note dated 1/23/2020 in am, indicated Resident 2 was screaming for assist. Resident 2 was self transferring independently and was sitting on edge of bed complained of loss of balance. Resident 2 reported having hallucinations and does this a lot. A review of a PT note dated 1/23/2020, indicated Resident 2 had decreased alertness and reported fell earlier attempting to transfer from wheelchair to bed. A review of a IDT progress note dated 1/23/2020, indicated Resident 2 upon admission after surgeries she has episodes of [MEDICAL CONDITION] it takes her one-two weeks post surgery to recover from general anesthesia. Resident 2 hallucinated when pain medications (opioids narcotics) were administered two tablets instead of one. SS indicated nursing to notify physician with pain medication management. A review of licensed nurse's daily skilled charting indicated on 1/24/2020 in the am, Resident 2 continued to hallucinate and had confusing dreams which started last night. A review of Resident 2's IDT notes, nursing notes, physician notes and orders, there was no notification to the physician of Resident 2's ongoing hallucinations, her fall on 1/23/2020 and there were no changes in pain medication orders. There were no new fall interventions put in place to prevent further falls in her care plans. A review of a OT note dated 1/28/2020, indicated Resident 2 required verbal cues for safety and direction, she continued to complain of pain at left knee and declined any further therapy today. A note dated 1/29/2020, indicated OT and Resident 2 were present at the care conference, she had decreased alertness and fell earlier attempting to transfer from wheelchair to bed without putting the breaks on. Resident 2 reported having [MEDICAL CONDITION] and nursing reviewed medications for changing [MEDICATION NAME] to another medication to give her better pain relief. A review of a PT analysis note dated 1/29/2020, indicated Resident 2 was progressing toward goals but unfortunately went home with daughter with understanding physician did not want her putting pressure on her left leg. Resident 2 had the inability to move or weightbear without severe left lower extremity pain, standing balance, cognitive deficits, weakness and poor functional activity tolerance. Resident 2 stated her knee surgeon explained she was to limit pressure as much as possible on her surgical knee due to inflammation and severe pain. A review of an email dated 1/29/2020 at 4:05 pm, authored by the Admin to a chief marketing officer, indicated a yelp review (online rating system) written by a resident and her family member, complained staff was not being responsive to her needs and it had to do with her being admitted into a room without an operational call light. The staff gave her a hand held bell and it could not be heard when she needed assistance or medication for pain. The call light issue has not been resolved and have had several complaints regarding the staff not responding to the hand bells, they are difficult to hear away from the room. A review of a nursing note dated 1/29/2020 at 5:30 pm, indicated Resident 2 and FM 1 arrived back at facility after orthopedic appointment, discharge to home initiated. A review of an admission assessment dated [DATE], indicated the reason for Resident 2's readmission was a failed discharge on 1/29/2020 with multiple falls at home. A review of a nursing note dated 2/1/2020 at 10 am, the DON documented FM 1 called the facility on 1/30/2020 in the morning, less then 24 hours of Resident 2 being discharged to home, and reported Resident 2 fell three times last night. FM 1 requested to have Resident 2 return to the facility. Three facility staff members, took their van and went to Resident 2's home, she was on the floor, on her back between the bed and wall. Resident 2 stated she twisted her knee during the last fall, knee was swollen. Resident 2 refused to go to hospital and was taken back to the facility to room [ROOM NUMBER] B. Resident 2 complained of pain, x-ray done at facility and results were negative for injury. A review of a PT note dated 1/31/2020, indicated Resident 2 had severe pain when weight bearing from left hip and leg, instructed CNAs to have resident non weight bearing until seen by orthopedic surgeon, and recommended nursing to x-ray lower leg leg hip due to having three falls at home before coming back to facility. Resident 2 continued to have hallucinations and nursing aware due to [MEDICATION NAME]. Portable x-ray done at facility, negative for acute fracture. A review of an portable X-ray report done at the facility on 1/31/2020 at 9:24 am, Resident 2 had an X-ray of the knee with no evidence of a fracture. A review of licensed nurse's daily skilled charting indicated on 1/31/2020, in the pm, Resident 2 received one tablet of [MEDICATION NAME] and her scheduled extended release [MEDICATION NAME]. She became more confused in the night and thought there was a man in her room and needed to get out of there. A review of licensed nurse's daily skilled charting indicated on 2/1/2020, in the pm, FM 1 stated Resident 2 called her crying due to have a lot of pain and wanted her daughter to take her to the hospital. LN informed FM 1 if Resident 2 went to the hospital they would have to readmit her. FM 1 did not want that and requested pain medication to be given. LN gave Resident 2 two tablets of [MEDICATION NAME] 5 mg and later in the night she had a fall at 2:14 am. A review of a nursing note dated 2/1/2020 at 10 am, the DON documented FM 1 called the facility on 1/30/2020 in the morning, less then 24 hours of Resident 2 being discharged to home, and reported Resident 2 fell three times last night. FM 1 requested to have Resident 2 return to the facility. Three facility staff members, took their van and went to Resident 2's home, she was on the floor, on her back between the bed and wall. Resident 2 stated she twisted her knee during the last fall, knee was swollen. Resident 2 refused to go to hospital and was taken back to the facility to room [ROOM NUMBER] B. Resident 2 complained of pain, X-ray done at facility and results were negative for injury. A review of an IDT resident safety investigation and intervention note dated 2/3/2020, indicated Resident 2 had an unwitnessed fall in her room on 2/1/2020 at 9:40 pm. Resident 2 fell on to the ground next to her bed while trying to turn off her bedside lamp. Resident 2 reported seeing things that were not there, this may be due to the use of [MEDICATION NAME] and now changed to [MEDICATION NAME] long acting pain medication. Speech therapy to review for cognition and continue PT and OT. A review of a history of physical from orthopedic surgeon dated 2/3/2020, indicated Resident 2 fell and injured her left knee over the weekend. She had fallen a number of times although her last fall was so severe that she wasn ' t ' unable to weight bear any longer. Resident 2 reported falling four times since seen last, which resulted in constant severe pain when moving left leg. Resident 2 required surgery on 2/4/2020, due to a new left tibial (lower leg) fracture and required a total knee revision. During an interview on 2/11/2020, Resident 2's FM 1 stated she was in constant pain

Based on interview and record review, the facility failed to ensure an effective pain management program for one resident (Resident 1), in accordance with its Pain Management Program, Pain Assessment, and Care Plan policies when: Physician ordered pain medication ([MEDICATION NAME]) was not administered for Resident 1's severe pain (rated above 6 out of 10 (6/10) on a standardized pain scale from zero to 10, where zero means no pain and 10 means the worst possible pain); Additional pain medication was not administered for Resident 1's severe pain levels 7-10/10; and Further assessment of Resident 1's pain to determine pain control measures and aggravating factors and provide necessary interventions to manage his severe pain was not done. This resulted in Resident 1 suffering moderate to severe pain over a three day period, contributing to increased levels of frustration, and symptoms of nausea and dizziness. Resident 1 went home to the care of his family/friends, per his request, due to inadequate pain management. Findings: On 5/27/16, the Department received a complaint alleging that the facility failed to administer Resident 1 physician ordered pain medication, to control his pain and Resident 1 left the facility to go home, due to the poor care he received. Review of facility admission records indicated Resident 1 was admitted to the facility on [DATE] at 12:50 pm, from a local hospital following a total left ankle joint replacement surgery on 5/20/16. A review of the facility's Pain Management Program policy, undated, indicated the pain management program would enhance the quality of life of residents with acute or chronic pain. The policy instructed, on admission, a resident's need for a pain management program will be identified by a licensed nurse on admission, a pain rating scale will be used to assess levels of pain using a scale of 0 to 10 (zero being none and 10 being unbearable). All pain medications will be stratified as following the pain scale 0 to 10 for severity. The physician will be contacted and further orders will be requested, as appropriate. When an intervention is implemented, staff will ask the resident to rate their pain prior to and after intervention/medication. If pain medication is implemented, staff will ask the resident to rate their pain prior to medication and one hour later; and document the effectiveness of pain medicating on the medication sheet. The care plan will identify pain management. The facility's Pain Assessment policy, dated 12/2015, instructed to assess for pain and provide patient care services to ensure resident's comfort. Pain refers to any type of physical discomfort in any part of the body that may be localized in one area or more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or movement. For residents with complaints of pain, further assessment of pain is necessary to determine interventions to manage pain. Areas of assessment shall include: location, character, intensity, quality, timing, setting, aggravating/alleviating factors, manner of expression, and associated symptoms. The pain experience is subjective; pain is whatever the resident says it is or however the resident experiences it. Indicators of pain include but are not limited to moaning, crying, screaming, yelling, wincing, frowning, saddened facial expression, guarding or protecting posture, and changes in mood, behavior, or sleeping patterns. A facility care plan policy, dated 12/30/15, indicated care plans would be developed and services provided per the plan, to meet residents' highest practical, physical, mental and psychosocial well being. Review of the hospital's Discharge Summary, dated 5/23/16, documented that Resident 1's surgical procedure consisted of a total left ankle replacement, excision and curettage (removal of tissue) of a bone cyst with allograft (tissue from a donor) and a lengthening of his Achilles tendon (a tendon that extends from the heel bone to the back of the calf). A review of the hospital's discharge orders, dated 5/23/16, signed by the surgeon, included: -A copy of a prescription for [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME] narcotic pain medication used to treat moderate to severe pain) 10/325 mg tablets (quantity-100 tablets), to take ½ to 2 tablets orally every four to six hours prn (as needed); and -[MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME], an opioid [MEDICATION NAME] that produces [MEDICATION