Every finding on record at Crestwood Wellness and Recovery Center

Based on interviews and record reviews the facility failed to protect the rights of one out of four sampled residents (Resident 1) to be free from physical abuse by Resident 2 when Resident 2 hit Resident 1 in the face. This resulted in Resident 1 sustaining bruising to the right side of the face that lasted for 15 days. Findings: A review of the facility's policy and procedure (P&P) titled, Crisis Intervention Program, updated 6/1/25, indicated, facility staff would recognize early warning signs of crisis (notice changes in behavior, mood, or thinking). The P&P indicated staff would provide early intervention (action and support provided to the resident from staff) when a resident exhibited an increase in behaviors (acting out). A review of the Certified Nurse Assistant [CNA] Job Description, updated 10/30/25, indicated, the CNA would report all changes, including agitation (feeling anxious, worked up, or irritable) to the Shift Coordinator (SC) immediately. A review of Resident 1's admission Record, dated 8/24/18, indicated that Resident 1 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder (schizophrenia, serious brain disorder that disrupts how a person thought, felt, or behaved, causing them to lose touch with reality and a mood disorder at the same time), bipolar (a mood disorder that caused extreme mood swings) type. Resident 1 was conserved (the courts appointed a conservator who made all decisions for the resident). A review of Resident 1's Annual Minimum Data Set (MDS, a resident assessment tool) titled, Section E-Behaviors, dated 10/6/25, indicated Resident 1 had delusions (believing in something that was not true) and verbal behavioral symptoms (threatening, screaming, and cursing) that were directed towards others. The MDS indicated Resident 1 intruded (barged in, placed self where one was not wanted) on others privacy and activities. The MDS indicated, Resident 1 significantly disrupted care or the living environment of others. A review of Resident 2's admission Record, dated 2/2/18, indicated that Resident 2 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. Resident 2 was conserved. A review of Resident 2's Quarterly MDS, titled Section E-Behaviors, dated 9/1/25, indicated that Resident 2 had delusions. A review of Resident 2's Quarterly MDS, titled Section C-Cognitive Patterns (brain function), dated 9/2/25 indicated Resident 2 experienced signs and symptoms of delirium (a sudden and severe state of mental confusion, change in usual behavior, and ability to think). A review of Resident 2's Progress Note, dated 11/2/25, indicated, on 11/2/25 at approximately 9:25 am, Resident 2 felt threatened when Resident 1 put her fists up as if they were going to fight and Resident 2 hit Resident 1 in the face approximately three times. During an interview on 1/6/26 at 2:26 pm, Certified Nurse Assistant (CNA) A stated, Resident 2 hit Resident 1 because Resident 1 was making threats to Resident 2 every single day. CNA A could not verbalize how many days Resident 1 had been verbally threatening Resident 2 and clarified threats as death threats. CNA A indicated, when a resident made verbal death threats to another resident, the SC was notified, the residents were separated with a room change, and then placed on welfare checks every 15 minutes. CNA A stated, Resident 2 admitted she only did that to Resident 1, because Resident 2 felt like she was being verbally attacked by Resident 1. CNA A confirmed reporting Resident 1's death threats to the SC and could not verbalize who it was reported to. During an interview on 1/7/26 at 1:01 pm, Licensed Nurse (LN) C stated, Resident 1 was experiencing an increase in psychosis (a loss of touch with reality), high anxiety, and screaming episodes. She [Resident 1] has paranoia (an intense feeling that people are out to get you) and delusions increase when psychosis increases. This all happened slowly over a few days. LN C confirmed having no knowledge that Resident 1 had been making death threats. During an interview on 1/7/26 at 1:49 pm, CNA A stated, I heard Resident 1 yelling I'm going to kill you, on the day it happened (11/2/25). CNA A confirmed, Resident 1 and Resident 2 were roommates on the day of the physical abuse and stated, they were both in their room. I'm not positive it was said directly to Resident 2, or if Resident 1 was just yelling it. CNA A confirmed that CNA A did not enter the room to ensure resident safety or to investigate what was happening. CNA A confirmed an inability to verbalize what the time frame was between Resident 1 making a death threat to the time Resident 2 had punched Resident 1 in the face. During a concurrent interview and record review on 1/7/26 at 2:02 pm, CNA B indicated that Resident 1 had delusions that she was married to Elvis. CNA B stated, I've heard Resident 1 have outbursts, not specific to I'm going to kill you, but yelling regarding a delusion, my husband is Elvis, there is a woman after him, and I'm going to kill her. CNA B reviewed Resident 1's Progress Notes, dated 5/5/25 through 12/25/25 and confirmed, there was no CNA documentation present that indicated that any CNA had witnessed Resident 1 making verbal death threats during reoccurring delusions. During an interview on 1/7/26 at 2:17 pm, LN D confirmed working the morning of 11/2/25 and stated, I've never heard anything about Resident 1 yelling death threats. LN D confirmed, Resident 1 had delusions that Resident 1 was married to Elvis and stated, Resident 1 yells that she wants to kill the woman after her husband. LN D confirmed, when Resident 1 yelled I'm going to kill you, that indicated a change in behavior, it should have been reported to LN D, and was not. LN D stated, if the CNA told me about her observation, I would have gone in and assessed the situation and seen what was going on, determine if [Resident 1's] statement of killing you was regarding a delusion or her roommate. I could have redirected or separated them. Had someone came and told me about it, I would have been in there to attempt to deescalate the incident before it happened. A review of the Skin Observation assessment, dated 11/2/25, indicated, LN C assessed Resident 1 after the physical abuse. The assessment indicated, Client has reddened areas on her neck and right side of face. Brusing is starting to develop on her right side and left side chin. A review of the Skin Observation assessment, dated 11/17/25, indicated the bruising to the right side of Resident 1's face had resolved (15 days after Resident 2 hit Resident 1). During an interview on 1/7/26 at 2:53 pm, Director of Nursing (DON) stated, CNA's start their shift at 6:30 am. DON confirmed, the incident between Resident 1 and Resident 2 occurred at approximately 9:50 am (there was three hours and 20 minutes from the time CNA A clocked in, and Resident 2 physically abused Resident 1). During an interview on 1/7/26 at 3:01 pm, Wellness and Recovery Director (WRD), DON, and Assistant Director of Nursing (ADON) confirmed, no staff had notified them that on the morning of 11/2/25, Resident 1 had yelled I'm going to kill her. WRD, ADON, and DON confirmed, CNA A's observation of Resident 1 yelling, I'm going to kill you, should have been reported to the SC. During in interview on 1/8/26 at 11:17 am, SC F stated, if a CNA is walking down the hall and heard a resident state I'm going to kill you, they should put eyes on them and see what's going on. It should have been reported to the nurse, bare minimum the medication nurse [LN] should have been notified. If I had been notified, I would have investigated and separated them.

Based on observations, interviews, and record reviews, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH, state agency dedicated to protecting and improving the health of Californians), the police department, and to the local Ombudsman [a person who worked to maintain resident rights] for one out of two sampled residents (Resident 3) when Resident 3 made statements about being sexually abused. This had the potential to negatively impact health status and psychosocial well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Client Abuse Prevention, updated 10/14/24, indicated, Staff will immediately and directly report to the Administrator any suspicions of client abuse, either witnessed or suspected. The P&P indicated, Due to the complexity of the clients being served by this facility (i.e., the seriously mentally ill), all reports of abuse will be initially screened by the Administrator or designee for the possibility of reality-based accusation (i.e., a flying dragon injured me, etc.,). All reality-based accusations will be immediately investigated and reported to officials in accordance with state law (including the state licensing and certification agency [CDPH]). A review of Resident 3's admission Record, dated 7/29/16, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder (schizophrenia, serious brain disorder that disrupts how a person thought, felt, or behaved, causing them to lose touch with reality and a mood disorder at the same time), bipolar type (a mood disorder that caused extreme mood swings). Resident 3 was conserved (the courts appointed a conservator who made all decisions for the resident). A review of Resident 3's Annual Minimum Data Set (MDS, a resident assessment tool), dated 12/30/25, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) was conducted. Resident 3 scored a 15-out-of 15, which indicated intact memory, orientation, and judgement. A review of Resident 3's Annual MDS, dated [DATE], section E-Behaviors, indicated that Resident 3 experienced hallucinations (seeing or hearing things that were not there) and delusions (believing in something that was not true). During a concurrent interview and record review on 1/8/26 at 11:33 am, with Wellness and recovery Director (WRD), a review of the SOC 341(a specific form used in California to report known or suspected abuse), dated 1/6/26 was reviewed. WRD confirmed the SOC 341 included an email that WRD had sent to Resident 3's Public Guardian's (also known as the conservator) office on 1/2/26 that indicated that a peer was having sex with Resident 3 without her consent and the facility had investigated the allegation. WRD stated, if I remember right, we were in a team meeting and I believe the nurse said it. After the allegation was made, during the team meeting, regarding the peer on 1/2/26, me and the Administrator (ADMIN) investigated after the meeting. WRD provided a Social Services Note, dated 1/2/26. WRD confirmed, the Social Services Note, indicated, WRD received an email from a Licensed Nurse (LN) that indicated, Resident 3 made an allegation of assault, and stated to the LN, .she felt that a peer was coming into her room and having sex with her without her consent. The Social Services Note indicated, It is noted that her statement was demonstrably similar in nature to previous unverifiable accusations of others. During a concurrent observation and interview on 1/8/26, at 1:25 pm, Resident 3 was observed calmly walking up to the nurse's station and had a normal rate and tone of speech during introductions. Resident 3's hands began to shake, and her speech became rapid and loud. Resident 3 stated, No! I never said that, why would they keep saying that? During Resident 3's statement, her head was moving from side to side, there was a tremble in her voice, and she was looking at the floor. Resident 3 was asked who they were, and Resident 3 indicated LN C. Resident 3 was no longer standing still and was moving from side-to-side and immediately ended the interview. During a concurrent interview and record review on 1/8/26 at 1:59 pm, ADMIN provided an email, dated 1/1/26. ADMIN confirmed, LN C sent an email to WRD and the Director of Nurses. ADMIN confirmed, the email indicated, She then began stating that people come into her room and rape her when she isn't fully awake. The words rape and fully awake contained quotation marks, indicating Resident 3 said those words while talking to LN C. During an interview on 1/8/26 at 2:08 pm, LN C stated, Resident 3 never told me that someone raped her. I sent a communication follow up to WRD. LN C indicated, LN C did not send WRD an email, and stated, it was an internal communication, my concern is she has a fixation of becoming pregnant and was expressing a plan of becoming pregnant. During an interview on 1/9/26 at 10:23 am, ADMIN described what should happen when there is an allegation of sexual abuse. ADMIN stated, We should take steps to keep residents safe, notify the police, DHS [social services, assisted with providing essential services], [CDPH, and the Ombudsman within two hours. ADMIN confirmed Resident 3's allegation of sexual abuse was not reported.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food product bags after opening the bags for use. The open, unlabeled, and undated product bags contained frozen soy chicken patties, frozen fried eggs, and frozen soy beef patties. This failure had the potential for the food products to be used for meals in an untimely manner leading to bacterial or fungal growth resulting in food borne illnesses amongst residents. Findings: During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2020, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . During a concurrent observation and interview on 6/1/25 at 2:30 pm, with Food Service Supervisor (FSS), in the kitchen at the second freezer, a package of frozen fried eggs, a package of frozen soy chicken patties, and a package of frozen soy beef patties were observed open and unlabeled. FSS confirmed the bags were previously opened for use and no apparent label was present. FSS confirmed once product packaging is open for use the products are to be labeled with an open date.