NAME]-like effects) 10/325 mg one tablet orally every 4-6 hours as needed for pain. Review of Resident 1's admission orders [REDACTED] -[MEDICATION NAME] 10/325 milligrams (mg) one tablet every 4 hours for pain, as needed for a pain level 4 to 6; and -[MEDICATION NAME] 10/325 mg, two tablets every 4 hours as needed for pain 7 to 10. Review of a nursing admission assessment, dated 5/23/16, timed Shift: at AM, and signed by Licensed Nurse (LN) A, indicated, Resident 1 was admitted from the hospital, alert and oriented to time, place and person with a swollen left ankle surgical incision which had been stapled closed. Resident 1 had limited weight bearing on his left leg and used a walker for mobility. Resident 1 rated his pain at 8/10 (severe). Review of an admission nurse-to-nurse report, dated 5/23/16 at 12:30 pm, indicated pain medication was last administered to Resident 1 at 10:30 am, prior to his admission to the facility, and his current pain was assessed by LN A to be at 7/10 pain level. A review of the facility's care plans for Resident 1 included: An Admission care plan, dated 5/24/16, indicated Resident 1 needed medical management and surgical recovery and pain was to be monitored every shift and medications were to be administered, as ordered. A Actual Pain care plan, undated, indicated Resident 1's pain was related to arthritis, recent surgery, and painful procedures. The care plan goal indicated Resident 1 would report adequate relief of pain and be comfortable evidenced by relaxed facial expression, etc. Interventions included assess and monitor pain every shift, every day, administer [MEDICATION NAME] (pain) medication, as ordered, evaluate pain control measures, identify location, duration, aggravating factors, quality, and intensity of pain, help resident identify pain control measures that reduce or eliminate pain, help resident identify factors that precipitate pain, offer warm compresses, and teach resident pain coping/prevention strategies. A review of the facility's Arthritis care plan, dated 5/24/16, indicated Resident 1 was at risk for swelling, deformity, decline, pain and discomfort. The medications prescribed for pain were documented as [MEDICATION NAME] 10/325 mg every 4 hours and [MEDICATION NAME] 10/325 mg two tabs every 4 hours, as needed. The approaches included to notify the MD if the resident's current pain is persistent and the resident was not responding to the current plan of care. A review of Nurses Notes from admission on 5/23/16 through 5/26/16 indicated: During the NOC (night shift) of 5/24/16, Resident 1 complained of pain and discomfort and was given [MEDICATION NAME]. Resident 1 complained of poor sleep and asked for a pill to help. Resident 1 was given [MEDICATION NAME] (ordered for anxiety); During the AM's shift on 5/24/16, Resident 1 complained of left ankle and foot pain, rated a 5/10, at 7:30 am. The nurse noted some anxiety from the resident when pain exists on his foot; During the NOC of 5/26/16, Resident 1 complained of pain and discomfort and was given [MEDICATION NAME]; There were no Nurses Notes documented in the AM shift of 5/26/16; and On 5/26/16 at 3:15 pm, Resident 1 was discharged home with [MEDICATION NAME] (a strong opioid painkiller used to treat moderately severe pain) and [MEDICATION NAME]. A review of the facility's 5/2016 Medication Administration Record [REDACTED]. and indicated that Resident 1 had not received the [MEDICATION NAME], as prescribed on 5/23/16, although the [MEDICATION NAME] order was transcribed on his MAR indicated [REDACTED] On 5/23/16 at 3 pm (2.5 hours after LN A had assessed Resident 1 to have 7/10 pain); On 5/24/16 at 4:30 pm for 8/10 pain; On 5/24/16 at 9:30 pm for 7/10 pain; and On 5/26/16 at 8 am for 7/10 pain, and again at 12:30 pm for 9/10 pain. Review of a Request for Removal of Controlled Substance Medication, dated 5/23/16, timed 1 pm, indicated LN A requested [MEDICATION NAME] 10/325 TABS 1/2 q (every) 4 hours for pain level 4-6; 1 TAB q 4 hours for pain level 7-10. There was no indication on the document that it had been faxed to or received by the facility's contracted pharmacy. A review of a Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 5/24/16, indicated Resident 1's pain was Pain at rest; intensity 5/10; constant, hourly, intermittent at his mid left calf, ankle and foot; aching, burning, discomforting, sharp, quick, shooting and throbbing. Pain with movement; intensity 8/10; constant, hourly, intermittent at his mid left calf, ankle and foot; aching, burning, discomforting, sharp, quick, shooting and throbbing. A physician's telephone order written by LN B, dated 5/25/16, timed at 7 pm, instructed to discontinue [MEDICATION NAME] 10/325 mg orally two tabs every 4 hours for a pain scale level of 7 to 10. The [MEDICATION NAME] order had not been clarified or discontinued for two days, approximately 54 hours while Resident 1 complained of moderate to severe pain. On 6/3/16 at 6:30 pm, Resident 1 was interviewed. Resident 1 stated he had crushed his ankle [AGE] years ago and had chronic pain to his left ankle ever since. He stated he had taken [MEDICATION NAME] 10/325 mg, prior to his ankle surgery, but after the surgery the [MEDICATION NAME] medication was not effective. He stated he was receiving [MEDICATION NAME] pain medication in the hospital and he had requested something not so strong. He stated he does not know why he did not receive the [MEDICATION NAME], as his surgeon had prescribed (a prescription was sent with him to the facility for [MEDICATION NAME]) and said the facility nurses took a long time to administer his [MEDICATION NAME] and he was very frustrated. Resident 1 stated it took so long to receive his pain medication, a nurse allowed him to take one of his [MEDICATION NAME] tablets from his own bottle, and then the nurse took the bottles of his home medications from him. Resident 1 stated he informed the facility's Clinical Coordinator (CC) that he wanted to go home after a few days because they were not controlling his pain. He stated his pain level was greater than 10 the majority of the time. Resident 1 stated he was in so much pain he became nauseated and dizzy. He stated while he was at the facility he went to a follow up appointment to see his surgeon on 5/24/16, and the surgeon said he couldn't understand why the facility was not giving him the [MEDICATION NAME] because he had sent him with a prescription. Resident 1 stated the surgeon agreed with him he should go home if his pain was not being controlled at the facility. Resident 1 stated he was in constant pain at the facility. On 6/3/16 at 6:45 pm, Resident 1's Family Member (FM) stated during a video chat phone conversation, Resident 1 was observed to be in so much pain that he was pulling at his hair. FM stated Resident 1 had told her he asked for pain medications, but would not get it for hours. FM stated she went to talk to the CC to ask what was going on and what the plan was for Resident 1's pain management. FM stated the CC was not clear, and could not explain what the plan was. FM stated she was present at the follow up appointment with Resident 1 on 5/24/16, and the surgeon stated he could not understand why the facility would not administer the [MEDICATION NAME] he had prescribed. In a follow up interview on 7/6/16 at 9:30 am, FM stated she checked her cell phone, and the day Resident 1 was pulling on his hair in pain was 5/24/16. FM stated their Pastor brought Resident 1 home from the facility when he was discharged on [DATE]. On 8/17/16 at 9:45 am, the Pastor was interviewed. He confirmed that he did pick Resident 1 up from the facility when he went home on 5/26/16. He stated when he arrived at the facility, Resident 1 was very frustrated and told him the facility staff were not taking care of him and he was not getting adequate pain relief. The Pastor stated, two days prior on 5/24/16, he and four others from the church visited Resident 1 at around 7 pm. During that visit, Resident 1 said he was in a lot of pain and had facial grimacing (a physical sign of uncontrolled pain), and said he was not receiving his pain medication. The Pastor stated, upon discharge, he observed a nurse return Resident 1's home medications and a prescription. On 7/6/16 at 10:55 am, the Director of Nurses (DON), Director of Staff Development (DSD), and CC were interviewed, and Resident 1's record was concurrently reviewed. The DSD stated Resident 1 did not get the [MEDICATION NAME] medication because it was not ordered on his discharge instructions from the hospital. Resident 1's 5/23/16 admission orders [REDACTED].when noticed. The DSD stated Resident 1 did not have any complaints of pain. The nursing admission note with the assessed pain level of 7/10 pain scale and the MAR indicated [REDACTED]. The DON, DSD and CC made no comment. The DON stated even though they have a physician's orders [REDACTED]. The DSD stated that Resident 1 did have his own [MEDICATION NAME] from home with him upon admission. On 7/6/16 at 1:15 pm, the facility's contracted pharmacy Registered Pharmacist Consultant (RPH) was interviewed and Resident 1's admission orders [REDACTED]. The RPH stated she received a fax from the hospital for Resident 1's prescriptions upon his admission to the facility, but never received the facility's admission orders [REDACTED]. The RPH stated she had not received a copy of the [MEDICATION NAME] triplicate prescription from Resident 1's surgeon and confirmed that Resident 1 did not have pain medication ordered for pain levels of 7 to 10/10. The RPH confirmed that the facility's E-kits do contain [MEDICATION NAME] medication. On 7/8/16 at 4:20 pm, LN B was interviewed. She confirmed that Resident 1 did have a prescription for [MEDICATION NAME] with him when he was admitted to the facility. LN B stated she remembered seeing the prescription in Resident 1's clinical record. She stated she handed the prescription back to him, along with his own medications he had brought from home, when he was discharged from the facility. LN B stated she called the MD for the [MEDICATION NAME] clarification because she saw it was written on his MAR, and was not administered nor in the medication cart. An emergency drug request by LN A to the pharmacy, dated 5/23/16 and timed 1 pm, was reviewed with LN B. The request was to remove the [MEDICATION NAME] 10/325 mg tabs 1/2 tabs every 4 hours for pain levels of 4 to 6, and 1 tab every 4 hours for a pain levels of 7 to 10 from the E-kit. LN B acknowledged the emergency drug request was not authorized and did not match the admission orders [REDACTED]. On 7/8/16 at 5:15 pm and 8/17/16 at 11:15 am, phone call attempts were made to interview LN A (the admitting nurse) from the phone number provided by the facility. LN A was unavailable for interview during the investigation. On 8/19/16 at 8:30 am, the DON stated all new admission orders [REDACTED]. On 8/19/16 at 2:45 pm, the DON confirmed she was not at the facility to review Resident 1's admission orders [REDACTED]. The DON stated she could not understand how the Department expects the facility to manage residents that have chronic pain and are addicted to drugs. On 8/23/16 at 3 pm, Resident 1's MAR, pain management assessments, and controlled drug records (one for the [MEDICATION NAME] delivered by the pharmacy and another of the [MEDICATION NAME] Resident 1 had brought from home) were reviewed with the DON. The DON stated Resident 1's pain was assessed and documented to be greater than 6/10 five different times, although he had no pain medication prescribed or administered for pain levels of 7 to 10/10. The DON stated Resident 1's MAR indicated [REDACTED].