Based on interview, and record review, the facility failed to ensure that one of 25 sampled Residents (Resident 56) was protected from verbal and physical abuse when Resident 38 yelled at Resident 56 calling him names and hit Resident 56 with a closed fist to his head, then continued to chase Resident 56 down the hall until staff could intervene. This failure resulted in increased anxiety, and the potential to result in emotional stress, anger, depression, feelings of neglect, and the potential for negative clinical outcomes for Resident 56. Findings: A review of the facility's policy revised 10/2024, titled, Client Abuse Prevention, indicated this facility will take all appropriate preventative measures to ensure that clients are not at risk for abuse. All Clients will be afforded the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, and misappropriation of client property. During a review of Resident 38's medical record, the Admisison Record, indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified (a serious brain injury that affects how a person thinks, feels and behaves which may include false beliefs), psychoactive substance abuse (uncontrolled use of drugs or other substances that affect how the brain works including mood, thoughts, and behaviors), and visual hallucinations (seeing things that are not really there). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 4/14/25, indicated that Resident 38 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). During a record review for Resident 38, a document dated 5/23/25, titled, Progress Notes, indicated, Staff was alerted to the dining room at 8:00 pm due to an altercation between a peer and [Resident 56]. The peer [Resident 38] was yelling at [Resident 56] stating you are a rapist, a pedophile, then jumped out of his chair and starting punching [Resident 56]. [Resident 56] got up and tried to run away but [Resident 38] proceeded to run after [Resident 56] down the hallway. Staff intervened and separated the two clients. During a review of Resident 56's medical record, the Admisison Record, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bi-polar type (hallucinations and delusions, and extreme mood swings between mania and depression; a mix of psychosis and mood instability), myopia (near sightedness, objects far away appear blurry) and self-reported anxiety (feeling of worry, nervousness or unease). A review of the most recent MDS dated [DATE], indicated that Resident 56 had a BIMS score of 15 out of 15 and was cognitively intact. During a record review for Resident 56, a document dated 5/24/25, titled, Progress Notes, indicated, Spoke with [Resident 56] regarding an altercation between him and another resident. [Resident 56] stated he was feeling fine, but his head felt tender. During an interview on 6/2/25 at 10:15 am, Resident 56 stated, I have anxiety. I remember the incident. It happened in the dining room, [Resident 36] even hit a staff member the next day. To be honest I blacked out for most of it, I was upset. I tried to block it out. Resident 56 demonstrated where he was hit, leaned head over and pointed to the top back part of his head. Resident 56 stated, The staff continued to check on me. I feel safe for the most part, if the man who hit me never comes back, I did not do anything to cause it. I have mental illness. During a concurrent interview and record review on 6/3/25 at 10:03 am, the Director of Nursing (DON) confirmed Resident 56 was hit by Resident 38 on 5/23/25, and was placed on every 15 minutes neurological checks (monitoring alertness) and for mental well-being, while they were trying to find placement for Resident 38. DON stated, [Resident 56] does have anxiety, and [Resident 38] no longer lives here, he was moved to a higher level of care.

Based on observation, interview, and record review, the facility failed to ensure the safety and security for one of two clients (Client 1) when: 1. The facility security door locking system malfunctioned and Client 1 eloped from the facility. 2. The Temporary-Office Assistant (TOA) did not recognize Client 1 as a client, when she passed through the front lobby and eloped out the front doors. 3. Program Staff (PS, an employee that does activities with clients), saw Client 1 outside the facility and made no inquiries as to why Client 1 was outside. This disregard for client safety allowed Client 1 to go missing from the facility and her whereabouts were unknown for 8 hours, which put Client 1 at risk for injury and exposure to cold weather and had the potential to negatively impact on Client 1's health, safety, and welfare. Findings: A review of the facility's policy titled, AWOL (absent without leave) updated 9/23/24, indicated, If a client goes absent without leave (AWOL), the proper authorities will be notified, and steps taken to hasten their return. 4. In the event an AWOL is witnessed, do not chase the client if not appropriate, as this may lead to impulsive behavior (i.e., running into traffic, etc.); however, efforts may be taken to voluntarily prompt the client to return to the facility. If unable to successfully prompt client to return, attempt to keep visual line of sight on client to support safety. 1.A review of Client 1's Admission Record (undated), indicated Client 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of psychosis which means your mind doesn't agree with reality). Client 1 had a conservator (a legal arrangement that allows a judge to appoint a guardian to manage the personal and financial affairs of another person) who made life decisions for her. A review of a facility reported incident dated 12/2/24, indicated that on 11/29/24 Client 1 was noted to be missing from the facility at approx. 6:18 pm. Facility reviewed cameras and found Client 1 was able to exit through an automatic locking door that had not sealed at 4:22 pm. A review of a facility's five day follow up report, dated 11/30/24, documented the shift coordinator initiated notification of missing client (on 11/29/24) to the Administrator at 6:29 pm, the Police Department at 6:34 pm, the Medical Director and Psychiatrist at 6:47 pm, and the Conservator at 6:47 pm. The shift coordinator also initiated staff search outside the facility. [Client name] was not able to be located at that time. A review of Client 1's progress notes dated 11/29/24 at 8:50 pm, showed that Licensed Nurse A (LN A) documented, Nursing staff was notified of [Client 1's name] not attending dinner at approx. 1815 [6:15 pm]. Room checks were completed, and client [Client 1] was unable to be located. During an observation on 12/2/24 at 10:00 am, the facility lobby and south door that led into the client care area was observed. The Administrator (Admin) placed a key in a key slot mounted in the wall to the right of the doors. A faint click sound was heard and then we were able to push open the push bar on the right side of the double doors and enter the client care area. The doors closed behind us and automatically locked. During an interview on 12/2/24 at 10:30 am, Admin indicated that she reviewed video footage of the south door that led into the client care area. The Admin stated, A nurse walked through the south door and into the client care area. The nurse reached back and put her hand on the door to assure it was closed. A few minutes later, at 4:22 pm, Client 1 was noted to push open the south door and walk through it and into the front lobby. Admin indicated the doors can only be opened with a key. Admin indicated that through their investigation of the event it was noted that the magnetic lock on the south door was malfunctioning intermittently. Admin indicated the locking system was replaced the evening of 11/29/24, after the incident and the staff were being educated to always check the doors behind them to make sure the locking system was working. 2. During an interview on 12/2/24 at 12:46 pm, the TOA indicated she was working at the front desk in the front lobby when Client 1 came out the south doors and into the lobby. TOA stated, It was at a time when staff were coming and going because the time clock was up here by the desk. Client 1 came into the lobby thru the door, I smiled, and she smiled back, and I thought she was an employee. TOA indicated she was the only person working at the front desk at that time. TOA stated, I started back in August and am unfamiliar with the residents. During an interview on 12/2/24 at 1:01 pm, the Director of Nursing (DON) indicated TOA did not know the clients. DON stated, She does not need to know the clients but now since this happened, she should have to know the clients. 3. A review of Client 1's progress notes dated 11/29/24 at 8:50 pm, showed that LN A documented, Writer was notified by Program Staff [PS] that [Client 1] was seen outside the lobby doors near the parking lot pacing. During a concurrent interview with the Admin and a record review on 12/2/24 at 12:47 pm, the documented statement of what PS saw, dated 11/30/24, was reviewed. PS documented, He (PS) was walking towards the building and seen [Client 1's name] standing by the mailbox. Then seen [the Central Supply and Scheduling Personal, CSS name] walking out of the facility and thought she was taking her [Client 1] on an outing. [PS name] stated he felt relieved and made his way back into the facility. During an interview with the Admin on 12/2/24 at 1:00 pm, the Admin indicated that PS should have stopped and at least checked on Client 1. During an interview with CSS on 12/2/24 at 1:15 pm, CSS indicated she was coming up the parking lot from the back door to clock out (in the front lobby). It was about 4:30 pm, on 11/29/24. CSS indicated she did see PS but when she came up to the front breezeway (by the mailbox), she did not see anyone standing there. CSS indicated that she never saw Client 1 and PS did not ask her about Client 1. On 12/2/24 at 1:23 pm, an interview and review of the video footage, dated 11/29/24 at 4:22 pm, was conducted with the DON. The video showed Client 1 standing at the mailbox at the end of the front porch outside of the facility. Client 1 was looking towards the parking lot. PS was viewed coming up behind Client 1 and walking past Client 1. At the same time CSS, looking at her phone, was walking from the back door of the facility and walking up the sidewalk alongside the parking lot towards the left side of Client 1. As soon as PS passed Client 1, Client 1 turns toward the street and walks away from the facility. During an interview on 12/2/24 at 1:26 pm, Admin indicated PS should have stayed with Client 1 and followed their facility policy. A review of Client 1's progress notes dated 11/30/24 at 4:58 am, by LN B, indicated Client 1 was discovered walking down a sidewalk a few blocks from the facility on 11/30/24 at 12:15 am, eight hours after Client 1 left facility.

Based on interview and record review, the facility failed to ensure that two of 20 sampled residents (Residents 3 and 82) were protected from physical abuse when: 1. On 6/12/24, Resident 84 struck Resident 82 in the face. 2. On 5/22/24, Resident 84 placed their hands around Resident 3's throat. This failure resulted in bleeding injuries to Resident 82, and had the potential to threaten the physical, emotional and psychological health and well-being of both residents. Findings: A facility policy, titled, Client (resident) Abuse Prevention, updated 4/5/22, was reviewed. The policy indicated clients should not have been subjected to verbal or physical abuse of any kind and clients should not have disciplined other clients. During pre-admission screening, all clients would have been assessed for history of poor impulse control, combativeness and assault to self and others. The interdisciplinary team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) would have identified which clients, per history treatment plan or active treatment plan, needed treatment planning and would have followed up after any incidents to update interventions and decrease potential reoccurrence. A review of Resident 84's clinical record indicated they were admitted to the faciltiy on 2/26/24. Resident 84's diagnoses included paranoid schizophrenia (a severe mental disorder that resulted in hallucinations, delusions, and extremely disordered thinking and behavior), and unspecified psychosis (a mental disorder characterized by a disconnection from the ability to perceive what is real and what is not), and tachycardia (fast heart rate). The Minimum Data Set (MDS, tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function), dated 5/7/24, indicated Resident 84 rated 15/15, which equated to being cognitively intact. Resident 84 was legally conserved (a judge appointed an individual to make decisions to protect and manage a needy individual's life choices and personal needs). 1. A review of Resident 82's medical record indicated that Resident 82 was admitted on [DATE] with diagnoses that included, schizophrenia, cerebral palsy (neurological disorder, damage to the developing brain appearing in infancy affecting movement and muscle coordination), and chronic obstructive pulmonary disease (COPD, inflammatory lung diseases that block airflow and make it difficult to breathe). The MDS BIMS Section C assessing cognitive function, dated 5/7/24, indicated Resident 82 rated 15/15, which equated to being cognitively intact. Resident 82 was legally conserved. During an interview on 6/18/24 at 3:00 pm with Resident 82 in the resident's room, Resident 82 stated he had just returned to the room following a shower, went to the bathroom in the room, and was walking past Resident 84's bed which was closest to the door. Resident 84 made the statement that Resident 82 had spit on them. Resident 82 replied they were not close enough to spit on them and Resident 84 got up and punched Resident 82 in the nose and face four to five times causing Resident 82's nose to bleed heavily. Immediately following the injury, Resident 82 struck out at Resident 84 in order to escape from the attack and retreat to the nursing station for assistance. During an interview, on 6/18/24, at 3:30 pm, with the Administrator (ADMIN) in the conference room, ADMIN confirmed the incident did occur and was substantiated in the facility investigation. The facility staff did not expect any such incident as there had been no indication of aggression from Resident 84 towards the roommate Resident 82. Believes hallucinations were involved in the incident. Conveyed Resident 84's conservator was, at the time the incident took place, looking for a facility more suitable for the very impulsive, aggressive behaviors, and inappropriate interactions commonly demonstrated by Resident 84. 2. Review of Resident 3's clinical record indicated they were originally admitted to the facility on [DATE]. Resident 3's diagnoses included schizoaffective disorder (a chronic mental health condition characterized by symptoms of schizophrenia and a mood disorder, such as mania and depression), and attention-deficit hyperactivity disorder (ADHD--an ongoing pattern of inattention and/or hyperactivity-impulsivity). Record review of a Nurses Note, dated 5/22/24 (21 days prior to the incident with Resident 82), at 2:34 AM, by Licensed Nurse (LN) A, showed a description of an incident. At approximately 2:15 AM staff was crossing through the day room and witnessed [Resident 84] standing over the top of [Resident 3], who was positioned reclined in a chair. [Resident 84] had his hands grasped around [Resident 3's] throat at the time and was bearing down on him. Staff immediately separated the clients from each other. The residents were both assessed for injuries and had none. Record review of an IDT Progress Note, dated 5/22/24, at 12:30 PM, by ADMIN, showed a note about a conversation with Resident 84. ADMIN wrote, Client [Resident 84] thought peer [Resident 3] was calling him names. Education provided regarding safety and nonviolent conflict resolution. [Resident 84] stated understanding related to not putting hands on peers. A Welfare Checks note, dated 5/22/24, at 3:41 PM, by the Service Coordinator (SC), was reviewed. The note indicated, [Resident 84] is on welfare checks Q15 (every 15 minutes) for aggressive behavior. SC spoke with [Resident 84] about the incident last night and he said he doesn't remember it and said, 'It's all hazy.' No further issues and will continue to monitor. Record review of a Telepsychiatry (a clinical visit with a psychiatrist done remotely via computer) Progress Note, dated 5/23/24, at 11:32 AM, by a Psychiatric Nurse Practitioner (NP), showed a summary of the visit with Resident 84. NP wrote, Denies any violence except hitting a cop before his last hospitalization , and Resident 84 stated, I'm ok except that I got mad at some [NAME] the other day and I ended up choking him because of the way that he was talking to me. NP also wrote, 'When asked what made him feel the need to choke the other patient, he stated, 'it doesn't matter while, it was stupid. I understand that I shouldn't have done that and I am not going to do it again.' Throughout the entire conversation, patient was smiling and laughing. Patient does not appear to have any insight to his wrongdoing/inappropriate behavior and is a safety risk for the environment in which he is currently in. During a concurrent observation and interview, on 6/17/24, at 10:41 AM, Resident 3 was calm and answered questions while sitting in his room. Resident 3 stated he got along with others, once in a while got in fights. Said he practiced [NAME] arts. Seemed to [NAME] off into other topics and was not able to speak specifically about the incident on 5/22/24. During an interview, on 6/19/24, at 8:40 AM, LN A described the incident from 5/22/24. LN A stated that Certified Nursing Assistant (CNA) B discovered the incident in the day room and called a Code Three (emergency situation alert). Then LN A and another nurse responded. LN A could only see the back of Resident 84 standing over Resident 3. Resident 3 was in a recliner chair and didn't appear to be in distress, but CNA B had separated the two. LN A said clients are up at all hours [NAME] around. LN A stated that Resident 84's behavior was sporadic and unpredictable and there was no warning beforehand. During an interview, on 6/20/24, at 7:15 AM, CNA B they were going through the day room on 5/22/24 at 2 AM, and saw Resident 84 choking Resident 3. CNA B stated they pulled Resident 84's hands off Resident 3's neck. Then Resident 84 backed off. Resident 3 was in a recliner chair. Both residents answered that they were OK. CNA B stated Resident 84 was kind of in a daze, not angry or anything else. CNA B stated there were other residents in the day room at the time who started yelling, then other staff came in to help. 43031

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food containers/ product bags of frozen breaded fish, frozen fried eggs, frozen hashbrowns, frozen frenchtoast, pepperoni, and peeled garlic cloves with open dates after the packages were open and the products being used for meals. This failure had the potential to allow food products to sit an inappropriate amount of time after the packaging was open with no dating label adehered leading to bacterial or fungal growth causing food borne illnesses amongst residents if the product was served for meals and not used by an appropriate date following guidelines. Findings: During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2020, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . During a concurrent observation and interview on 6/17/24 at 11:18 am with [NAME] in the kitchen, multiple packages were observed in the freezer unit open and unlabeled, including frozen breaded fish, frozen frenchtoast, frozen hashbrowns, and frozen fried eggs. [NAME] stated, I just opened and used some of those, I forgot to label them. During a concurrent observation and interview on 6/17/24 at 11:18 am with Food Service Supervisor (FSS) in the walk-in refrigerator, a package of fresh pepperoni and a bag of peeled garlic cloves were observed open and unlabeled. FSS confirmed the bags were previously opened with no label applied nor present. During an interview on 6/19/24 at 10:45 am with FSS in the kitchen by the back sink, FSS confirmed once product packaging is open for use the products are to be labeled with an open date.

Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurate for two out of two sampled clients (Client 1 and Client 2) when there was not a process in place for updating and maintaining the Personal Property Inventory sheet (PPI, a document that described what personal items a client had at the facility). This failure had the potential to inaccurately capture client personal property which could cause frustration for clients. Findings: During a review of the facility's policy and procedure (P&P) titled, Medical Records, updated 10/13/03, indicated, Clients' health records are current and kept in detail consistent with good medical and professional practice During an interview on 9/8/23 at 10:46 am, Client 1 stated when he had been admitted to the facility, he had an Xbox (video game system) and two cell phones that had been listed on his PPI. Client 1 stated he had previously sold the Xbox and was upset because the PPI was inaccurate and indicated he had an Xbox when he did not. During a concurrent interview and record review on 9/8/23 at 11:28 am, with AM Service Coordinator (AMSC), Client 1's PPI sheet dated 3/3/22 through 5/31/23, was reviewed. AMSC stated Client 1's PPI indicated that Client 1 had an Xbox with two controllers and two cellphones but had not included what staff had added these items and there was not date. AMSC stated when staff updated the PPI sheet, staff were expected to initial and date each item that was added or removed from the client's inventory. During a concurrent observation, record review, and interview on 9/8/23 at 11:44 am, in Client 2's room with AMSC and Client 2, Client 2 was observed in his room playing a video game. Client 2 stated his brother had given him two Xboxes and a PS2 (gaming system). Client 2 pointed to a black Xbox sitting next to the television and pointed to a white PS2 located on the floor. Client 1 stated the second Xbox was in the facility storage room. Client 2's PPI dated 4/11/16 through 8/28/23, was reviewed. AMSC stated Client 2's PPI had not included one of the Xboxes or the PS2 and should have. During an interview on 9/8/23 at 11:56 am, with Program Director (PD), PD stated after a search of the facility's storage area, it was confirmed there were no cell phones or an Xbox that belonged to Client 1, but they had found an Xbox that belonged to Client 2. During a concurrent interview and record review on 9/8/23 at 3:42 pm, with Director of Staff Development (DSD) and Director of Nursing (DON), Client 1 and Client 2's PPI records dated 3/3/22 through 5/31/23 and 4/11/16 through 8/28/23, were reviewed. DON confirmed both PPIs were missing dates, missing staff initials, and stated the PPI sheets did not accurately reflect Client 1 or Client 2's personal inventory. DON stated when staff discovered Client 1 had sold his Xbox, the PPI should have been updated and was not. DON stated staff were expected to initial and date the PPI when client belongings were brought in to, or taken out of the facility. DSD was asked what process was in place for training staff on completing the PPI and DSD stated, which ever Mental Health Aide (MHA) was assigned to train the new MHA, was responsible for PPI documentation training. DSD and DON reviewed an undated copy of the, MHA Orientation/Competency Checklist and confirmed the MHA Orientation/Competency Checklist did not include a competency (understanding or knowledge), check off for filling out or updating the PPI sheet. DON stated, currently there was not a process in place to ensure client PPI forms were being updated for accuracy or completeness.

Based on interview and record review, the facility failed to protect 3 of 3 sampled clients (Clients 1, 2 and 3) from abuse and/or exploitation when Housekeeper (HSK A) gave a marijuana vape pen (a vaporizing device used to smoke marijuana) to Client's 1, 2 and 3 to vape marijuana in their bedrooms. This resulted in Client's 1 and 2 requiring a hospital transfer due to marijuana intoxication and adverse clinical outcomes. Findings: The facility's policy titled, Client Abuse Prevention dated 4/5/22, indicated that, All staff receive orientation from the Director of Staff Development on subjects of abuse, theft and loss, and reporting allegations. Ongoing inservice training will be scheduled which will include the category of Patient Rights. On October 8, 2022, the facility reported that Client's 1 and 2 (C1 and C2), were observed by other peers inhaling a substance through a vape device (electronic smoking device). After the inhalation both C1 and C2 suffered altered levels of consciousness and were transferred to the local hospital for emergency care. Record review showed that C1 was admitted to the facility on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . C1 had an assessment of his mental function known as a Brief Interview for Mental Status (BIMS) and scored 14 of 15. The score reflects a high level of mental function for C1 however, due to mental illness C1 is unable to make decisions about healthcare, has an appointed guardian for all decision making, and resides in a locked facility for his own safety. Record review showed that C2 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C2's BIMS score was 15. The score reflects a high level of mental function for C2 however, due to mental illness C2 is unable to make decisions about healthcare, has an appointed guardian for all decision making and resides in a locked facility for his own safety. Record review showed that C3 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The score reflects a high level of mental function for C3 however, due to mental illness C3 is unable to make decisions about healthcare, has an appointed guardian for all decision making and resides in a locked facility for his own safety. On 10/19/2022 at 9:00 AM, during a concurrent record reviews and interview the Director of Nursing (DON) stated, They got ahold of a vape with marijuana and had reactions to it. With the other medications they are on they shouldn't do that. They know it. But the housekeeper brought it in. The DON confirmed that documentation in the records of C1 and C2 reflected the altered levels of consciousness after using the vape pen as well as transfers to the emergency room . On 10/19/2022 at 2:15 PM, C3 was interviewed. C3 stated, The housekeeper, she was the one that brought it in . she did on her break. It was definitely the housekeeping lady [HSK A] and not someone on pass. I took a hit of it. C3 also confirmed that C1 and C2 were sent to the hospital as a result of vaping that marijuana. On 10/19/2022 at 2:45 PM, the DON confirmed that Client's 1, 2 and 3 smoked marijuanna that was provided to them by HSK A and that Client's 1 and 2 required a transfer to the emergency room following their use of that marijuana. The DON stated that HSK A was terminated as a result of her actions which violated Client 1, 2 and 3's right to be free from abuse and exploitation. Documentation of HSK A's termination was provided for review and confirmation.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement when Resident 1 eloped at approximately 11:30 pm on 7/29/22 and was not discovered to be missing until 7:45 am on 7/30/22. This failure had the potential to contribute to the decompensation and loss of well-being experienced by Resident 1 after his elopement, and place other residents at risk of elopement, harm, and loss of well-being. Findings: A review of a facility document titled Head Count updated 7/23/03, indicated that a complete head count of all residents must be completed and documented by the assigned Certified Nursing Assistant (CNA) at the start of each shift, at 7:30 am, 6 pm, and 11 pm daily. Additionally, the night shift must also conduct and document a head count at 1 am, 3 am, and 5 am. A review of the clinical record indicated that Resident 1 was admitted on [DATE] with diagnoses of [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), [CONDITION(S)] disorder, and lung disease. He was unable to make his own healthcare decisions. A review of an Alert Note dated 7/30/22 at 10:51 am, indicated that Resident 1 had not appeared for breakfast, and was not found on the premises. It was discovered his window locks were broken, the screen removed, and the bars pushed out. A review of an Alert Note dated 7/30/22 at 3:17 pm, indicated that Resident 1 had been found by police and returned to the facility at 2:15 pm. Resident 1 was then transported to the hospital for medical clearance. A review of an Alert Note dated 7/30/22 at 6:17 pm indicated that Resident 1 returned to the facility at about 4:40 pm after obtaining medical clearance at the hospital. A review of a Psychiatry Note dated 8/1/22 at 11:44 am indicated that Resident 1 was disorganized and decompensated psychiatrically after missing his medications during his elopement. During an interview on 8/8/22 at 2:36 pm, Licensed Nurse (LN) C stated he was charge nurse on the night shift on 7/29/22. LN C denied any unusual reports at shift change or during the shift. LN C stated that the CNAs were expected to see each resident during head count, even if curtains were pulled around the bed. During an interview on 8/8/22 at 2:58 pm, the CNA stated that he did the night shift head counts alone on 7/29/22. The curtains were pulled around Resident 1 ' s bed at the 1, 3, and 5 am checks, and CNA stated this is usual for Resident 1. CNA confirmed that he did not see Resident 1 during any head count that shift. CNA also confirmed that Resident 1 is independent with toileting, so does not require additional incontinence checks during the nights, and no other checks were done. During an interview on 8/10/22 at 2:57 pm, the Director of Nursing (DON) confirmed that staff had not properly performed the head count, which contributed to Resident 1 ' s elopement.