Based on interview, and record review, the facility failed to prevent an avoidable fall with injury for one of three residents receiving physical therapy services (Resident 1). Resident 1 was left unattended in a bed that was raised to a height of three feet above the floor. Resident 1 fell out of the bed sustaining a broke right upper leg, a broken nose and a subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain that can cause a coma, paralysis, and even death). Finding: The facility's Record of Admission, dated 8/28/15 at 10:30 am, showed that Resident 1 was admitted to the facility on that date with [DIAGNOSES REDACTED]. She required monitoring following surgical treatment for [REDACTED]. Post operative care included the continuous use of a wound vac (a device that provided continuous suction to the wound) to assist with the wound healing process and therapies for strengthening and rehabilitation. Resident 1's Admission Nursing Assessment, dated 8/28/15, described the resident as alert to person with moderately impaired thought processes. Resident 1 was noted to be on bedrest and required total assistance for bed mobility. Physician orders, dated 8/28/15, included orders for Physical Therapy and Occupational Therapy (PT & OT) five times a week for two weeks, to evaluate and treat muscle weakness and debilitation. PT and OT treatments included therapy exercise, therapy activity for positioning in bed, and caregiver training. Physician orders, dated 9/8/15, showed that PT and OT services were increased to five times a week for eight weeks. Both services focused on increasing Resident 1's strength and mobility, both in bed and in transferring from the bed to a wheelchair. The Occupational Therapy Recertification and Updated Plan of treatment for [REDACTED]. OT assessed Resident 1's current level of function as: bed mobility equals total dependence with attempts to initiate. The PT Therapy Progress Report, dates of services 9/8/2015 - 9/15/2015 identified that Resident 1 required maximum assistance with bed mobility and the use of side rails. The short term goal was for Resident 1 to be able to move in bed using side rails and minimal assistance. On 9/22/15, Diathermy, the use of high frequency current to generate heat and increase blood flow to specific areas of the body promoting wound healing, was added to Resident 1's plan of treatment. In an interview, on 11/19/15 at 10 am, Physical Therapist (PT 1) stated that he worked with Resident 1 the day she fell out of bed. According to PT 1, Resident 1 was dependent on staff for changes in her position while in bed. PT 1 stated that he administer the Diathermy treatment to Resident 1 while she was in her room lying in bed and the bed was raised to the maximum height. Upon completion of her treatment PT 1 stated that he lowered Resident 1's bed to approximately three feet from the floor. Because Resident 1 was uncomfortable about men touching her, PT 1 left the room to find a female certified nursing assistant (CNA) to assist in reposition Resident 1 in her bed. Upon finding a female CNA (CNA 2) and telling CNA 2 that Resident 1 needed assistance in her bed, PT 1 left and returned to the PT/OT therapy room. PT 1 stated that he did not think a fall was possible for Resident 1 because she never moved. In a phone interview, on 12/18/15 at 11 am, CNA 3 stated that on 9/29/15 at approximately 4:00 pm she was working in the area of Resident 1's room. CNA 3 said she saw Resident 1 receiving a treatment from PT 1. CNA 3 stated that Resident 1 was in bed and the bed was in a high position during the treatment. CNA 3 stated that a few minutes later she heard a loud noise and immediately ran into the hallway and then to Resident 1's room. When CNA 3 entered Resident 1's room she found the resident laying on the floor. CNA 3 stated that no one else was in the room at that time and that the bed was in a higher than normal position. CNA 3 said she yelled for help and then asked Resident 1 if she was okay. CNA 3 said that Resident 1's face looked swollen around her eyes, nose and forehead, and that her knee (thinks it was the right) was swollen. Licensed Vocational Nurse (LVN 4) responded to the room and assessed Resident 1. CNA 3 stated that she remembered that Resident 1's bed had to be lowered before she and LVN 4 could put Resident 1 back into bed. During a phone interview, on 12/22/15 at 1 pm, CNA 2 described her account of what happened to Resident 1 on 9/29/15. CNA 2 stated, at approximately 4:00 pm she was in another resident's room assisting that resident out of the restroom when PT 1 came in and asked her to assist repositioning Resident 1 in her bed. CNA 2 stated that she told PT 1 she was busy changing another residents briefs and would be there to assist him as soon as possible. CNA 2 stated that shortly after that she heard a noise and then heard an overhead page, STAT (immediate response) to Resident 1 room. The STAT call was because Resident 1 was found on the floor. CNA 2 stated that when PT 1 asked her to assist repositioning Resident 1, PT 1 never indicated that Resident 1 was left alone, that the bed was left up in a high position, and that the side rails were down. CNA 2 stated that she does not know how Resident 1 fell out of the bed since she (CNA 2) had never seen Resident 1 physically move. Nurses notes, written by LVN 4 on 9/29/15, contained the following entries. At 5 pm, Resident (1) was found on the left side of the bed on floor, Resident was lying in side lying position with right leg on top of left. Resident was bleeding from her forehead and it's bruised. Right knee is swollen with bruise on. MD notified. New orders for x-ray. R/P (responsible party, son) notified regarding the fall. At 6 pm, X-ray were taken, waiting on the report. Resident in bed eating dinner. At 6:50 pm, X-ray report received, MD notified. The findings on the x-ray report, dated 9/29/15 at 6:38 pm, were that Resident 1 broke the bone in her right upper leg just above the knee. The bone broke into fragments and the end of one broken bone was firmly driven into the other. Acute distal femoral fracture with impaction at the fracture site. The nurses note continued, New orders to send patient (Resident 1) to ER (emergency room ). Ambulance called. Family and Resident notified. At 7:30 pm, Resident (1) went to hospital. The emergency room Physician Note, dated 9/29/15 at 7:52 pm, contained a physical assessment of Resident 1, laboratory blood test results, and radiology test findings. The results of Resident 1's CT scan of her head read, FINDING CONSIDERED CRITICAL TO PATIENT CARE: Minimal subarachnoid hemorrhage . Additionally, Resident 1 had a broken right upper leg, and nasal bone fractures with soft tissue swelling and bruising. Resident 1 was admitted to the hospital and treated for [REDACTED].

Based on observation, interview, and record review, the facility failed to maintain an effective infection control (IC) program designed to prevent the development and transmission of disease and infection when: The facility failed to ensure 10 of 15 sampled residents (Residents 2, 3, 4, 5, 6, 7, 10, 13, 14, and 15), 40 of a possible 59 facility residents overall, and facility employees were screened for [DIAGNOSES REDACTED] (TB, an infectious bacterial disease caused by [DIAGNOSES REDACTED] [DIAGNOSES REDACTED], which most commonly affects the lungs. It is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease). Residents 2, 3, 4, 6, 7, 10, 13, 14, and 15 did not receive initial TB screening within 24 hours of admission to the facility. Resident 5 did not receive a second step TB screening (PPD, purified protein derivative injected under the skin to check for TB). The facility's Infection Control Committee (ICC) failed to identify and correct the system failure to ensure TB screening for all residents and employees. The Director of Staff Development/Infection Control Nurse (DSD/ICN) did not have an effective IC system for tracking residents and employees TB screening to esnrue compliance with current IC standards and facility policy. These failures have the potential for TB to be spread throughout the facility (congregate living situation, more prevalent) which could ultimately result in resident, staff, and/or visitor death. The Administrator (Admin) was notified an Immediate Jeopardy (IJ) situation was identified and declared by the survey team on 3/10/16 at 2:12 pm. The facility presented a corrective action plan which included TB screening for all residents and employees who had not been screened, staff education and training in current infection control practices, and related documentation. On 3/17/15 at 10:10 am, the IJ was abated with the Admin. Findings: On 3/8/16 at 11 am, the facility's three nursing stations were observed to not have current IC Manuals. There were no IC Manuals for the nurses to refer to at the Bungalow or Cottage stations. The Villa station had an outdated (2007-2009) Infection Control Manual. Concurrently, the facility's DSD/ICN confirmed there were no up to date IC Manuals available at the nurse's stations for the nurses to refer to. A review of the facility's undated TB Skin Testing facility policy indicated the purpose was to provide guidance for TB skin testing and used CDPH - CTCA (California Department of Public Health - Control of [DIAGNOSES REDACTED] Controllers Association) Joint Guidelines as their reference. Those guidelines showed that all residents, including new and re-admissions, were to have a TB symptom screen done to identify the presence of cough longer than 3 weeks, unexplained or new onset fever, coughing up blood, night sweats, weight loss, loss of appetitive, fatigue, chest pain, and reoccurring or antibiotic resistant pneumonia. The policy instructed: All Residents shall have a two step skin (PPD) test within 24 hours of admission; PPD tests should be read in 48 to 72 hours by a licensed nurse (LN). When the site is read, it is to be palpated and measured [MEDICATION NAME] and recorded in millimeters (mm) in the medical record. Results of 0-4 mm is considered a negative reaction. A result of 5 mm or greater is considered a positive reaction. If the test is positive, the physician and family are to be notified within one hour, and a chest X-ray must be taken within 24 hours. Residents should be screened prior to admission for communicable diseases and if a resident has signs and symptoms of TB (chronic cough, bloody sputum, fever, night sweats and weight loss) a chest X-ray will be done immediately to rule out active TB. The second PPD test shall be performed within seven to 21 days; Residents discharged and readmitted after 30 days shall be considered a new admission and have the two step PPD test completed. Employees shall have PPD skin test within seven days of hire. The PPD test should be read in 48 to 72 hours by a licensed nurse and also require the 2 step process when first hired. On 3/9/16 at 10:50 am, DSD/ICN was interviewed. He stated the facility's ICC met monthly with the Maintenance Supervisor, Housekeeping Supervisor, Director of Nursing (DON), Social Services, and sometimes a Certified Nursing Assistant (CNA). DSD/ICN stated the Medical Director (MD, a physician) and the Administrator (Admin) do not attend the monthly meetings. He stated the facility's policy is to do the two step TB screening on all residents and employees, and if the TB results are positive, a chest X-ray is obtained. DSD/ICN stated the facility uses the Centers for Disease Control (CDC), California Department of Health Services, and the local Health Department as a reference and resource for infection control concerns. During the interview, a resident list or tracking log was requested for residents who received TB screening during the past year. a. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's physician's orders [REDACTED]. Read 48 -72 hours after administration. Repeat in 1 week if negative. There was no documented evidence that Resident 5 had a repeat PPD (2nd step) in his clinical record. Proof of a 2nd step PPD after admission was requested, but not provided. b. Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's physician's orders [REDACTED]. Read 48 -72 hours after administration. Repeat in 1 week if negative. A review of Resident 15's 4/2015 Medication Administration Record (MAR) indicated that she had received her TB test on 4/11/15, four days after her admission, not within 24 hours per the facility policy. c. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her record showed that her one-step TB skin test was not completed upon re-admission on 12/18/15. d. Resident 10's record was reviewed. Resident 10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence in Resident 10's medical record that she was screened for TB upon readmission. e. Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE] and was discharged on [DATE]. There was no evidence of TB screening in his medical record. f. Resident 6's record was reviewed. Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. His physician's orders [REDACTED]. Read 48 -72 hours after administration. Repeat in 1 week if negative. During an interview with LN C on 3/10/16 at 4:10 pm, she reviewed the record for Resident 6 and confirmed that all newly admitted residents should be screened for TB, that the physicians orders indicated this testing should have been done, and that there was no documentation to indicate Resident 6 had received this test. LN C was unable to clarify why this did not occur. g. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence of TB screening done within 24 hours, found in her record. h. Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. i. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Admission Physician Orders, dated 2/15/16, showed a two-step PPD test to rule out TB test was to be done on admission and annually and the orders were to be verified by a second nurse, but were not. A review of Resident 3's handwritten MARs for February 2016 showed the orders to do the [DIAGNOSES REDACTED] tests were not transcribed onto the MAR. There was no evidence that Resident 3's two step [DIAGNOSES REDACTED] test was done. j. Resident 7's record was reviewed. Resident 7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's Admission Physician Orders, dated 2/20/16, showed a two-step PPD to rule out TB test was to be done on admission and annually. A review of Resident 7's handwritten MARs for February 2016 showed the orders to do the TB testing were not transcribed onto the MAR. There was no evidence that Resident 7's two step TB test was done. On 3/16/16 at 10:40 am, Resident 7's February 2016 MARs were reviewed with ADON who confirmed the orders for TB screening were not transcribed onto the MARs nor implemented. The ADON stated there was a problem with Admission Physician order [REDACTED]. A 2016 resident TB log was provided and reviewed. The log contained columns with resident names, admitted s, when the #1 PPD step test was first administered, #2 step PPD was administered, and when the annual (yearly) test was administered. The Log listed 58 residents and the following information: -Fourteen residents had no documented 1st or 2nd step PPD screening conducted on or after admission (from 1/1 to 3/8/16); -Three residents had late or pending or need written in the columns for 1st or 2nd step PPD screening; -Thirteen residents were documented to have received their 1st step PPD screening, but not their 2nd step PPD screening; -Four residents were documented to have been readmitted and their records needed to be updated; and -Sixteen residents had N/A documented in their columns for their 1st and 2nd step PPD screening. A review of employee health physicals and PPD screening on hire and annually was conducted. The current employee list was not current or up to date. There were no records available for 6/2015, 7/2015 and 8/2015 for new hire TB screening. A total of 152 employees were on the list of employees. Seventy current employee records were reviewed. Thirty two employees' TB screenings were not done and 82 employees' screenings were missing. On 3/10/16 at 8:43 am, the MD was interviewed and stated he was not aware residents were not being screened upon admission or annually. When MD was asked how this would effect the facility, he stated, .disastrous. He stated the elder population are more likely to have it. Oh my gosh everyone here could come down with it. They could get reactivated. On 3/10/16 at 9:20 am, DSD/ICN was interviewed and stated he had been in his position since 11/2015. He stated he thought there were eleven or twelve residents that did not receive their TB screening on admission. He stated that he reviewed this information weekly .at a minimum. DSD/ICN was unable to provide an accurate number of residents that did not receive their TB screening. On 3/10/16 at 11:23 am, the DON and the Assistant DON (ADON) were concurrently interviewed. The DON stated she was present for one ICC meeting. The DON and the ADON stated they were not aware of residents not receiving their TB screenings on admission. Both stated, the potential is very high, and the outcome could be catastrophic to the residents, staff, and the community. The DON stated that she reviewed all admissions, and if the TB test was positive, a chest X-ray was taken and then an annual symptom questionnaire was administered to the resident. The ADON stated that within 24 hours of admission, residents receive a TB test, and then later the 2nd step test is performed. The 1st step was read within 72 hours. He stated it is the expectation that all new employee hires receive PPD testing before working with residents and then 1 step annuals are done yearly. The ADON stated the missing employee screening from 6/15 to 8/2015 was due to another DSD that was not giving her role the attention it needed, and was no longer employed with the facility. Review of the facility's 2003 Infection Control Nurse (ICN) job description, indicated the ICN would plan, organize, evaluate, and coordinate the infection control program in accordance with current regulations and guidelines. The job description also included the responsibility of assisting in the development and implementation of a facility wide TB management control program for residents and employees. The description included the ICN would make written notes/reports monthly and as necessary to the ADMIN. The Committee function included evaluating and implementing recommendations. A review of the ICC minutes indicated there were meetings conducted on 11/19/15, 12/3/15, 12/18/15, 1/20/16 and 2/12/16. The persons that were documented as attending did not include administrative staff (ADMIN or a Registered Nurse/DON). The ICC did not identify issues with TB screening of the residents and employees. On 3/10/16 at 11:48 am, the Admin was interviewed and asked what his role was in the ICC. The Admin stated monitoring and assessments were an .ongoing inquiry process . He stated his expectation is that the 2 step TB testing was part of the admission process and if a resident had a history of [REDACTED]. If the chest X-ray was positive they would have to get some consultation from the acute hospital setting to proceed further, as needed. The Admin stated improper screening has the potential to cause possible exposure of TB to residents, staff, and visitors. He stated that the facility must re-test residents and employees if they lack proper documentation of TB screening. The Admin stated it is his expectation that employees receive PPD testing prior to working, and then yearly. The Admin was unable to clarify what happened to employee TB screening from 6/15 to 8/31/15. On 3/10/16 at 2:12 pm, an IJ was declared with the Admin for a systems failure that failed to ensure TB screening for residents and employees. The CDC 2005 guidelines for preventing the transmission of TB in health care settings indicated that the Advisory Council for the Elimination of TB (ACTE) had updated the 1994 infection control documents and the CDC has reassessed the infection control guidelines for the health care setting with emphasis on expertise to identify persons with latent (undiagnosed ) TB. Persons with latent (not active) TB are symptomatic (without symptoms) and can remain this way for many years. Approximately 5 to 10 % of latent TB will develop in a resident's lifetime usually after their immune system is weakened due to a chronic (long term) disease or an infection. TB rates are higher for persons [AGE] years and older in the United States. Persons at high risk of exposure to TB are those who share the same air space listing residents and employees of Long Term Care Facilities. Furthermore the CDC states TB Screening Procedures for Settings (or HCWs) Classified as Medium Risk. All HCWs should receive baseline TB screening upon hire, using two-step TST or a single blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (the bacteria that causes [DIAGNOSES REDACTED]) (BAMT) to test for infection with M. [DIAGNOSES REDACTED]. After baseline testing for infection with M. [DIAGNOSES REDACTED], HCWs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. [DIAGNOSES REDACTED] for HCWs with baseline negative test results). HCWs with a baseline positive or newly positive test result for M. [DIAGNOSES REDACTED] infection or documentation of previous treatment for [REDACTED]. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit. treatment for [REDACTED]. During a interview with the DON on 3/14/15 at 11 am, she stated TB screening orders (PPD skin testing) are automatic and are the only standing orders (routinely inputted on all residents physician's orders [REDACTED]. The DON stated all residents will have the same physician order. During an interview on 3/14/16 at 4:20 pm, Nurse Consultant (NC) R stated she had identified 11 residents from the Bungalow Unit, 16 from the Cottage Unit, and 13 from the Villa Unit for a total of 40 out of 59 residents that did not have initial admission TB screening, the 2nd step screening, nor their annual screening completed. On 3/15/16 at 4 pm, during an interview with NC R and NC S, they both stated they spent an entire weekend trying to recover paperwork regarding resident and employee TB screening. They stated that some were found after the IJ was declared, some were just missing, and some results were not measured in millimeters (mm). They stated the paperwork was not in the residents clinical records but should have been. A 2003 job description for the facility's DON instructed that the job duties included assisting the Infection Control Coordinator in developing, implementing, maintaining, and establishing a TB program for residents and employees. Per the CDPH - CTCA Guidelines, May 2013 (currently incorporated into facility's policy), Health Care Worker Screening was to include an annual face-to-face interview to implement the symptom-screen questionnaire which then determined whether the employee was to be excluded from work and guided the screening process. For new hires the guidelines read, TB Symptom Screen must be performed prior to employment and had not been done. On 3/16/16 at 11 am ADON was asked if he had interviewed the unscreened Health Care Workers on a face to face basis with the symptom screen questionnaire. ADON stated he had attached the questionnaire to the TB test information sheet when he handed it to the Health Care Workers. The ADON was not able to confirm the face to face interview was done, per guidelines. On 3/16/16 at 12 pm, RNA was interviewed about his TB screen. He confirmed that he was not interviewed about the symptoms but did his own questionnaire (not according to policy guidelines). On 3/16/16 at 5 pm, the Admin stated the ICN/DSD had not been supervised properly and that the DON should have been providing oversight to him. The facility presented a corrective action plan which included TB screening for all residents and employees who had not been screened, staff education and training in current infection control practices, and related documentation. On 3/17/15 at 10:10 am, the IJ was abated with the Admin.

Based on observation, interview and record review, the facility failed to have a comprehensive, effective pain management program that provided the necessary care and services to provide effective pain control and follow its pain and medication administration policies for seven of 15 sampled residents (Residents 1, 2, 3, 4, 7, 12 and 13) when: 1. The facility failed to ensure effective pain management for Resident 12 by failing to comprehensively assess, monitor, re-assess and treat Resident 12's severe, uncontrolled pain, according to policy and physician's orders [REDACTED]. This resulted in Resident 12 having to wait over 3 hours for requested pain medication, pain medication being unavailable for administration and avoidable severe, uncontrolled pain. Resident 12 expressed refusing care due to having severe, uncontrolled pain that has adversely affected her ability to participate in care, activities, and physical therapy. 2. The facility failed to ensure effective pain management for Resident 2 by failing to comprehensively assess, monitor, re-assess and treat Resident 12's severe, uncontrolled pain, according to policy and physician's orders [REDACTED]. This resulted in Resident 2 suffering severe, uncontrolled pain and frustration regarding getting her pain medications so late (or not at all) which adversely affected her sleep pattern and ability to participate in care, activities and rehabilitation therapy. 3. The facility failed to ensure effective pain management for Resident 13 by failing to administer ordered pain medication, as requested. This resulted in Resident 13 expressing fear that she won't receive pain medication when needed, and that her severe pain will continue to be uncontrolled. 4. The facility failed to ensure effective pain management for Resident 1 by failing to administer pain medication timely, as ordered by the physician. This resulted in ineffective treatment for [REDACTED]. 5. The facility failed to administer [MEDICATION NAME] sulfate extended release (MSER, a long acting narcotic) every (q) 12 hours, as ordered by the physician, and to assess Resident 3's pain each shift and before and after the [MEDICATION NAME] was administered. This failure placed Resident 3 at risk for suffering avoidable, unrelieved severe pain and adverse symptoms of narcotic withdrawal (muscle aches, restlessness, anxiety, lacrimation (eyes tearing up), runny nose, excessive sweating, inability to sleep, yawning very often). 