Based on observation, interview and record review, the facility failed to protect all residents from abuse when 1. Resident 4 hit Resident 2 on the head, and 2. After an allegation of abuse by Resident 1 against Resident 3, no care plan (a plan for the care staff are to deliver to the resident) was made to address Resident 1 ' s feelings or safety. These failures had the potential to contribute to fear and a loss of well-being among all residents. Findings: 1. A review of a facility document titled Client Abuse Prevention reviewed 4/5/22, indicated that the facility would take all appropriate preventive measures to prevent client abuse. A review of the clinical record indicated that Resident 2 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of the clinical record indicated that Resident 4 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was unable to make his own healthcare decisions. A review of a nursing note dated 5/19/22 at 10:45 pm, indicated that earlier that day, about 8:55 pm, staff heard someone in the common room say loudly, He hit me, he hit me! When staff arrived, Resident 2 was seated and accused Resident 4 of hitting her. Both residents were separated, assessed, and placed on welfare checks (checking the resident every 15 minutes). A review of an administration note dated 5/20/22 at 1:32 am, indicated that Resident 2 requested and was given two Ibuprofen (a mild pain medication) for neck pain she described as severe. A review of an Interdisciplinary Progress Note (a clinical note made by a meeting of different types of staff to share expertise, knowledge and skills to improve resident's care) dated 5/23/22 at 9:43 am, indicated that the Director of Nursing (DON) reviewed the camera recording from the facility common room, which showed that Resident 4 struck Resident 2 on the head. During an observation and interview on 8/3/22 at 11:30 am, Resident 2 stated that a guy had hit her on the head, but she did not remember anything else about it. During an interview on 8/9/22 at 11:49 pm, the DON confirmed that she had viewed the video from 5/19/22 showing Resident 4 hitting Resident 2 on the head, and Resident 2 becoming angry that she had been hit. 2. A review of a facility document titled Client Abuse Prevention reviewed 4/5/22, indicated that any resident-to-resident problems would be addressed in care plans for the residents involved. A review of the clinical record indicated that Resident 1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of the clinical record indicated that Resident 3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of an alert note dated 6/23/22 at 10:30 pm, indicated that Resident 1 came to the nursing station at about 9:40 that evening, and stated that her roommate, Resident 3, had kissed her without her permission while they were in their room and she felt uncomfortable. Staff moved both residents to different rooms. A review of the clinical record indicated that no care plan addressing the allegation of abuse was made for Resident 1. During an interview on 8/9/22 at 11:49 am, the DON confirmed that there was no care plan done for Resident 1 regarding her allegation of abuse. Based on observation, interview and record review, the facility failed to protect all residents from abuse when 1. Resident 4 hit Resident 2 on the head, and 2. After an allegation of abuse by Resident 1 against Resident 3, no care plan (a plan for the care staff are to deliver to the resident) was made to address Resident 1 ' s feelings or safety. These failures had the potential to contribute to fear and a loss of well-being among all residents. Findings: 1. A review of a facility document titled Client Abuse Prevention reviewed 4/5/22, indicated that the facility would take all appropriate preventive measures to prevent client abuse. A review of the clinical record indicated that Resident 2 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of the clinical record indicated that Resident 4 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was unable to make his own healthcare decisions. A review of a nursing note dated 5/19/22 at 10:45 pm, indicated that earlier that day, about 8:55 pm, staff heard someone in the common room say loudly, He hit me, he hit me! When staff arrived, Resident 2 was seated and accused Resident 4 of hitting her. Both residents were separated, assessed, and placed on welfare checks (checking the resident every 15 minutes). A review of an administration note dated 5/20/22 at 1:32 am, indicated that Resident 2 requested and was given two Ibuprofen (a mild pain medication) for neck pain she described as severe. A review of an Interdisciplinary Progress Note (a clinical note made by a meeting of different types of staff to share expertise, knowledge and skills to improve resident's care) dated 5/23/22 at 9:43 am, indicated that the Director of Nursing (DON) reviewed the camera recording from the facility common room, which showed that Resident 4 struck Resident 2 on the head. During an observation and interview on 8/3/22 at 11:30 am, Resident 2 stated that a guy had hit her on the head, but she did not remember anything else about it. During an interview on 8/9/22 at 11:49 pm, the DON confirmed that she had viewed the video from 5/19/22 showing Resident 4 hitting Resident 2 on the head, and Resident 2 becoming angry that she had been hit. 2. A review of a facility document titled Client Abuse Prevention reviewed 4/5/22, indicated that any resident-to-resident problems would be addressed in care plans for the residents involved. A review of the clinical record indicated that Resident 1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of the clinical record indicated that Resident 3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to make her own healthcare decisions. A review of an alert note dated 6/23/22 at 10:30 pm, indicated that Resident 1 came to the nursing station at about 9:40 that evening, and stated that her roommate, Resident 3, had kissed her without her permission while they were in their room and she felt uncomfortable. Staff moved both residents to different rooms. A review of the clinical record indicated that no care plan addressing the allegation of abuse was made for Resident 1. During an interview on 8/9/22 at 11:49 am, the DON confirmed that there was no care plan done for Resident 1 regarding her allegation of abuse.

Based on interview and record review the facility did not report a Clients allegation of rape to the California Department of Health as required. By not reporting the allegation of rape the facility created the possibility for ongoing abuse of the Client potentially causing mental anguish and physical injuries leading to adverse clinical outcomes. Findings: On 4/5/22 at 10:45 AM Client 50's medical record was reviewed. Client 50 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/2022 Client 50 reported to her Conservator (RP) (person that makes medical decisions) that she had been violated. The medical record does not reflect the facilities required reporting to the California Department of Public Health (CDPH) was completed. On 4/5/22 at 02:30 PM during an interview with the Director of Nursing (DON) regarding the rape allegation the DON stated, We found out about it when the police showed up. She has reported rape in the past. This time she reported it to the Conservator, and we found out about it when the police arrived. When asked about notifying CDPH the DON stated, We didn't fill out the abuse reporting form because the conservator had already reported it. It was reported to the police and CDPH by the conservator. On 4/5/22 at 03:15 PM during an interview with the Facility Administrator (FA) the allegations were discussed. The FA stated, We know the Clients and if they continually report they have been raped as part of their delusions we do investigate and depending on what we find we might report it. If we were to report all of them, we would have a lot of investigations by the State. On 4/5/22 at 04:20 PM, the FA provided a copy of the facility policy titled, IDENTIFICATION, REPORTING AND INVESTIGATION: REPORTING ALLEGED CLIENT ABUSE. The policy quotes regulatory requirements however, the policy does not include specifically required reporting of abuse allegations to CDPH. In addition, the reporting timeframe found on page two, paragraph two states 36 hours rather than the required 2- or 24-hour abuse reporting. FA is aware of the timeframe differences as discussed. On 04/06/22 at 09:46 AM The RP was called to clarify the reported abuse. The RP stated, I got a call from her and she left a message. I called her back and she told me she felt she was violated at night. I reported it to the local Police (PD), Adult Protective Services (APS), the Patient Advocate and Ombudsman. I filled out the [abuse reporting form] form and sent it to APS. The police investigator got back to me and said it was 'unfound' and he was forwarding it to their investigations for review. 04/06/22 11:20 AM Discussion with FA and DON regarding failure to report. The FA stated .that the reporting timeframe should be revised to 2 hours instead of 36. To correct the issue the DON stated, staff training will include that all staff are mandated reporters. The FA and DON agree that they will report all here forward and communicate with CDPH more frequently when there are multiple delusional allegations.

Based on observation, interview and record review, the facility failed to ensure that one of one sampled residents had complete admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential for Resident 185 not to receive the necessary care he needed to prevent malfunctioning of the catheter and avoid bladder infections. Findings: Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent Minimum Data Set (MDS a standardized assessment tool used by all skilled nursing facilities), dated 1/4/22, showed that he was alert and oriented and used a urinary catheter. On 4/5/22 at 9:30am, Resident 185 was observed in his room. He had a urinary catheter in place. A review of Resident 185's Admission Physician's Orders for March 2022, had not included immediate orders for the care and management of his bladder catheter. The current orders for April 2022, also had not contained any orders for a bladder catheter. A review of the facility's policy titled, Admission of Resident/Client dated 9/1/2013, directed that a Licensed Nurse will inform the physician of arrival and .body check findings that require treatment. Verify, and clarify .all of the physician's orders . A review of the facility's policy titled, Foley Catheter Drainage Charting And Documentation updated 11/19/10, was reviewed. The policy directed that the following information must be documented in the client's clinical record, the need for an indwelling catheter, the type of catheter, the type and frequency of care and symptoms which would precipitate catheter change. On 4/5/22 at 2:15pm, during an interview and record review, the Director of Nursing (DON) confirmed that Resident 185's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to ensure that 1 of 22 sampled residents had Baseline Care Plans developed within 48 hours after admission. (Resident 185) This failure to identify Resident 185's immediate basic health and safety needs had the potential to negatively impact his physical and psychosocial well-being. Findings: Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent Minimum Data Set (MDS, a standardized assessment used by all skilled nursing facilities), dated 1/4/22, showed that he was alert and oriented, had a urinary catheter and was taking [CONDITION(S)] (alters mood and behavior) medications. On 4/5/22 at 11am, during an observation and interview, Resident 185 was observed with a urinary catheter and was sitting in a wheelchair. He stated that he did not go outside of his room because he felt, a little paranoid. A review of Resident 185's record showed that there were no Baseline care plans developed within 48 hours after he was admitted . Therefore, his needs were not identified and there were no instructions for staff to follow to ensure that his basic needs were met. A review of the facility's policy titled, Admission of Resident/Client dated 9/1/13, directed that the Licensed Nurse will initiate care plan entries for immediate care needs. On 4/5/22 at 2:15pm, an interview and care plan review was conducted with the Director of Nursing (DON). The DON confirmed that Baseline care plans were not developed for Resident 185 within 48 hours after he was admitted and stated, they were not done and should have been.