6. The facility failed to assess Resident 7's pain each shift, as ordered by the physician, and physician's orders [REDACTED]. This has the potential for Resident 7 to suffer avoidable, unrelieved pain. 7. The facility failed to comprehensively assess and effectively manage Resident 4's severe pain and did not have pain medication ordered for pain levels of 7-10/10 (severe pain on a scale of zero, no pain to 10, the worst possible pain) and post medication pain ratings were incomplete in 13 episodes reviewed for the prior two and a half months. The cumulative effects of these failures resulted in substandard quality of care and immediate jeopardy (IJ) to the health and welfare of residents, due to the facility's ability to provide timely pain medication treatment and comprehensively assess and evaluate pain treatment effectiveness to ensure adequate pain management for its residents, IJ was declared on 3/10/16 at 7:20 pm in the presence of the Director of Nursing (DON), Administrator (Admin), and Clinical Nurse Consultant (NC R). A corrective action plan was provided by the facility's Admin on 3/16/16 at 5:10 pm. The IJ was lifted on 10/17/16 at 10:10 am with the Admin. Refer to F333, F353, F354, F425, F490, F493, F501 and F520. Findings: 1. The record for Resident 12 was reviewed. Resident 12 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's most recent Minimum Data Set (MDS, a resident assessment) indicated she had no difficulty with thoughts or memory. A review of a physician's orders [REDACTED]. A physician's orders [REDACTED]. (A numerical pain scale is used to rate levels of pain. Zero, meaning no pain, up to 10, meaning the worst possible pain). A review of physician's orders [REDACTED]. [MEDICATION NAME] (a long acting patch placed on the skin that releases pain medication) 12 micrograms (mcg) (apply every) 72 hours; Tylenol 325 mg two tablets (every) four hours (as needed) for mild pain scale 1 - 3; and [MEDICATION NAME] 325 mg/5 mg one tablet (every) four hours (as needed) for pain level 4 - 6. [MEDICATION NAME] 325 mg/5 mg two tablets (every) 4 hours (as needed) for pain level 4 - 6. A review of the facility's Medication Administration Records (MARs) for Resident 12 from 11/2015 to 3/2016 were reviewed and indicated the following: The 11/2015 MAR indicated six days licensed nurse (LN) staff documented Resident 12's pain rated from 6-9/10 during their shift. [MEDICATION NAME] two tablets was administered 40 times, but time of administration and/or pain assessment of Resident 12's pain was only documented 28 of 40 times. Only two of the 28 documented pain assessments included a numerical rating after pain medication administration. Resident 12 refused care on 11/14/15 and 11/15/15 due to uncontrolled pain. The 12/2015 MAR indicated two [MEDICATION NAME] tablets were administered to Resident 12 50 times in the month of December. Only 25 of 50 entries included the time this medication was given or recorded Resident 12's pain level. Each of the 25 documented pain rating levels were 8-10/10 (above the pain level the [MEDICATION NAME] was prescribed for). Only six of these 25 entries included a post pain medication administration pain scale numerical rating. All other assessments were left blank or entered a subjective response of effective or helpful. Resident 12 had refused care due to pain on 12/2/15, 12/5/15, 12/9/15, 12/16/15, 12/19/15, and 12/26/15 (6 days). The 1/2016 MAR indicated two tablets of [MEDICATION NAME] was administered 58 times. The time of administration and the resident's pre pain medication administration pain assessments were documented only 29 of 58 times. Twenty seven of these 29 entries indicated Resident 12 rated her pain as 8-9/10 (above the pain level [MEDICATION NAME] was prescribed for). Only one of 58 entries included an assessment of Resident 12's pain after medication had been administered. The 2/2016 MAR indicated two tablets of [MEDICATION NAME] was administered 47 times. LN staff documented a time of administration and assessment of Resident 12's pain only 33 of 47 times. On two occasions, Resident 12 rated her pain as 7/10, eleven times it was 8/10, 13 times it was 9/10 (above the pain level [MEDICATION NAME] was prescribed for). Resident 12's pain was not consistently re-assessed after medication was administered, a numerical pain scale rating was only documented three times, and post pain medication re-assessment was left blank twice. There were six entries that indicated effective, but gave no numerical pain rating. The 3/2016 MAR indicated two tablets of [MEDICATION NAME] was administered 31 times. LN staff documented an assessment of Resident 12's pain prior to administering medication only 15 of 31 times and post pain medication administration assessment only 11 of 31 times. Two of 11 post medication assessments had no numerical pain rating; only helpful was documented. During an interview with the Director of Nursing (DON) and Assistant DON (ADON) on 3/10/16 at 6:42 pm, both confirmed that every time an as needed medication for breakthrough pain was administered, staff should have documented a numerical pain rating before and after the resident received medication. Both stated that, for scheduled medications (given at set times daily), staff only asses that the medication was effective, and do not use a numbers scale. The ADON was unable to clarify how the residents overall pain management needs could be adequately reviewed without objective data, such as a numerical pain rating. The DON stated that the physician sees residents and speaks to them about their pain. During an interview with Resident 12 on 3/11/16 at 9 am, she stated she had chronic poorly controlled pain in her legs and shoulders. She stated she had seen her physician in the hallway, but said he had not ever spoken to her about her pain, and stated she was unable to catch him to report her ongoing pain issues. Resident 12 stated her pain is generally 8/10 (very severe) before she receives medication and generally 6/10 (moderately severe) after she receives pain medication. Resident 12 stated staff rarely reassess her after administering pain medication. Resident 12 stated she had refused care, such as showers, due to uncontrolled pain and her pain affected her ability to participate in activities and physical therapy. Resident 12 stated she had recently waited over three and a half hours for night shift staff to provide her pain medication. Resident 12 stated the night shift nurse does not give her the pain medication she requested and she had to wait for the day shift nurse to arrive before she received medication. Resident 12 stated that this resulted in her inability to participate in her care the next day, due to exhaustion and it took much longer for the medication to reduce her pain. During an interview with Licensed Vocational Nurse (LVN) H, on 3/11/16 at 11:40 am, he acknowledged he was the only nurse available to provide resident care during the night shift. LVN H stated he had recently been an hour and a half late providing pain medication to Resident 12, but that it had only occurred once sometime last week and described Resident 12's demeanor the next day as loud in the morning when she saw him and that Resident 12 yelled at him. LVN H stated Resident 12 is experiencing restless legs and asserted that she was not having actual pain and was requesting pain medication inappropriately to treat her restless legs. LVN H stated, To the best of my knowledge every resident has full pain management. During an interview with Licensed Nurse (LN) F on 3/14/16 at 10:45 am, she reviewed Resident 12's record and confirmed that the physician's orders [REDACTED]. LN F acknowledged that LN staff had documented Resident 12's pain level above 6 on multiple occasions and that the resident did not have any medication ordered to treat pain at that level of severity. LN F stated the physician's orders [REDACTED]. LN F was unable to find any documentation that the order was clarified with the physician or that medication orders for pain levels above 6/10 was obtained. During an interview with Resident 12 on 3/15/16 at 9:30 am, she stated, during the night of 3/13/16, staff ran out of her pain medication. Resident 12 stated that she was not provided any medication for break through pain until the day shift nurse came, on the morning of 3/14/16, and obtained her pain medication. Resident 12 stated, Oh it was terrible, just terrible, and described that throughout both the PM shift and Night shift, her pain was severe and uncontrolled. When asked to describe how her uncontrolled pain effected her, Resident 12 stated, I was so messed up after that and complained she was unable to participate in activities, felt foggy headed due to lack of sleep, and that it took much longer for the medication to reduce her pain. During an interview with LN F on 3/15/16 at 11:10 am, she reviewed the 3/3016 MAR for Resident 12 and confirmed that Resident 12 had complained of uncontrolled pain at the beginning of her shift (am) on 3/14/16 and that staff on the night shift had reported they had been unable to medicate the patient, due to an inability to obtain medications from the E-Kit (emergency drug supply kit that contains limited doses of medications for use in case of an emergency) without an authorization from the pharmacy. LN F stated that she discovered the fax machine was broken and pharmacy had not received the requests to access the E-Kit. LN F stated staff could have phoned pharmacy to confirm they had received the request, but was unable to find any documentation this had occurred. LN F stated that LN staff had documented administering two tablets of [MEDICATION NAME] on 3/13/16, but there was no time or assessment documented on the MAR for this medication. LN F confirmed that Resident 12's pain went uncontrolled until 7:30 in the morning when she called the pharmacy and received consent to obtain pain medication for the resident from the E-Kit. The facility's 3/2016 Controlled Drug Record (documentation of administration of narcotic medications) for Resident 12's [MEDICATION NAME] was reviewed. Staff LNs documented Resident 12 received two tablets of [MEDICATION NAME] on 3/13/16 at 8 pm. Documentation indicated that the [MEDICATION NAME] given at 8 pm was the last available to Resident 12. During an interview with the Medical Director (MD) on 3/15/16 at 3 pm, he stated that there was insufficient staff to provide residents with non-pharmacological (not medication based) treatments such as massage. He stated there was no administrative oversight to ensure that residents were being provided adequate care and receiving their medications in a timely manner. (Refer to F 353, F 354, F 490, and F 493). During an interview and record review with LN U on 3/17/16 at 2:25 pm, she reviewed Resident 12's record and the MARs for 11/2015, 12/2015, 1/2016, 2/2016, and 3/2016. LN U confirmed the lack of documentation of medication administration times, pre medication assessments, and post medication assessments. She confirmed that every time an as needed pain medication was administered, LN staff should have been numerically assessing Resident 12's pain, prior to administration, then an hour after, and that these assessments should have been documented on the MAR. LN U confirmed that Resident 12 had refused care multiple times in November and December 2015 and that the LNs should have assessed the resident and treated her pain, but there was no documentation to indicate assessments had occurred or to indicate that Resident 12's severe pain was being communicated to the physician and addressed. LN U stated, resident care comes first so charting doesn't get done because we are short staffed and have heavy workloads. LN U confirmed it would be difficult for the physician and staff to ensure Resident 12 had adequate pain control without consistent, accurate, objective assessments. The facility's undated policy and procedure related to pain management indicated, The pain rating scale will be used to assess levels of pain using a scale of 0 - 10 . 10 being unbearable . All pain medications will be stratified as following the pain scale 0 - 10 for severity . When an intervention is implemented, the staff will ask the resident to rate their pain prior to the intervention, and after an appropriate time period has lapse. Effectiveness of the intervention is summarized in the weekly nurse's notes . If pain medication is implemented, the staff will ask the resident to rate their pain prior to medication and one hour later; effectiveness of pain medications is documented on the medication sheet. A review of the facility's policy titled, Administering Medication, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section listed 20 rules to be followed: . #3.) Medications must be administered in accordance with the orders, including any required time frames. #4.) Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. #13.) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. #14.) The individual administering the medication must initial the residents MAR on the appropriate line after giving each medication and before administering the next one. #15.) As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection sit (if applicable); e. Any complaints/symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. and #20.) If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. 2. In an interview with Resident 2, on 3/10/16 at 3:45 pm, Resident 2 expressed her frustration regarding getting her pain medications so late (or not at all) that she is only getting a few hours of sleep and either misses or is not able to function well in her rehabilitation therapy or participate in activities. Resident 2 expressed that she experiences a lot of pain especially at night and that she has had a hard time controlling her pain. Resident 2 stated that many times she cannot get medication for pain until she has waited for hours and by the time her pain medicine is given, her pain is out of control. Resident 2 stated that this happens with one particular nurse that works the night shift (LVN H). Resident 2 stated that when she requests pain medication at night, LVN H asks her what is the level of her pain and, if she states that the level of pain is 8, 9 or 10/10, LVN H tells her that if her pain level is that high then he needs to send her to the hospital right away for care. Resident 2 stated, One night I asked for pain medication for my right shoulder. The first thing he asked was what level was the pain. I told him my shoulder pain was at 8. He approached the side of my bed, flipped back my covers and said I think you need to be repositioned. He proceeded to poke me in my shoulder asking me, 'Does that hurt, does that hurt?' I almost started to cry, but I would not let him see me do that. He is just mean sometimes and he makes you feel stupid by the way he talks to you. Now I don't talk to him at all if I can help it. Resident 2's record was reviewed and indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was to receive physical therapy, occupational therapy, as well as, non-medication pain control techniques and pain medications. A review of the facility's MDS, dated [DATE], indicated Resident 2 is alert and oriented to person place and time, has no cognitive impairment, and is able to make her needs known and make her own decisions. A review of physician's admission orders [REDACTED]. On 2/18/16, the [MEDICATION NAME] order was changed to 10/325 mg one tablet three times daily for pain and every 4 hours as needed for breakthrough pain (no specified pain levels were indicated). A review of an undated Potential Pain care plan, developed by a LVN and not reviewed or evaluated by a registered nurse, indicated Resident 2 had the potential for pain due to a fracture (broken bone, location not indicated). The care plan goals included using the pain scale to describe pain daily, ensuring adequate pain relief, and that Resident 2 would have no complaints of pain. The interventions included daily pain assessments every shift, administering pain medication, monitoring for pain related behaviors (not specified), report pain to the charge nurse, help resident identify pain control measures that reduce or eliminate pain, offer warm compresses, teach pain coping strategies, the importance of reporting pain, and about pain medications. A review of a LN Weekly Summary, dated 2/16/16, indicated Resident 2 rated her pain as 8/10 (severe). The Physical Condition section indicated, Continue on current orders and the Resident Progress toward Goals/Expected Outcomes Addressed in Plan of Care, indicated, Works towards current POC to achieve goals. In an interview with the ADON on 3/10/16 at 6:40 pm, regarding Resident 2 and pain control, the ADON stated that he had recently worked on the night shift twice and became aware of complaints regarding Resident 2 and pain control concerns. The ADON stated he talked to LVN H about Resident 2's pain medications, however he did not follow up with Resident 2. The ADON stated, (LVN H) creates anxiety for (Resident 2). When asked if another nurse could care for Resident 2, the ADON stated, There is no other nurse on the night shift. A review of the facility's February 2016 MAR (Medication Administration Record) indicated the MARs provided for review did not include the [MEDICATION NAME] order. Resident 2's scheduled [MEDICATION NAME] 10/325 mg was to be given three times a day at 8 am, 12 pm, and 4 pm in the afternoon. There were no scheduled pain medications to be administered between the hours of 4 pm until 8 am (a 16 hour period). Therefore, if Resident 2 needed prn pain medication between 4 pm and 8 am, she would have to ask for it from the nurse on duty, including the night shifts when LVN H was on duty, unsupervised. Resident 2 had a physician's orders [REDACTED]. Rotate site. Start once available. The orders included to monitor pain level every shift and assess pain on a scale of 1-10. No orders were written for severe pain (a 7-10 rating). The March 2016 MAR indicated Resident 12 included Administer [MEDICATION NAME] 50 mcg one patch [MEDICATION NAME] now. 5 pm. Site. There was no order date indicated. The first documented application of the [MEDICATION NAME] was on 3/12/16. The MAR included 03/12/16 Monitor Pain Q (every) Shift (0-10). There was no documented pain monitoring from 3/1 to 3/8/16. The MAR also included, 3/12/16 [MEDICATION NAME] Patch 75 mcg 1 patch Q 72 hours for pain mat. Rotate site. Start when available. This entry was signed as being carried out on 3/14/16 at 5 pm (neither of the two previous [MEDICATION NAME] orders were discontinued, posing a risk for an overdose of opioid and the several dates of no documentation as to whether the medication was ever applied or not, could result in Resident 2's pain level worsening, not being controlled and ineffective pain management). A review of a LN Weekly Summary, dated 3/7/16, indicated Resident 2 rated her pain as 8/10 (severe). The Physical Condition section indicated, No change past week and the Resident Progress toward Goals/Expected Outcomes Addressed in Plan of Care, indicated, Continue on current care plan. In an interview on 3/11/16 at 6:30 pm, Resident 2 stated the pain medications are not controlling her pain, especially at night and that if she is asleep at night, LVN H will not wake her up to administer her medications, and if she is awake, she does not see LVN H and he does not answer her call light. 3. Resident 13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 13 had undergone numerous surgeries including gastric bypass (a surgical procedure in which the stomach is divided into a small upper pouch and a much larger lower remnant pouch and then the small intestine is rearranged to connect to both), hysterectomy, lumbar (back), shoulder, knee surgery, rod insertion and removal of the right and left femur, has had chronic pain for many years, and attempts to control her pain through medications, therapy, positioning, assistive devices, as well as unconventional methods such as music, meditation, and mind control. The facility's February and March 2016 MARs and physician's orders [REDACTED]. -[MEDICATION NAME] (potent narcotic pain medication) 4 mg, 1 tablet by mouth every 4 hours for pain; -Hysingla ER 24 hour (an extended release, long acting pain medication) 120 mg for pain management; -[MEDICATION NAME] (used for nerve pain) 600 mg every 6 hours; -[MEDICATION NAME] ( a potent narcotic) 10/325 mg every 12 hours; and -[MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 750 mg by mouth twice a day. In an interview on 3/10/16 at 11 am, Resident 13 expressed fear that her pain would not be properly kept under control, due to the lack of pain medication she was able to have or lack of administration of the medications she could have. Resident 13 stated pain medication was not administered during certain shifts by one particular nurse (LVN H). During an interview with Licensed Vocational Nurse (LVN) H on 3/11/16 at 10:30 am, he stated he was hired within the last 90 days, and had been a previous employee as well. LVN H stated Resident 13 routinely requested prn (as needed) [MEDICATION NAME] pain medication every four hours during the night shift. LVN H stated that Resident 13 had made accusations that he was intentionally withholding her pain medication and that he informed the ADON of Resident 13's accusations a couple of weeks ago. LVN H stated he generally attends to Resident 13's request for pain medication within an hour window and tries not to exceed one hour past the time a resident requests pain medication, but he is the only licensed nurse (LN) on the night shift to care for 59 residents. LVN H stated there was an incident when Resident 13 may be referring did not get her pain medication during a night shift when an emergency occurred. LVN H stated, (Resident 13) tells me her pain scale is 15, prior to administering her pain medication. He stated that he felt when Resident 13 says she has 15 out of 10 pain, she needs to be sent to the hospital because he cannot control her pain . No greater than 9, I need to send her out. LVN H stated on one occasion, Resident 13 came to him outside of her room to the medication cart in her wheel chair to obtain her pain medication. He stated, pain is subjective (personal opinion) and that he tries to make his assessment using all his skills to include neurological checks (assessment of pupil reaction, consciousness, motor, sensory brain function and vital signs) if he feels a resident is receiving too much narcotics. LVN H stated that Resident 13 has expectations that she wants to be awakened for her pain medication during the night shift, and had asked why she was not awakened. LVN H stated he will only wake residents up if they have routine medication prescribed. LVN H was asked about documenting residents' pain assessment and administration of pain medications on the MARS. LVN H stated he tries to document residents' pain results after 30 minutes of administering them and their effect. He stated he often writes helpful if the resident is sleeping, he will not wake up the resident, and will write effective on the MAR when they are sleeping. When LVN H was asked what the facility policy was on assessing effectiveness of pain medication administration he stated, I don't know. On 3/11/16 at 11:45 am, the ADON confirmed that he became aware of Resident 13's allegation of neglect by LVN H and not receiving her pain medication timely on 2/28 or 2/29/16 when he had worked. The ADON stated there was no care conference or investigation started and the allegation had not been reported. 4. Resident 1's record, was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of the facility's MDS, dated [DATE], indicated Resident 1 could not walk and required assistance from staff for transfers, dressing, and hygiene, and required routine and prn (as needed) pain medication to manage her 9/10 (severe) leg/feet pain. On 3/11/16 at 8:30 am, Resident 1 stated that about a month ago she complained to the ADON that a male nurse (not a current employee) that worked the day shift for two days did not give her pain medications or her routine morning medications until the evening shift (approximately 2 pm to 11 pm) arrived. Resident 1 stated this made her very frustrated, made her upset and mad. (Resident 1 was alert, oriented to self, place, season, and time of day during this interview). Resident 1 stated she has constant pain to her legs and feet with the worst pain being a 9/10, on a scale of 0 to 10. On 3/11/16 at 7:25 am, Certified Nursing Assistant (CNA DD) was interviewed. She stated she works the night shift and that it can take up to 45 minutes to 1.5 hour for residents to receive their pain medications, especially if an emergency occurs. She stated she recalls Resident 13 getting out of bed twice to look for LVN H so she could get her pain medication. CNA DD stated that on several occasions Residents 1, 2, 12, and 13 complained of not receiving their pain medications on the night shift. She stated a couple of weeks ago, after work, the facility had an in-service to prepare for the State coming and . where we brought up the pain complaints . to the Director of Staff Development/ Infection Control Nurse (DSD/ICN). On 3/11/16 at 11:45 am, the ADON stated he worked the floor on a evening shift either 2/28 or 2/29/16 due to a nurse calling off, and Resident 1 told him she did not receive her pain medication. He stated this was not brought to the Administrator or the IDT's attention (Interdisciplinary Team, a group of professionals that meet to discuss resident care needs and plans of care), and an investigation was not conducted. ADON stated Resident 1 was not specific to when the incident occurred, and only told him it was a male nurse that did not administer her medications, although ADON was able to identify the male LN that no longer was employed at the facility. A review of the facility's undated Nursing Pain policy indicated the policy instructed the following: At the time of admission, a initial nursing assessment will be completed and will identify the need for a pain management program. The pain rating scale will be used to assess levels of pain using a scale of 0 to 10 (a standardized scale with 0 representing no pain and 10 being unbearable. If the residents are unable to verbalize pain, the face scale would be used which provides visual expressions of pain. All pain medication will be stratified

Based on observation, interview, and record review, the facility failed to implement its Abuse, Protection from Adult/Elder Abuse Reporting and Reporting Known or Suspected Abuse policies to prevent and protect residents from potential willful mistreatment, abuse, and/or neglect toward residents and to investigate and report allegations of staff to residents mistreatment and neglect when: 1. The facility failed to investigate and report an allegation of mistreatment and neglect by Licensed Vocational Nurse (LVN) H toward one of 15 sampled residents (Resident 13) when it became aware of the allegation on 2/29/16. The facility failed to prevent potential ongoing willful mistreatment and neglect by LVN H toward two of 15 sampled residents (Residents 2 and 13) whereby LVN H allegedly failed to respond timely to calls for assistance and requests for pain treatment, and withholds pain medications during the night shift and that LVN H treats the residents disrespectfully. The facility continued to schedule LVN H, permitting him to work unsupervised, during the night shift, having access to all facility residents from 2/29 to 3/10/16, posing an immediate threat for residents to be potentially neglected or mistreated by LVN H. Due to concern for resident safety and welfare during the night shift and the potential for substandard care and neglect, abuse or mistreatment by LVN H, an Immediate Jeopardy (IJ) was declared on 3/10/16 at 7:20 pm in the presence of the Director of Nursing (DON), Administrator (Admin), and Clinical Nurse Consultant (NC R). In response to the IJ, LVN H was taken off the schedule the night of 3/10/16 and suspended, pending further investigation regarding this and other care concerns. A corrective action plan was provided by the facility's Admin on 3/16/16 at 5:10 pm. The IJ was lifted on 10/17/16 at 10:10 am with the Admin. Refer to F309 and F353. 