Based on observation, interview and record review, the facility failed to develop comprehensive care plans for 3 of 22 sampled residents (Residents 185, 75 and 81) when: 1. Resident 185 had one care plan developed for his isolation problem but no other problems were identified or care planned. 2. Resident 75 did not have a care plan developed for his need to be straight cathed (insertion of a tube in the bladder to remove urine intermittently as needed, instead of having a permanent catheter in the bladder). 3. Resident 81's care plans did not identify medications, symptoms to monitor or report, or any non-pharmacological interventions. These failures had the potential for these Resident's needs to go unrecognized and untreated and negatively impact their ability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: 1. Resident 185 was admitted on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent Minimum Data Set (MDS, a standardized assessment used by all skilled nursing facilities), dated 1/4/22, showed that he had a urinary catheter and was taking [CONDITION(S)] (alters mood and behavior) medications. On 4/5/22 at 11 am, during an observation and interview, Resident 185 was observed with a urinary catheter and was sitting in a wheelchair. He stated that he did not go outside of his room because he felt, a little paranoid. A review of Resident 185's care plans showed that he only had one care plan developed which addressed that he isolated himself in his room due to [CONDITION(S)]. There were no other care plans developed for his physical needs, safety, or other psychosocial needs. A review of the facility's policy titled, Documentation of Client Care Planning updated 12/31/15, directed that a resident's care plan will include the identifying condition, brief history of the condition, a goal, an objective that is measurable and time specific, a target date for completion and interventions specific to a designated discipline and responsible person. On 4/5/22 at 2:15 pm, a care plan review and interview was conducted with the Director of Nursing (DON). The DON confirmed that Resident 185 did not have care plans developed for all of his needs and stated, He was considered a new admission and all new care plans should have been developed. 2. A review of Resident 75's record indicated he was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for [CONDITION(S)] included, give medication as ordered as the only intervention. A care plan for urinary retention included, give medication as ordered and treatment as needed as the only interventions. There were no care plans relating to Resident 75's need to be catheterized or the specific physician ordered interventions. During a concurrent interview and record review on 4/6/22 at 4:35 pm, the care plans were reviewed with the DON. She confirmed the care plans did not include catheterizing Resident 75. She said this should have been included in the care plan. 3. Resident 81 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Her physicians orders for four medications were reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record for Resident 81 was reviewed on 4/7/22 at 09:20 am. Four care plans for Resident 81 were reviewed. A . A care plan dated 8/18/19 and revised 2/22/22 indicated; Ct (Resident 81) has delusions r/t (related to) [CONDITION(S)] Disorder [CONDITION(S)] Type. The goal of the plan was for the resident to have no delusions. There were two listed interventions Medicate as ordered by MD and Monitor and document through BDC's The medication to be administered was not included. Behaviors to be monitored were not included. There were no non-pharmacological (not medication based) interventions. B. A care plan dated 9/21/18 and revised 9/21/21 indicated The client uses [CONDITION(S)] medications r/t Disease process [CONDITION(S)]. The goal listed for this plan was The client will be/remain free of [CONDITION(S)] drug related complications . The care plan included the following interventions, Administer [CONDITION(S)] medications . monitor for side effects and Discuss with MD . ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness per facility policy The plan did not identify any of the [CONDITION(S)] medications Resident 81 is currently prescribed. The care plan did not identify what behaviors should be monitored. The care plan did not identify any alternate therapies attempted or include any non-pharmacological interventions. C. A care plan dated 9/22/18 indicated, Client has [CONDITION(S)]. The intervention listed was administer medication as ordered The care plan did not indicate which medication (Resident 81 prescribed two different medication Trazadone and [MEDICATION(S)]). The care plan did not include any non-pharmacological interventions. D. A care plan dated 4/1/19 and revised 5/14/21 indicated Client has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was Client will be compliant with treatment The care plan included three interventions Administer medications . Follow up with cardiologist . and Notify MD immediately if symptoms occur. The care plan did not identify the medication being used and listed none of the symptoms which would indicate the physician should be notified. During an interview and concurrent record review on 4/7/22 at 11:07 am with DON, she reviewed the care plans related to the use of psychotherapeutic medications and/or psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reviewed Resident 81's care plan for cardiac concerns. DON acknowledged the care plan did not identify the medication. Initially DON stated Resident 81 may not have been prescribed any medication. DON clarified that care plans include medicate as ordered in case a medication is ordered, but that does not indicate a medication has been ordered. After review of Resident 81's current physician orders, DON stated the medication referenced in the care plan could be Aspirin. DON acknowledged the care plan did not identify the medication ordered or symptoms to be monitored and reported. DON stated the facility expectation is for the nurses to know the medication and symptoms to monitor, so there is no reason to include it in the care plan. During an interview and concurrent record review conducted on 4/7/22 at 2:05 pm with the Program Director (PD) she stated that staff document behavioral and symptom monitoring under the heading TASKS. PD confirmed staff were monitoring the following, episodes of delusional statements Q shift, episodes of isolative behavior, and hours of sleep. PD reviewed the Care Plans for Resident 81 and confirmed that care plans did not include any non-pharmacological interventions, did not include specific behaviors/symptoms to monitor, or identify which medication is being referenced. PD clarified that she had not been involved in Resident 81's care plans, and was unable to clarify why this information was not included. PD showed surveyor out of sample resident care plans that did include this information, and clarified that this information should be included in the care plan.

Based on interview and record review, the facility failed to ensure a post fall injury, including a bump on the head, was monitored according to facility policy, and a fall assessment done, upon readmission, was completed accurately, for one of two residents (Resident 48), with a history of falls. This had the potential to result in a delay in the recognition of a worsening injury and result in more falls with major injuries. Findings: The facility's Fall Prevention & Management policy, dated 4/3/20, was reviewed. It indicated, Upon admission, each resident is assessed using a Fall Risk Assessment Tool to determine possible risk for sustaining a fall. The procedure for responding to a fall included, Resident is to be placed on observation of vital signs, pain and other post-fall complications. Fall details, assessment findings, interventions & notifications are to be documented in the resident's clinical record & care plan updated accordingly. Continued monitoring is necessary, as symptoms may present at any time, even days following the actual event. Follow-up orthostatic vital signs (a series of vital signs of a patient taken while the patient is supine then again while standing), assessment pain evaluations, and neurological checks (when indicated) will be conducted for a minimum of 72 hours for any actual or suspected fall, with or without injury. A review of Resident 48's record indicated she was originally admitted on [DATE], with diagnoses that included [CONDITION(S)] disorder, [CONDITION(S)] type (a combination of symptoms of [CONDITION(S)] and mood disorder such as [CONDITION(S)] disorder, a condition marked by unusual shifts in mood, energy, activity levels and the ability to carry out day to day tasks). Resident 48 fell on [DATE] and suffered no injuries. She fell again on 11/30/21 and suffered a bump on the head, as a result of that fall. She was discharged on [DATE] to a higher level of care and readmitted on [DATE]. During an interview on 4/6/22 at 3:10 pm, the Medical Records manager (MR A) said this resident did not trigger as being a high risk for a fall, during the fall readmission assessment done, on 1/25/22. She provided a copy of that assessment which indicated Resident 48's fall score was a 9. A score of 10 was high risk. The fall risk assessment done upon readmission was reviewed. Section F included taking the resident's blood pressure (BP). No points were added to the score if there was no noted drop between the lying and standing BP, two points added if there was a drop in the BP of less than 20 between lying and standing, and four points added if there was a drop in the BP of more than 20 between lying and standing. There was a place for the BP findings to be documented but it had been left blank. After Resident 48 fell on [DATE] it was noted in the initial post fall assessment that she had received a bump to her head. Neurological checks (to check a person's nervous system and cognition) were done for 24 hours but made no mention of the bump on the head. Further assessments for the next 72 hours in the nursing progress notes indicated there were no adverse side effects from the fall, but make no mention of the bump on resident's head, its size, or how long it remained. During a concurrent interview and record review on 4/7/22 at 9:10 am the follow up assessments of Resident 48's injury after her fall on 11/30/21 was discussed with the Director of Nurses (DON). She said there was an order to monitor the bump to Resident 48's right temple, but there was nothing charted about it, including the size from 11/30/21 through 12/2/21. On 12/3/21, there was a note that the resident refused assessments including vital signs (BP, pulse, respirations), then she was transferred to the other facility on 12/4/21. She agreed the bump to the head was something that should have been monitored after the fall on 11/30/21. The fall risk assessment done upon readmission on 1/25/22 was reviewed with the DON. It indicated a score of 9, and a score of 10 was a high risk. A review of the fall assessment indicated there was a space under section F for the BP findings and this section of the falls assessment dealt with drops in BP between lying and standing. DON said this section should have been completed since the fall assessment was part of their policy. She reviewed the vital signs section of the electronic health record and although there are BP's charted on 1/25/22, they do not indicate if the BP was taken with the resident standing or lying.

Based on interview and record review: 1. The facility's pharmacy consultant failed to identify drug irregularities which included duplicate therapy (more than one medication for the same purpose without a clear distinction of when one medication should be given over another medication), for one of six sampled residents (Resident 48) whose records were reviewed for unnecessary drugs. Resident 48 had orders, for two as needed (prn) medications, used to treat anxiety or agitation, without any direction from the physician, as to which medication to use first or why both medications were needed, on a prn basis. This had the potential to result in Resident 48 receiving unnecessary drugs with potential adverse side effects. 2. The facility failed to ensure their pharmacy consultant provided documentation for each resident when the medication regimen review was done on a monthly basis. There was nothing in each resident's medical record to indicate that a medication regimen review was done, if there were no drug irregularities found. The facility's pharmacy consultant instead provided a summary with the names of all residents, when no irregularities had been found. This resulted in the inability to ensure that each resident had a monthly medication regimen review. Findings: The facility's pharmacy consultant policy and procedure manual was reviewed. The medication regimen review policy, dated 12/8/06, indicated, as required by state regulations and as specified by contract, consultant pharmacists will perform medication regimen reviews monthly or more frequently as appropriate to the resident's needs. The review included preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. Significant findings or irregularities will be communicated to the attending Physician/prescriber, director of nursing, and other appropriate individuals. Process 2. The consultant pharmacist conducts a comprehensive resident-specific review of medication therapy. Analysis of the medication regimen includes reviewing for: 2.3 Use of a medication in an excessive dose (including duplicate therapy) . 2.11 PRN drug use. 5. Medication Regimen Review Documentation: 5.1 The pharmacist dates and signs the resident's record on the designated form when the review is completed. This form is part of the resident's permanent medical record. 6.1 If no irregularities are observed, the consultant pharmacist documents this in the resident's permanent medical record. 1. A review of Resident 48's record indicated she was originally admitted on [DATE], with diagnoses that included [CONDITION(S)] disorder, [CONDITION(S)] type (a combination of symptoms of [CONDITION(S)] and mood disorder such as [CONDITION(S)] disorder, a condition marked by unusual shifts in mood, energy, activity levels and the ability to carry out day to day tasks). She was discharged on [DATE] to a higher level of care and readmitted on [DATE]. A review of the physician orders included an order, dated 1/26/22, for [MEDICATION(S)] (drug used to treat anxiety) one milligram (mg) every eight hours as needed (prn) for anxiety and/or agitation. There was also a physician's order, dated 1/25/22, for [MEDICATION(S)] (drug used to treat anxiety) 50 mg every six hours prn for anxiety/agitation. There was nothing in the record to indicate which medication should be used first, or why Resident 48 needed both these medications, on an as needed basis, to treat the same symptom. The medication regimen review (MRR) could not be located in the record. During an interview on 4/7/22 at 9:34 am, the facility's pharmacy consultant was asked to provide a copy of the drug reviews done for this resident, since her readmission on 1/25/22, and send to the DON via email. During a concurrent interview and record review, on 4/7/22 at 11:15 am, the DON provided the above mentioned physician's orders for the [MEDICATION(S)] and [MEDICATION(S)]. She was asked how her staff would know which medication to give should the resident become anxious or agitated and need one of these medications, since they were both ordered for the same symptom. The DON said they would not know which one to give as the order does not specify this. She agreed this was duplicate therapy and said she had not looked into the orders in great detail because their pharmacy consultant should have done this. The DON provided a copy of the MRR done by their pharmacy consultant for this resident, dated 3/3/22 and 4/4/22, and no irregularities or recommendations were noted. 2. During an interview on 4/6/22 at 2:45 pm, the DON said she does not get a separate page for each resident, who gets reviewed by the pharmacist, if there were no recommendations or drug irregularities found for those residents. During an interview on 4/7/22 at 9:34 am, the facility's pharmacy consultant said she provides a list to the facility, with the names of all residents, with no recommendations or drug irregularities, as opposed to a separate page for each of these residents.