2. The facility failed to contact the state certification board for two of six Certified Nursing Assistant (CNA AA and CNA BB) files reviewed to determine current certification, to verify there were no findings of abuse, neglect or mistreatment in their individual files, and to conduct previous employer reference checks, and to verify prior employment before hiring for one of five LVNs (LVN H) files reviewed. These failures had the potential for residents to be mistreated, neglected or abused by staff. Findings: 1. On 3/10/16 at 3:45 pm, during an interview, Resident 2 stated that she was upset by the manner in which LVN H, the night shift charge nurse, unstrapped the lower part of her arm sling to examine her arm and was not prompt to respond to her requests for pain medication and her pain care needs. Resident 2 expressed that she experiences a lot of pain especially at night. Resident 2 stated many times she cannot get medication for pain when she needs it and by the time her pain medication is given, her pain is out of control. Resident 2 stated that this happens when LVN H is working on the night shift. Resident 2 stated that when she requests pain medication at night, LVN H asks her what is the level of her pain, and if she states her level of pain is 8, 9 or 10, LVN H tells her if her pain level is that high, then he needs to send her to the hospital right away for care. Resident 2 stated, One night I asked for pain medication for my right shoulder. The first thing he asked was what level was the pain. I told him my shoulder pain was 8/10 (severe). LVN H approached the side of my bed, flipped back my covers and said I think you need to be repositioned. He proceeded to poke me in my shoulder asking me, 'Does that hurt, does that hurt?' I almost started to cry, but I would not let him see me do that. He is just mean sometimes and he makes me feel stupid by the way he talks to me. Now I don't talk to him at all if I can help it. Resident 2 then handed the surveyor a sealed envelope that her roommate, Resident 13, had asked her to give to the surveyor. The envelope contained hand written documentation describing Resident 13's experiences on seven different night shifts when she was having severe, unrelieved pain and was in need of her pain medications from LVN H. A review of Resident 2's record indicated Resident 2 was admitted [DATE], for wound care post surgery, rehabilitation and strengthening after sustaining a fall from which she fractured her right knee and right humerus (upper arm bone). Prior to admission, Resident 2 lived alone. She is alert and orientated to person, place, and time and able to make her needs known. Resident 2 has a history of depression, anxiety and [MEDICAL CONDITION] (brittle bone due to loss of bone tissue). According to documentation on the facility's February and March 2016 MARs (Medication Administration Records), Resident 2 had orders for Tylenol 325 mg, 2 tablets by mouth every 4 hours, as needed (prn), for pain and [MEDICATION NAME] (a potent narcotic) 10/325 mg, one tablet every 6 hours for pain. Neither of the entries indicated for what level of pain the medications were to be given. Resident 2's scheduled [MEDICATION NAME] 10/325 mg was to be given three times a day at 8 am, 12 pm, and 4 pm in the afternoon. There were no scheduled pain medications to be administered between the hours of 4 pm until 8 am (a 16 hour period). Therefore, if Resident 2 needed prn pain medication between 4 pm and 8 am, she would have to ask for it from the nurse on duty. A review of the letters written by Resident 13 indicated the following: In a letter to the Admin, dated 2/27/16, Resident 13 wrote, .my concern is not having my blood pressure monitored very much (if at all), and coming from the hospital having [MEDICAL CONDITION] .it is scary having my blood pressure go from high to low . my meds are not stabilized because your pharmacy doesn't have Hysingla (a pain control medication that she had been taking at home). Help! . I have attempted to talk to a number of people and had not gotten a lot of satisfaction . Sir, I am not sleeping and feeling pretty miserable. Please tell me what I can do? Sunday night, 2/28/16 . this morning (got meds) 9 am-1 hr late (medication) . -asked for (pain medications) at 1:45 am (because he (LVN H) is usually busy) -CNA came back 2nd time @ 2:41 when called; said he (LVN H) told her I was not to have meds til 3:30?? Got out of bed to talk to him (and not wake my roommate) & he saw me, but stayed away. Finally came back to dining room @ 4 AM & gave me another [MEDICATION NAME] (a medication used as a sleeping aid) which made me so sleepy I could not do any therapy until 4:30 pm, ANOTHER WASTED DAY! Written at 3:15 am .3/2/16 .every time (LVN H) is the nighttime nurse I know that I am going to be in for a nighttime of no sleep & a lot of pain. I asked @ 10:15 for an additional pain med as I was having hard pain & as the (evening nurse) was going off duty, she told me she was going to have (LVN H) bring it down, 'right away.' Of course, he did not come. I tossed & turned trying to get to sleep even with [MEDICATION NAME] 30 MG (another name for [MEDICATION NAME]) could not. Rang bell later, not sure of time, asked again. At 2:15 got out of bed & went to dining room where he was standing, writing in a book. He asked me my level of pain & when I said it was quickly climbing to a '10' he went through a long explanation of levels of pain & if it was really a 10 he would have to put me in the hospital. His reply was 'an 8, 9, 10 would be the same result'. I told him by this time the [MEDICATION NAME] was no longer in my system & I still had not been able to sleep due to the pain. I interrupted his long speech about taking care of 60 patients to ask, was he going to give me the meds or not? It was almost 3 AM by this time. I finally got into bed with two #5 [MEDICATION NAME] (a potent narcotic pain medication) in me. It will take another 30 minutes for the pain to calm down so maybe I can get some sleep. I expect he will be coming in @ 4 AM to give me [MEDICAL CONDITION] meds & wake up me to do so? We shall see . PAIN & NO SLEEP = NEG ATTITUDE- HATE IT! DOES NO GOOD TO TELL ANYONE. 3/2/16 WED, (4:30 AM 3/3) asked for another pain medication from (evening nurse) before she ends shift .don't remember her bringing it? (LVN H) won't. Rang the bell several times but he did not come during night until 4 AM when I saw him go across the hall. Asked where my meds were & he started with the pain level thing again. I said, (LVN H), lets not go there- just bring me my pain medicine & also my [MEDICAL CONDITION] early, please, so if I finally sleep you don't wake me up in an hour like last night . when he brought it at 4:30 AM he said he was making a note in on my chart that I'm taking too many pain pills in a 24 hour period and for (the doctor) to have order changed. He insisted on talking loudly and woke up my roommate. I don't understand why he made me go 6 hours in pain? How will I ever do physical therapy when I have had just a couple hours of sleep in 2 days? So tired! Resident 13 went on to describe her pain as Pain is in a knot in my stomach, back of legs & bad headache in #8 level. Numbness in feet now up to calves & fingers of left hand. My right hand jerks more. Resident 13 indicated her home pain medication regime was working for her and did not understand why the facility changed that and expressed that her blood pressure is not being taken by anyone except herself (with a hand held home monitor) and when she checked her own blood pressure it was 188/116 (normal is 120/80 mm Hg (less than 120 systolic AND less than 80 diastolic) for an adult age 20 or over). Friday A.M. 3-4-16 3:30 A.M. Rang for PRN med as I hadn't been able to sleep yet, pain level 8. Resident 13 described that she had been painting (to take her mind off the pain) until it was time for her pain medication so she rang her call light. The night CNA answered and went to get LVN H. The CNA returned with LVN H and LVN H brought one pain pill with him. Resident 13 explained to LVN H that she had also asked for her [MEDICAL CONDITION] medication (scheduled to be given at 6 am) so she would not be awakened in another hour. LVN H left and returned with the CNA. Resident 13 said to them, I get both of you? LVN H said, I wanted a witness. Resident 13 asked, For everyone? LVN H said, No, just this room.' From (Resident 13) room [ROOM NUMBER] A 3/6/16 to MD listing other issues she wanted to discuss with him- Dr. (MD): 1.) Knot on left side under breast VERY painful still! (approx 5 x 3) 2.) It can be felt through skin 3.) Hard cramps in lower stomach after every meal- as well as knot hurts. 4.) No fever but rarely run fever anyway. 5.) Pain started in hospital and as I [MEDICAL CONDITION] no test were done. 6.) I have had diarrhea for most of three weeks unless I take medications to make me have regular bowel movements. I am usually very regular. 7.) This is making it very hard to do therapy to get stronger. WHEN CAN I SEE YOU ?!? 3/6/16 Monday Night .2:15 AM, Called for pain medication- the CNA said she would go & find him (LVN H) as I had waited an hour before calling. I rang again I think around 4 AM as I was hurting a lot by now. Finally he came in with his witness as well, and at 4:40, received a [MEDICATION NAME] (potent narcotic) and [MEDICAL CONDITION] medication (shone his little flash light in my eyes until I asked him to stop). During an interview on 3/10/16 at 11 am with Resident 13, she complained about not seeing her physician, except for one time. She said did not get a chance to talk to him so she wrote him a letter requesting to see him on 3/6/16. Resident 13 stated that she wanted to explain to the physician that she is not pleased with her pain control regime and wants to get back to the medications she was receiving before her admission to the facility because they worked better to control her pain. She stated that at night, her pain is not controlled, and if a certain nurse (LVN H) is on duty, it will only get worse. Resident 13 continued to explain that she feels LVN H is trying to punish her because she asks for pain medication. Resident 13 stated when she asks for medications, LVN H questions her pain level. When she replies that her pain is any level above 7/10, LVN H tells her, .if you are in pain at level 7, 8, 9, or 10, then I should pick up the phone, call the doctor, and send you to the hospital. Resident 13's record was reviewed and indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13 has an extensive, long history of chronic pain and has endured numerous surgeries. Resident 13 attempts to control her pain through medications, therapy, positioning, assistive devices, as well as, unconventional methods such as music, meditation, and mind control. On 3/10/16 at 6:40 pm, during concurrent interviews with the DON and ADON, the survey team's concern for resident safety and allegations made by Residents 2 and 13 regarding LVN H were discussed. The ADON stated he was aware of Resident 13's allegation of mistreatment and neglect by LVN H on 2/29/16 and that he talked with (LVN H) at that time. The ADON stated, LVN H denied the allegations and withholding medications. The ADON confirmed he did not investigate or report the situation to the California Department of Public Health (CDPH), and the facility continued to schedule LVN H to work on the night shift, unsupervised. On 3/10/16, a review of the facility's night shift schedule indicated LVN H was the only nurse scheduled to work on the night shift from 3/10 to 3/11/16. Due to concern for resident safety and welfare during the night shift, and the potential for substandard care and neglect, abuse or mistreatment by LVN H, an IJ was declared on 3/10/16 at 7:20 pm in the presence of the DON, Admin, and NC R. In response to the IJ, LVN H was taken off the schedule the night of 3/10/16 for further investigation regarding this and other care issues. On 3/17/16 at 10:10 am, the IJ was lifted with the Admin. On 3/11/16 at 10:30 am, in an interview with LVN H, he stated he works the night shift and is the only nurse on duty to care for all residents in the facility (about 59 residents) with three CNAs on staff as well. LVN H stated he usually works four nights per week. LVN H stated, Resident 13 accused me of refusing to administer pain medications to her. That I was intentionally withholding medications from her. She expects me to give it to her right away, but I have other residents to care for. I told the ADON that I wanted another staff witness with me whenever I interact with that room. On 3/11/16 at 11:45 am, the ADON stated he worked the floor on a evening shift either 2/28 or 2/29/16 due to a nurse calling off, and Resident 13 told him she did not receive her pain medication. He stated this was not brought to the Administrator or the IDT's attention (Interdisciplinary Team, a group of professionals that meet to discuss resident care needs and plans of care), and a investigation was not conducted. ADON stated Resident 1 was not specific to when the incident occurred, and only told him it was a male nurse that did not administer her medications, although ADON was able to identify the male LN that no longer was employed at the facility. The ADON stated that he became aware of Resident 13's allegation of mistreatment and neglect by LVN H and not receiving her pain medication timely on 2/28 or 2/29/16. The ADON verified the facility did not conduct an interdisciplinary team meeting or care conference, an investigation was not done, the allegation had not been reported to the CDPH, and LVN H was allowed to continue to work unsupervised during the night shift. The ADON stated, (LVN H) creates anxiety for (Resident 2). When asked if another nurse could care for Resident 2, the ADON stated, There is no other nurse on the night shift. A review of the facility's undated Abuse, Protection From Adult/Elder Abuse Reporting indicated the policy requires facility staff to fully protect the residents' rights to be free from abuse or neglect. The facility will not tolerate any form of behavior that might be construed as abuse by .any staff member. The basic responsibility of any employee is to ensure the safety and well-being of residents. The resident has the right to be free from .other treatment with resulting physical harm or pain or mental suffering and the deprivation of goods or services that are necessary to avoid physical harm and to attain/maintain physical, mental, psychosocial well-being. (Refer to F309 and F353). A review of the facility's undated Reporting Known or Suspected Abuse policy requires all employees to report known or suspected abuse, a report shall be made in writing, using a Form SOC 341, to the appropriate agency (CDPH) within two working days, and management will help with the required reporting. 2. On 3/11/16 at 9 am, during an interview and concurrent review of employee files, the Director of Staff Development (DSD) confirmed that two of six CNA employee files reviewed did not contain evidence that the state certification board had been contacted to verify the certification, expiration date and to ensure that there were no restrictions or findings of abuse. The DSD confirmed that one of five LN employee (LVN H) files reviewed did not have proof that the facility had attempted to contact the previous employer and check for history of abuse or mistreatment of [REDACTED]. The facility's undated policy for Abuse, Protection From Adult/Elder Abuse Reporting indicated, The Facility will assure that no person will be employed who has been convicted of abusing, neglecting, mistreating misappropriating the property of any individual or has had a finding entered into the Nurse Aide Registry concerning abuse, neglect, mistreatment of [REDACTED]. The applicable registry board or licensing board is contacted and clearance is obtained, documentation of verification is entered on the employment application, .previous employers are contacted for work history verification and evaluation of work performance, . previous employers will be asked if they have any knowledge of abuse .the individual who screens the employee will sign and date the application signifying the screen is complete and accurately records information obtained.

Based on interview and record review, the facility failed to ensure that three of 15 sampled residents and one resident outside the sample (Resident 1, 3 and 15) were free from significant medication errors when: 1. The facility failed to have admission orders [REDACTED]. 2. Resident 15 received medication prescribed for another resident outside of the sample in error (Resident 16). One of the medications was an antipsychotic medication, [MEDICATION NAME] (strong tranquilizer used to manage hallucinations, paranoia and disorganized thinking, contraindicated in elderly residents due to the significant side effects). 3. Resident 3 did not receive scheduled pain medication for 10 doses and received the incorrect medication as a substitute when it ran out. These medication errors had the potential for allergic reaction, pain, narcotic withdrawal (muscle aches, restlessness, anxiety, lacrimation (eyes tearing up), runny nose, excessive sweating, inability to sleep, yawning very often) and other negative outcomes which could adversely affect residents' physical and psychosocial health and well-being. Findings: A review of a facility 2001 admission policy indicated, prior to or at the time of admission, the resident's attending physician must provide medication orders. The Administrator and the Admission Department shall assure that the resident and the facility follow their admission policy. A review of a facility policy titled, #638 Physicians Orders: Staff Responsibility indicated, all physicians' orders are noted on the order sheet by a licensed nurse (LN). The new computerized orders are checked by a LN and compared to the medication records to ensure the new list is accurate and complete. The attending physician would sign and date the new orders on his next scheduled visit. A review of a facility Administering Medications 2012 policy, indicated, medication would be administered in a safe and timely manner, as prescribed, and in accordance to the physicians' orders. 1. Resident 1's record was reviewed on 3/8/16. Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Hospitalist's (hospital physician) Progress Note, dated 3/2/16 at 11:49 pm, indicated that he had spoken to Resident 1's primary care physician (PCP) regarding her abnormal elevated blood urea nitrogen (BUN) and Creatinine (laboratory blood tests that were elevated, indicative of kidney failure). The PCP recommended Resident 1 be sent to a local hospital for [MEDICAL TREATMENT] (a procedure where toxins and wastes are removed from the blood). Resident 1's record indicated she returned to the facility on [DATE] at approximately 2:30 pm. The admission physician's orders [REDACTED]. When the admission orders [REDACTED] -[MEDICATION NAME] 100 milligrams (mg) PO (orally), one tablet q (every) day. Resident 1 received 100 mg BID (twice a day) in error from 3/4 to 3/8/16, receiving four extra doses (400 mg ) that was not prescribed; -[MEDICATION NAME] 40 mg orally every day for lower extremity [MEDICAL CONDITION] (swelling) from 3/5 to 3/8/16, without a physician's orders [REDACTED]. -[MEDICATION NAME] 200 mg ER (extended release, for obstructive lung disease) orally from 3/5 to 3/8/16 for three days was administered without a physician's orders [REDACTED].>-[MEDICATION NAME] 100 units/milliliter (u/ml, injected in fat tissue to control blood sugars in diabetics) 15 units every hour of sleep (HS) was prescribed for Resident 1 on her admission orders [REDACTED]. -[MEDICATION NAME] 500 mg orally, one tablet daily for diabetes, was not administered from 3/5 to 3/8/16 for three days, as prescribed on the admission orders [REDACTED] -[MEDICATION NAME][MEDICATION NAME] (HCL, prescribed for allergies [REDACTED].> Additional medications that were on Resident 1's MAR indicated [REDACTED] -Tylenol 325 mg, two tablets orally every four hours as needed every four hour for discomfort for a pain level of 1 to 3 (minimal pain on a scale of one being the least and ten being the worst). -Milk of Magnesium 30 ml (for constipation) every day as needed for bowel care. -[MEDICATION NAME] (a combination of [MEDICATION NAME][MEDICATION NAME] used to treat and prevent symptoms of wheezing and shortness of breath, caused by ongoing [MEDICAL CONDITION]) 1 unit dose inhalation via a hand held nebulizer (machine that delivers aerosol medications) every four hours for shortness of breath. On 3/16/16 at 12:20 pm, the Nurse Consultant (NC R, a Registered Nurse) confirmed that Resident 1's admission orders [REDACTED]. 2. Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set (MDS, a resident assessment), dated 4/21/15, indicated Resident 1 was rarely understood and dependant on staff for transfers, dressing, and eating. A nurses progress note, dated 7/31/15 at 7 pm, indicated Resident 15 received Tylenol and [MEDICATION NAME]. On 3/9/16 at 11:30 am, the Director of Staff Development/ Infection Control Nurse (DSD/ICN) was interviewed. The DSD/ICN stated he remembered the incident when Resident 15 received Resident 16's medication in error. He stated LN D was orientating LN Z who put Resident 16's medication in a cup of med pass (liquid supplement) and left it on the table where Resident 15 was sitting. The DSD/ICN stated it was his understanding that Certified Nursing Assistant (CNA) AA then gave Resident 16's medpass (with medications inside) to Resident 15 because it was placed in front of her. On 3/8/15 at 9:30 am, the Administrator (Admin) was asked about the medication error incident. Admin stated the CNAs involved were no longer working at the facility. On 3/9/16 at 4:45 pm, Admin stated he could not find an investigation associated with the above medication error. On 3/17/16 at 12:05 pm, the DON and the NC R were interviewed. The DON confirmed that Resident 15 received Resident 16's Tylenol and [MEDICATION NAME] in error. Resident 16's physician's orders [REDACTED]. This was not provided by NC R, but an Event Investigation Worksheet, dated 7/31/15, signed by the ADON, was provided for review. The worksheet indicated Resident was given the incorrect medication, notified MD of incident and RP (responsible party) . was notified. Under witnesses to event, the word No was circled. An attached hand written statement indicated that LN Z was being oriented by LN D and was witnessed placing a cup of med pass (a liquid supplement) with medication in it on the table in front of Resident 16. The person writing the attachment documented they then witnessed .another CNA . pick up the cup and give it to Resident 15, the wrong resident. This hand written statement was not signed or dated by the writer. 3. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], showed she experienced pain and had received both scheduled and as needed pain medication in the previous 5 days. Resident 3's Admission Physician Orders, dated 2/15/16, included orders for [MEDICATION NAME] sulfate extended release (MSER, long acting narcotic) 15 mg by mouth PO every q 12 hours and [MEDICATION NAME] sulfate instant release ([MEDICATION NAME], fast acting narcotic for breakthrough pain) 15 mg PO q 4 hours as needed (prn). A review of the facility's pharmacy invoice for Resident 3 showed that 10 of the MSERs (5 days supply) and 30 of the [MEDICATION NAME] were delivered on 2/15/16 at 9:03 pm (her admitted ). A second invoice showed another 28 MSERs were delivered on 2/29/16 at 7:02 pm (14 days after the initial 5 days doses arrived). Resident 3's February 2016 MAR indicated [REDACTED]. The morning doses for 2/20, 2/21, 2/28, and 2/29 and the evening doses for 2/19, 2/22, 2/23, 2/24, 2/25, and 2/28 were all circled as not administered (10 doses). There was an undated notation on the backside of the MAR indicated [REDACTED]. The facility's Controlled Drug Record, dated 2/15/16, for Resident 3 showed 10 MSER pills were used between 2/16 and 2/22/16 (8 am). A second Controlled Drug Record, dated 2/15/16, showed the [MEDICATION NAME] as administered in the morning and evening between 2/21 and 2/27/16 at the times when the MSER was to be given, but was not available. A third Controlled Drug Record, dated 2/29/16, showed the 28 MSERs received by the facility for Resident 3 (two weeks after the initial 5 days doses were delivered). On 3/9/16 at 3:30 pm, the ADON confirmed he could not locate a Controlled Drug Record for Resident 3's MSER from 2/22 to 2/29/16 and was not able to provide documentation that the doses between those dates were removed from the emergency supply. There was no evidence that Resident 3 received her scheduled MSER during that week long period. On 3/9/16 at 3:50 pm, during and interview and concurrent review of Resident 3's Controlled Drug Records with the ADON, he stated that it appeared the nurses were giving her the [MEDICATION NAME] for the MSER she was to be receiving. On 3/10/16 at 8:30 am, the facility's Medical Director (MD) was asked what the effects could be to Resident 3 from not receiving her MSER as scheduled for 7 days. The MD stated that she could experience pain and go into drug (narcotic) withdrawal. When the MD was asked why this happened, he stated that the facility did not have enough Registered Nurses (RNs) and that the nurses did not seem to know what to do. The MD stated that the nurses could have gotten an emergency order 7 days a week, but the facility had new nurses all the time. On 3/16/16 at 10 am, LN F stated that she found the medication error of the nurses giving Resident 3 [MEDICATION NAME] instead of MSER and reported it to the management to fix when she first started there.

Based on observation, interview, and record review, the facility failed to protect two female residents, Residents 1 and 2, from sexual and verbal abuse by Resident A, by not following their written care plan to closely supervise him and to involve the family for medication administration. The facility staff was to provide one to one (1:1; one staff member to one resident) visual checks by staff for Resident A while he was awake, as a protection for the female residents in the Memory Villa Unit, which housed male and female residents with dementia. The facility failed to call the family to assist Resident A when he refused his [MEDICAL CONDITION] medications that was documented as being effective when taken daily to decrease his sexual inappropriate behaviors. Findings: On 5/8/11 at 5:16 pm, the Department received a Suspected Dependent Adult/Elder Abuse form that Resident A had his pants down and pushed a female resident's face down to perform oral sex. On 5/11/12 at 3:51 pm, the Department received a second Suspected Dependent Adult/Elder Abuse form that Resident A had inappropriately touched another female resident. On 5/16/12, a review of Resident A's record disclosed that the [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS-a resident assessment tool), dated 5/14/12, disclosed Resident A had difficulty making decisions, could usually understand others, and had short and long term memory problems. Resident A's behaviors included physical (hitting, kicking, and sexually abusing others) and other behavioral symptoms such as, public sexual acts and disrobing in public. The resident required limited to extensive assist with his activities of daily living and required standby assistance when ambulating with a walker. A care plan, dated 10/26/11, indicated that Resident A exhibited inappropriate sexual behavior. One of the interventions to prevent sexual behavior with female residents was to provide continuous 1:1 visual checks. The following were examples of Resident A's sexual behaviors in the Memory Villa Unit: 1. An entry documented in a interdisciplinary progress note (IDT) on 10/26/11 described an incident of Resident A's sexual inappropriate behaviors. Resident A was found naked from the waist down lying on the floor with an unidentified female resident sitting beside him. 2. On 5/6/12 at 1 pm, a licensed nurse entry in the nurses notes indicated that Resident A beckoned an unidentified female resident to masturbate him while sitting in the living room. The residents were separated. 3. On 5/7/12 at 1:40 pm, License Nurse (LN) 3 had documented that Resident A had three episodes that morning shift of verbal and sexual behavior towards the female residents in the Memory Villa Unit. A weekly summary report, written by LN 3 on 5/8/12, disclosed Resident A had 37 inappropriate verbal and sexual behaviors during the week of 5/1 to 5/8/12. 4. On 5/17/12 at 3:25 pm in an interview, CNA G confirmed on 5/8/12 at 3:35 pm that Resident A had his pants unzipped with his genitals exposed outside of his clothing and had his hand down Resident 1's blouse when she separated both Resident A and Resident 1. CNA G's assigned duties included 1:1 visual checks for Resident A that evening shift. Resident 1, a [AGE] year old female, had been admitted on [DATE] with dementia. The MDS disclosed that she had severe cognition problems with long and short time memory loss. She also needed extensive help with her daily care and used a wheelchair for mobility. 5. On 5/8/12 at 1 pm, LN 3 documented that Resident A had continually disrobed, exposed, touched himself, along with ten sexual statements towards Resident 2 throughout the day. The staff had difficulty detouring Resident A away from the female residents that day due to his angry outburst towards them. Resident 2, an [AGE] year old female, had been admitted [DATE] with [MEDICAL CONDITION] with behaviors. 6. On 5/10/12 at 6:45 pm, the facility's Janitor F was cleaning the day room on the Villa Memory Unit when he witnessed Resident A telling Resident 2 to perform oral sex on him. On 5/17/12 at 3:25 pm, Janitor F was interviewed. He stated he was cleaning the day room when he witnessed and overheard Resident A tell Resident 2 to perform oral sex. He had been too embarrassed to continue to watch and went for help. Janitor F stated Resident A had grabbed Resident 2 by the back of her hair and was trying to force her down to his exposed genitals. Janitor F returned with CNA H within three minutes who separated the two residents. On 5/17/12 at 3:15 pm, LN 3, who was on duty the morning shift on 5/8/12, was interviewed. She stated that she had reported to the evening shift nurse that Resident A had increased inappropriate sexual behaviors on the day shift. On 5/18/12 at 4 pm, LN 4 confirmed that Resident A's incident on 5/8/12 involving Resident 1 and the 5/10/12 incident involving Resident 2 could have been prevented with continuous 1:1 visual checks by staff instead of sporadic supervision that was ineffective in keeping Resident A from abusing female residents.