Based on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 92) was protected from physical abuse on 10/19/18. Resident 193 was observed to be in an agitated state and was visibly upset. The staff did not protect Resident 92 from Resident 193's physical aggression when he struck Resident 92 in the face, multiple times, and kicked her when she was on the ground. This resulted in minor physical injuries and had the potential to negatively impact Resident 92's emotional and psychological health and lead to potential negative clinical outcomes. Findings: A review of Resident 193's clinical record indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 193's Progress Notes, dated 10/19/18, indicated at approximately 3:15 PM, staff smelled marijuana (a controlled substance) in the hallway. Staff approached Resident 193's room, where the smell was coming from, and Resident 193 was in the bathroom. Resident 193 was asked about the smell and he denied having marijuana and left his room. Staff searched Resident 193's room and found the marijuana, hidden in the trash can. Resident 193 initially denied the marijuana was his but eventually confessed. The note indicated Client was agitated at this time At approximately 3:40 PM, Resident 193 became physically aggressive, striking two program staff and a Resident 92. A review of Resident 92's clinical record indicated that she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 92's Progress Notes, dated 10/19/18, indicated at approximately 3:40 PM, Resident 92 was in the courtyard. Resident 92 asked Resident 193 why staff members were searching his room. Resident 193 gestured his hands at Resident 92 as if he did not want to communicate. Resident 92 continued to question Resident 193 and said You don't have to be disrespectful. Resident 193 then struck Resident 92, making contact with the left side of he face more than one time. Resident 92 had red, raised swollen areas on her left temple and right knee. During an interview on 4/11/19 at 2:36 PM, the Wellness Recovery Director (WRD) stated that he was not a witness to the incident. He was in a meeting and he was called out to assist staff. The WRD stated that Resident 193 had no history of aggressive or violent behaviors but did have paranoia (an unrealistic distrust of others or a feeling of being persecuted). The WRD stated that Resident 193 was found to have a small amount of marijuana in his possession and his room was being searched. Resident 193 went out to the courtyard where he was approached by Resident 92. The WRD stated that Resident 92 had poor personal boundaries. Resident 92 was asking Resident 193 about the marijuana. Resident 193 asked Resident 92 to go away. When Resident 92 did not go away, Resident 193 struck her in the face and Resident 92 fell to the ground. When Service Coordinator (SC) A intervened, Resident 193 struck her in the face and she fell to the ground. Resident 193 went back into the facility and struck SC B as well before he was detained by staff. The WRD stated Resident 92 was culpable (deserving to be blamed or considered responsible for something bad) and put herself at risk. The WRD stated a reasonable person would stay away. The WRD stated Resident 193 had poor impulse control and he was not trying to hurt Resident 92. During an interview on 4/11/19 at 4:15 PM, SC A stated that she was out in the courtyard. Resident 193 came out and he was visibly upset. SC A stated Resident 193's demeanor concerned her and she was watching him closely. SC A stated that Resident 92 approached Resident 193. SC A stated she wanted to see how Resident 193 responded so she waited to intervene. Resident 193 asked Resident 92 to go away and she did not go. SC A stated that Resident 193 struck Resident 92 in the head and neck area. Resident 92 fell to the ground and Resident 193 began to kick her. When SC A tried to stop Resident 193, he hit her in the face and she fell to the ground. Resident 193 then left the courtyard and entered the facility. During an interview on 4/11/19 at 4:26 PM, SC B stated she was inside when she heard yelling outside. She looked out the window and saw SC A fall to the ground. Resident 193 came inside. SC B stated that she did not confront Resident 193, she was just trying to get other residents out of the room. Then Resident 193 hit her in the head and she blacked out. Resident 193 was secured by staff after that.

Based on interview and record review, the facility failed to provide sufficient staff to meet the behavioral and physical health needs of the residents when the facility was unable to maintain minimum safe staffing ratios on two nocturnal (during the night) shifts (11 pm to 6:30 am). This had the potential for the health and safety needs of residents to be neglected. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] disorder often involves a loss of control and reality base during extreme behaviors. During an interview, on 4/9/18 at 11:30 am, Resident 1 stated that he was often up during the nocturnal shift. He stated he was concerned that the facility had only two licensed nurses (total) on duty on the nocturnal shift for 95 residents about one month ago. He stated that nocturnal staff was having problems getting enough staff to work for about one week during that time period. During an interview, on 4/10/18 at 11:30 am, the Director of Nursing (DON) stated that she considered four staff on the nocturnal shift to be the minimum safe staffing level to meet the behavioral and physical health needs of the residents. The DON stated that she had recently assumed more control, ensuring staffing needs were covered. During a review of staffing and payroll records, and a phone interview with the DON, on 4/19/18 at 2:16 pm, the DON acknowledged that the nocturnal staffing records identified that there was insufficient staff to meet the needs of the residents on 3/24/18 when the facility nocturnal shift had only two staff on duty for over 90 residents, and on 3/30/18 when the nocturnal shift had three staff on duty. The DON stated that she was not called when the staffing problems had occurred. As the facility had a Special Treatment Program for residents with chronic mental/behavioral health needs, the DON was asked how nocturnal staff were able to ensure control of residents with behaviors that required physical redirection and/or restraint for the safety of the resident and others when staffed with less than four persons. The DON stated that the facility rarely had behavioral incidents that required immediate restraint, but acknowledged that staff would not be able to do an emergency restraint intervention for residents who were actively presenting with harm to self, staff, or peers, when there were less than four staff on duty, and that outside agencies would need to be called.

Based on observation and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in one of one kitchens when the facility failed to adhere to proper handwashing, proper thermometer usage, and proper food temperatures. Findings: An observation of the kitchen, on 4/25/18 throughout the lunch meal service, revealed the following: At 10:41 am, five carts were observed as prepped for tray line (a system of food preparation). One cart had two glasses of milk, one cup of cottage cheese, and three glasses of prune juice. A second cart was observed with one cup of cottage cheese. A third cart was observed with two glasses of prune juice. At 10:53 am, Cook 2 was observed taking temperatures of the steam table food items. Cook 2 placed thermometers in two food items (mashed potatoes and spinach) and placed the lid back on the containers. He left the thermometers in place. At 10:55 am, Cook 2 was observed picking up a piece of aluminum foil off of the floor. He continued to place foods on the steam table. No handwashing was observed. At 11:02 am, a thermometer, that was placed into the gravy, fell into the gravy and was almost fully submerged. Cook 2 then placed a scoop into the gravy and left the thermometer in the food item. Cook 2 was observed sanitizing another thermometer with an alcohol pad. He placed the thermometer stem under the water from the faucet and then placed the thermometer into a food item on the steam table. Cook 2 placed a second thermometer into the gravy. The previous gravy thermometer was still in the gravy, almost fully submerged. At 11:06 am, Cook 2 was observed at the handwashing sink. He washed his hands for a few seconds and then wiped his hands on his apron before getting a paper towel to finish drying his hands. During a concurrent observation, Cook 1 placed four bowls onto the steam table. He placed meatloaf into the first bowl, mashed potatoes into the second bowl, spinach into the third bowl, and garlic bread into the fourth bowl. He then placed the bowls near the small blender. At 11:13 am, Cook 1 was observed pureeing the garlic bread with some added butter. The consistency looked like bread crumbs. He confirmed this was the pureed bread, and stated it needed to be pudding consistency kind of, but can mash it up. Cook 1 put the bread mixture back into a bowl. He proceeded to put the spinach into the same blender. The blender was not cleaned. He placed the pureed spinach back into the bowl. At 11:16 am, Cook 1 tested the temperature of the spinach and it was 110 degrees Fahrenheit (F). He then put the mashed potatoes into the same blender. The blender was not cleaned. He placed the pureed mashed potatoes with some spinach pieces back into the bowl. He repeated this process with the meatloaf. Cook 1 took the temperature of the meatloaf and it was 110 degrees F. The mashed potatoes were 100 degrees F. Cook 1 verbalized the food temperatures. At 11:21 am, Cook 1 placed a lid on the bowls and placed the bowls onto the steam table. Staff continued to serve these pureed foods items at the temperatures indicated above. At 11:25 am, the kitchen tray line was observed. The cold items remained on the carts, at room temperature. At 11:30 am, Dietary Aide 1 took the temperature of the cottage cheese on one of the carts. The temperature was 58 degrees F. She verbalized this temperature. Staff continued to serve these items. A review of the facility's policy titled, Handwashing, dated 12/8/08, indicated staff were to scrub for at least 20 seconds over every part of hands, paying special attention to area between fingers, skin folds, and wrists. A review of the facility's policy titled, Food Temperature, dated 7/21/10, indicated hot foods were to be 140 degrees or higher during meal service . make sure the thermometer is clean and has been sanitized with an appropriate sanitizer . allow time for the alcohol to evaporate before inserting the probe into the food. The Food Service Supervisor (FSS) was interviewed on 4/25/18 at 11:47 am. When asked about the pureed food temperatures, he stated they would just keep them the same as the rest of the food. He stated, It didn't need to be hotter or colder than the rest of the food. The FSS confirmed they did not have any recipes for the pureed foods and did not have anything to specify the proper food consistency or the proper pureed food temperatures. The Registered Dietitian (RD) and the FSS were interviewed on 4/25/18 at 12:21 pm. The FSS stated they did monthly inservices, but would have to look back at the topics. He stated the staff had been trained on proper handwashing. He stated he was in the kitchen week to week, and stated, I'm out there. He stated that the staff were trained to use the alcohol pads for sanitization. The FSS acknowledged he wasn't sure why the cook would have placed the thermometer under water after sanitizing it and before placing it into the food item, and stated I need to talk to them about it. When asked about the cold food items, he stated that the staff was supposed to wait until closer to food service before placing the cold food items on the cart. When asked about the pureed diet education with the staff, the RD and FSS could not verify that the staff had been trained. The FSS was not aware of the proper temperature for the pureed food.

Based on interview and record review, the facility failed to ensure the physician for one of eleven sampled clients was immediately notified when her clinical condition deteriorated (Client 4). This resulted in the client's clinical status declining to a guarded (seriously ill with questionable outlook) state when evaluated at the hospital emergency room , due to not receiving timely appropriate treatment. Findings: Client 4's record was reviewed. Client 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 5/12/15, showed she was able to stand up, transfer from sitting to standing, walk in the hall, eat, dress, and go to the bathroom without any assistance from the staff. According to the AMDA (American Medical Director's Association) Acute Change of Condition in the Long Term Care Setting, Clinical Practice Guideline, an acute change of condition is a sudden, clinically important deviation (change) from the client's baseline in physical, cognitive (thinking), behavioral or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The facility's Change of Client Condition Procedure, dated 10/23/03, showed it was the facility's policy to notify the physician (MD, medical doctor) when there was a change in the client's condition. It showed they were to report all findings promptly to the MD and document the name of the person acknowledging contact. The facility's Physician Notification policy, dated 5/18/15, showed that the client's MD would be promptly notified of, Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited. The policy showed that the notification would be documented in the client's record with the name of the person acknowledging contact and that if the MD were unavailable, the client would be sent to the hospital emergency room (ER). During a review of Client 4's record on 6/16/15, an MD's Communication Note, dated 6/4/15, showed she had an unwitnessed fall and had hit her head on the wall. Client 4's Nurse Notes and Progress notes showed the following entries: 6/6/15 at 10:32 am, Client refused all medication, appeared very pale in color, seemed weak, had a hard time standing and holding herself up, denied any fluids, and had a blood pressure (BP) of 90/50 ([MEDICAL CONDITION], low BP is below 90/60, normal is between 120/80 and 140/90, National Heart, Lung and Blood Institute); 6/6/15 at 2:25 pm, Client has not consumed fluids except for meals; 6/6/15 at 10:10 pm, Client had 1 episode of vomiting and complains of feeling dizzy; 6/7/15 at 2 pm, Client appears very weak, speaks in soft tone, difficult to hear or understand, continues to refuse her [MEDICATION NAME] (laxative mixed with 8 ounces of water, not taken); 6/8/15 at 9:39 pm, Client appears weak and pale; 6/9/15 at 9:57 pm, Client started on antibiotic, BP 84/58 (low); 6/11/15 at 3:38 pm, Client has not come to groups, has been sick, confused when talking in conversation; 6/11/15 at 10:53 pm (Thursday evening), Client had unwitnessed fall at 9 pm and hit her head, MD notified; 6/12/15 at 5:04 am (Friday morning), Client called for help to bathroom, slumped over, head rolled back, body stiffened, began tremor (shaking), eye pupils dilated (enlarged), for 20 seconds, lost control of herself, did not recall incident, MD notified ([MEDICAL CONDITION] episode); 6/12/15 at 1:43 pm, Client was encouraged to take fluids but declined many times, witness taking 4 ounces fluid consumption client refused all other fluid offers per shift offered multiples times. BP at 10 am 104/80 laying down, 80/60 sitting (Orthostatic (postural) [MEDICAL CONDITION] is an excessive fall in BP when an upright position is assumed, typically involves volume depletion, Merck Manual), unable to stand due to weakness, Client has not been consuming adequate amount of food nor fluids; A review of an MD note in Client 4's nurse's note dated 6/12/15 at 1:58 pm (Friday afternoon), read: ___________ (MD), Please be advised of changes in Client 4's condition: 1) Increasing weakness to the point where she is not able to stand. 2) VS (vital signs) continue to drop, and are extremely difficult to palpate (feel a pulse). She is now posturally hypotensive; .unable to obtain standing VS as she is W/C (wheelchair bound) at this time. 3) She continues to eat poorly. Wt (weight) loss. 4) She continues with adequate fluid intake. 5) She experienced N/V (nausea and vomiting) x 2 this week (twice). 6) She is extremely pale and reports that she does not feel well, and requests to stay in bed RT (related to) increasing weakness. My concern is that she will deteriorate over the weekend and end up in the ED (Emergency Department, ER). I have little confidence that she will be assessed thoroughly. Please advise, Director of Nursing Services Intern (DONI); Continued review of Client 4's nurse's notes contained the following entries: 6/12/15 at 10:47 pm Client refused [MEDICATION NAME] (mixed with 8 ounces water) and [MEDICATION NAME] (fiber taken with another 8 ounces of water); 6/12/15 at 11:35 pm, Staff was called to ct's (client's) room for a medical code. CT had been help to her chair to use the toilet and was standing to transfer to the toilet when she became limp and unresponsive and slumped over in her chair. Her head rolled backward toward the ceiling and her eyes dilated.lasted approximately 30 seconds.no recollection of incident. She does seem slightly confused.BP 92/60 sitting, 108/58 laying. (second [MEDICAL CONDITION] episode) There is no notation that MD was notified); 6/13/15 at 12:15 pm, Client was asked to take herself to dining room for lunch but refused; 6/13/15 1:13 pm, BP 90/68, Client refusing all fluids client did consume 1/2 cup during med pass., consumed 25 % (percent) breakfast, refused lunch and all other fluids. BP recheck at 11 am 76/52, Client weak and pale and refusing all care. Doctor notified, client sent out the ER for evaluation and fluids; 6/13/15 at 2 pm, Notified to send client to ER, was sent to acute care hospital for evaluation. On 6/16/15 at 10 am, the Director of Nurses (DON) and DONI were concurrently asked why MD was not called about DONI's above referenced note to MD that was faxed on 6/12/15 at 1:58 pm. DON stated that MD wanted to be faxed, as opposed to being called. When DON and DONI were asked if MD's office was even open on Friday afternoons to see faxes sent, they were not able to answer. On 6/16/15 at 3 pm, MD's office was called about their availability on Friday afternoons. MD's Receptionist (MDR) stated that their office was closed Fridays and had been for several years. MDR confirmed that if they received a fax Thursday evening (after closing) or Friday, neither the MD of his office staff would be aware of it, until they opened up on Monday morning, unless he was paged. On 6/16/15 at 3:15 pm, MD confirmed that he did not become aware of Client 4's change of condition (DONI's 6/12/15 1:58 pm change of condition note) until 1:08 pm on 6/13/15, (nearly 24 hours later, the following afternoon). Client 4's record showed an MD phone order, dated 6/13/15 at 1:32 pm, to send her to the acute care hospital. Client 4's record included a faxed MD communication note, dated 6/11/15 at 9:45 pm (Thursday evening), that showed she had an unwitnessed fall, her BP was low at 88/60. Client 4's record included a faxed MD communication note, dated 6/12/15 at 5:20 am (Friday morning) that noted a Change of Condition that described her [MEDICAL CONDITION] episode that occurred at 5:04 am. MD's responses were noted (acknowledged) and signed by MD on 6/15/15 (Monday). Client 4's record did not include any documentation or verification that MD was aware of her unwitnessed fall on 6/11/15 and the 6/12/15 [MEDICAL CONDITION] episodes until 6/15/15. On 6/16/15 at 4:55 pm, Licensed Nurse (LN) C stated that MD was, unapproachable but was available on his cell phone. LN C concurrently reviewed DONI's fax to MD regarding Client 4's change of condition on 6/12/15. LN C stated that she would have called MD, although he does not make anyone feel their reasons for calling about a client are adequate. LN C confirmed that she was not aware that MD's office was closed on Fridays, as she usually called him on his cell phone. On 6/16/15 at 5:05 pm, LN D stated that the best way to get a hold of MD was to call him on his cell. LN D stated that she had heard in report that day (6/12/15) that staff had been unable to get a hold of MD and so they had faxed him. LN D stated that she was not aware MD's office was closed on Fridays. On 6/17/15 at 10 am, LN B stated that she had taken care of Client 4 on 6/12/15 and created the Nurse Note on 6/12/15 at 2:06 pm. LN B stated that on 6/12/15, she was Absolutely worried about dehydration with Client 4, due to her orthostatic BPs, ongoing urinary tract infection (UTI, bladder infection), and fluid intake problem. LN B stated Client 4 refused all fluids; even the water she typically took with her [MEDICATION NAME] and [MEDICATION NAME]. LN B stated that she had heard about Client 4's [MEDICAL CONDITION] episode that morning from the Shift Lead Nurse (SLN). LN B stated that she continued to report Client 4's status and ongoing refusal of fluids to SLN throughout her shift on 6/12/15, but did not report it directly to the MD. LN B confirmed that she was not aware that MD's office was not open on Fridays. On 6/17/15 at 2:45 pm, DONI was asked about her written note, faxed to MD, regarding Client 4's change of condition. DONI confirmed that she was concerned Client 4 would continue to decline and faxed the note to MD because she wanted to Make him aware of her assessment of Client 4. When DONI was asked if she was aware that MD's office was closed on Fridays and that no one would see faxes sent until the following Monday, DONI confirmed that she was not aware of that when she had sent her assessment about Client 4's clinical change of condition.

Based on observation, interview, and record review, the facility failed to ensure necessary, timely care and services from 1/12/15 to 1/17/15 for one of 19 sampled residents (Resident 12) when Resident 12 had an unwitnessed fall with injury and pain, and the physician was not notified timely of the fall with injury, pain, and continued changes in the resident's condition. This resulted in Resident 12 having unrelieved pain, a five day delay in diagnosis, evaluation, and treatment for [REDACTED]. Resident 12 stated she had Horrible pain! .when she fell and landed on the floor, her leg was twisted and bent out to the left and she had not been able to stand up or take care of herself after that. Findings: The record for Resident 12 was reviewed. According to Resident 12's face sheet (lists pertinent resident information) Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 12 was unable to make her own medical decisions and had a court appointed conservator to make decisions for her. Review of the facility's Behavioral Data Collection for the month of December 2014 indicated Resident 12 exhibited a total of 9 delusions, 7 impulsive behaviors, and 28 severe mood fluctuations. Review of January 2015 physician's orders [REDACTED]. [MEDICATION NAME] 300 milligrams (mg) by mouth (po) three times daily was originally prescribed on 4/4/12 for unspecified arthropathy (a disease of a joint which may be associated with arthritis). [MEDICATION NAME] 5/325 mg (5 mg [MEDICATION NAME] and 325 mg acetominophen) one tablet po three times daily was originally prescribed on 10/24/14 for pain (type, location and severity not specified). [MEDICATION NAME] IB Tablet ([MEDICATION NAME]) 600 mg po every 8 hours, as needed for mild pain, was originally prescribed on 4/17/13. The facility policy for pain assessment, dated 9/2/10, indicated a complaint of new pain or increase in severity would be brought to the shift coordinator's attention immediately, but did not indicate when to notify the physician. The policy indicated the facility's pain level scale was 0-10 (0=no pain, 1-3=mild pain, 4-5=moderate pain and 6-9= severe pain). Review of nurses notes, dated 1/12/15 at 10:57 am, indicated Resident 12 had an unwitnessed fall in the facility and heard client yell and found on the floor. Client was sitting on the floor at the end of the bed with left leg turned to the left and right leg straight out. Client complained of pain in the left knee and back. Stated her back hit the footboard. Assessed to have an abrasion and bruising on right side. Staff progress notes, Medication Administration Record [REDACTED] On 1/12/15, the nurses notes contained the following: At 10:57 am, Resident 12 had a fall and was found sitting on the floor with her Left leg turned to the left. At 10 pm, Has been complaining of pain from her fall all shift (eight hours). she hurts. There were no further nursing assessments documented in the record and no documented evidence that the physician was notified of Resident 12's fall with injury. Review of the January 2015 MAR indicated [REDACTED]. On 1/13/15, the nurses notes contained the following: At 6:26 am, c/o (complains of) severe pain in left hip and knee.; At 10:57 am, Resident 12 had a fall on 1/12/15 and is c/o pain. Order (from physician) obtained to xray (left knee).; At 5:46 pm, Continues to complain of terrible pain in her left hip. XRAY done this morning of left knee only showed no acute issues.; At 5:59 pm, Is not able to eat by herself.; At 9 pm, Client has remained lethargic, difficult to arouse and complaining of pain most of this shift. Client has required assistance with transfers, toileting, feeding and undressing all this shift. Review of the January 2015 MAR indicated [REDACTED]. There was no documented evidence to indicate the physician was notified of Resident 12's terrible pain in her left hip or increased need for assistance with ADL care. The quarterly Minimum Data Set (MDS, a resident assessment), dated 1/13/15, signed by the Registered Nurse (RN) on 1/21/15 to indicate the assessment was completed, indicated that Resident 12 was alert, oriented and independent in the Activity of Daily Living (ADL) areas of bed mobility, eating, dressing, toilet use and walking in the hall and in her room. Resident 12 had full control of her bladder function and had no symptoms of delusions, hallucinations, behavioral symptoms, agitation, or rejection of care. A change of condition MDS had not been completed for Resident 12's 1/12/15 fall with injury and pain. On 1/14/15, the nurses notes contained the following: At 2:42 pm, . c/o 8/10 pain. At 10:06 pm, Assisted to the restroom all shift as well as ADL's. Review of the January 2015 MAR indicated [REDACTED]. There was no documentation to indicate the physician was notified of Resident 12's decline in ADL abilities. On 1/15/15, the nurses notes contained the following: At 5:59 am, Ct (client) c/o pain in her knee when changed. declines to help move in bed. C/o right sided rib pain.purple bruise noted right side.; At 12:14 pm, unable to attend community meeting this week.unable to sit up straight in wheelchair.Also has a jerking movement. Has been asking for more assist from staff for eating and ADL's.; At 2:04 pm, c/o pain and requesting help to transfer.leaning to her right in her chair.; At 10:21 pm, Increasingly confused.leaning to the far right in her wheelchair. Review of the January 2015 MAR indicated [REDACTED]. There was no nursing documentation to indicate the physician was contacted regarding Resident 12's ongoing pain, decline in ADL abilities, and new onset of confusion. The record contained an untimed physician's handwritten order on 1/15/15 to obtain a left hip xray. During an interview on 2/27/15 at 3 pm, the Director of Nursing stated the physician had come into the facility about midnight on 1/15/15, after having been out of town and written the order to xray Resident 12's left hip. On 1/16/15, the nurses notes contained the following: At 12:35 am, nurses notes documented, Refuses to get out of bed to go to the bathroom.stated I have been abused enough today stated she doesn't want her leg to be twisted anymore by us (nursing staff) and will just pee in bed. At 6:13 am, Resident 12's oxygen level decreased requiring supplemental oxygen. At 12:35 pm, Resident 12 was awake but confused. Incomplete sentences, disjointed thought process, affect [MEDICATION NAME] and glazed eyes. Some uncoordinated motor behavior of right upper extremity. Difficulty sitting upright in wheelchair. Speech is mumbling and drifts off into incoherent verbalizations.; At 2:09 pm, 8/10 pain.very disoriented.slurring speech leaning in wheelchair. At 2:43 pm, .needing assistance with ADLs, transfers, and toileting.screaming, yelling, and cussing at staff. A facsimile, faxed to the facility on [DATE] at 4:53 pm, included left hip xray results which indicated the impression of a femoral bone (long bone in the upper leg) fracture. A review of the January 2015 MAR indicated [REDACTED]. There were no new pain medication orders obtained to address Resident 12's moderate 5/10 pain. There was no documentation that the physician was notified of Resident 12's continuing decline in ADL abilities, ongoing confusion and disorientation, pain levels that exceeded the prn [MEDICATION NAME] medication parameters, or that the xray results showed a femoral bone fracture. On 1/17/15, nurses notes contained the following: At 1:49 am, Behavioral Data Collection notes Resident 12 has had an increase in the past 7 days in delusions and severe mood fluctuations; At 5:57 am, Uncooperative and refused to get out of bed and said she purposely urinated in her bed.; Between 6 am and 4 pm, Resident 12 continued to have clinical changes (decline in respiratory status, low oxygenation levels requiring supplemental oxygen, and elevated temperature). At 4:03 pm, Resident 12 was sent to the hospital emergency room for evaluation of her left hip pain and xray indicating a fracture (five days after her fall, continuing complaints of pain, decline in ADL abilities, and new onset of confusion). Review of the January MAR for 2015 indicated Resident 12 had not received any prn pain medication at the facility on 1/17/15, and no new pain medication orders were obtained to address Resident 12's pain. Review of the hospital's follow up instructions, dated 1/17/15 at 11:41 pm, indicated the hospital physician ordered for Resident 12 to follow up with an orthopedic MD (specialist physician for bone injuries), use a knee immobilize at all times, a narcotic prn pain medication for moderate and severe pain, and to have no weight bearing on her left leg due to a fractured bone. On 1/19/15, Resident 12's physician ordered an increase in [MEDICATION NAME] from three times daily to four times daily for pain for Resident 12's 9/10, severe pain. Review of the ADL documentation for January 2015, indicated after 1/13/15, Resident 12 had declined in function, needing assistance with toileting, total assistance with dressing and grooming, frequently refused care, had daily episodes of urinary incontinence (wetting herself) and frequent undesirable behaviors. Review of the facility's Behavioral Data Collection for January 2015 indicated Resident 12 exhibited a total of 64 delusions, 63 impulsive behaviors, and 60 severe mood fluctuations; many of these behaviors were exhibited after Resident 12's unwitnessed fall with injury on 1/12/15. During an interview on 2/26/15 at 1:30 pm, Licensed Nurse (LN) D stated Resident 12 had started having increased behaviors and needing assistance with eating, dressing, and toilet use, and had been unable to walk since her fall on 1/12/15, over one month ago. LN D confirmed Resident 12 had complained of hip pain since her fall, an xray was not obtained until 4 days after her fall, and Resident 12 was not sent to the hospital for evaluation and treatment until 1/17/15, after another day had passed. During an interview on 2/27/15 at 8 am, the Clinical Nurse responsible for shift operations, LN A stated she would expect if a resident complains of pain after a fall, nursing should notify the physician of the exact area(s) of pain so it can be xrayed to rule out a fracture. LN A stated if a resident complains of pain at a level higher than the prn medication is ordered for, the physician should be notified so the order can be adjusted, if needed. LN A stated when the physician orders [REDACTED]. During an interview on 2/27/15 at 8:15 am with Resident 12, she readily recalled when she fell last month. Resident 12 exclaimed she had Horrible pain! .when she fell and landed on the floor, her leg was twisted and bent out to the left and she had not been able to stand up or take care of herself after that.

Based on interview and record review, the facility failed to ensure one of eleven sampled clients did not become dehydrated and treat it promptly (Client 5). This resulted in the client's admission to the hospital for acute [MEDICAL CONDITION] (abrupt serious kidney failure) with severe dehydration. Findings: Client 4's record was reviewed. Client 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 5/12/15, showed she was able to stand up, transfer from sitting to standing, walk in the hall, eat, dress, and go to the bathroom without any assistance from the staff. The facility's Intake and Output (I&Os) policy, dated 10/21/11, showed that intake and output records (in cubic centimeters, volume measure of fluids) would be maintained if dehydration were suspected. On 6/16/15, Client 4's record included an MD's (medical doctor) Communication Note, dated 6/4/15, that showed she had an unwitnessed fall and had hit her head on the wall. Client 4's Nurse Notes and Progress notes showed the following entries that revealed problems with her getting adequate fluids and symptoms of dehydration that included weakness, [MEDICAL CONDITION] (low blood pressure (BP) below 90/60, normal is between 120/80 and 140/90, National Heart, Lung and Blood Institute), low blood volume (orthostatic (postural) [MEDICAL CONDITION] is an excessive drop in BP when an upright position is assumed, typically involves volume depletion, Merck Manual), confusion, dizziness, [MEDICAL CONDITION], falls: 6/6/15 at 10:32 am, Client refused all medication, appeared very pale in color, seemed weak, had a hard time standing and holding herself up, denied any fluids, and had a BP of 90/50; 6/6/15 at 2:25 pm, Client has not consumed fluids except for meals; 6/6/15 at 10:10 pm, Client had 1 episode of vomiting and complains of feeling dizzy; 6/7/15 at 2 pm, Client appears very weak, speaks in soft tone, difficult to hear or understand, continues to refuse her [MEDICATION NAME] (laxative mixed with 8 ounces of water, not taken); 6/8/15 at 9:39 pm, Client appears weak and pale; 6/9/15 at 9:57 pm, Client started on antibiotic, BP 84/58 (low); 6/11/15 at 3:38 pm, Client has not come to groups, has been sick, confused when talking in conversation; 6/11/15 at 10:53 pm (Thursday evening), Client had unwitnessed fall at 9 pm and hit her head, MD notified; 6/12/15 at 5:04 am (Friday morning), Client called for help to bathroom, slumped over, head rolled back, body stiffened, began tremor (shaking), eye pupils dilated (enlarged), for 20 seconds, lost control of herself, did not recall incident, MD notified; 6/12/15 at 1:43 pm, Client was encouraged to take fluids but declined many times, witness taking 4 ounces fluid consumption client refused all other fluid offers per shift offered multiples times. BP at 10 am 104/80 laying down, 80/60 sitting (orthostatic [MEDICAL CONDITION], volume depletion, dehydration), unable to stand due to weakness, Client has not been consuming adequate amount of food nor fluids; A review of an MD note in Client 4's nurse's note dated 6/12/15 at 1:58 pm (Friday afternoon), read: ___________ (MD), Please be advised of changes in Client 4's condition: 1) Increasing weakness to the point where she is not able to stand. 2) VS (vital signs) continue to drop, and are extremely difficult to palpate (feel a pulse). She is now posturally hypotensive; .unable to obtain standing VS as she is W/C (wheelchair bound) at this time. 3) She continues to eat poorly. Wt (weight) loss. 4) She continues with adequate fluid intake. 5) She experienced N/V (nausea and vomiting) x 2 this week (twice). 6) She is extremely pale and reports that she does not feel well, and requests to stay in bed RT (related to) increasing weakness. My concern is that she will deteriorate over the weekend and end up in the ED (Emergency Department, ER). I have little confidence that she will be assessed thoroughly. Please advise, Director of Nursing Services Intern (DONI); Continued review of Client 4's nurse's notes contained the following entries: 6/12/15 at 10:47 pm Client refused [MEDICATION NAME] (mixed with 8 ounces water) and [MEDICATION NAME] (fiber taken with another 8 ounces of water); 6/12/15 at 11:35 pm, Staff was called to ct's (client's) room for a medical code. CT had been help to her chair to use the toilet and was standing to transfer to the toilet when she became limp and unresponsive and slumped over in her chair. Her head rolled backward toward the ceiling and her eyes dilated.lasted approximately 30 seconds.no recollection of incident. She does seem slightly confused.BP 92/60 sitting, 108/58 laying. (There is no notation that MD was notified); 6/13/15 at 12:15 pm, Client was asked to take herself to dining room for lunch but refused; 6/13/15 1:13 pm, BP 90/68, Client refusing all fluids client did consume 1/2 cup during med pass, consumed 25 % (percent) breakfast, refused lunch and all other fluids. BP recheck at 11 am 76/52, Client weak and pale and refusing all care. Doctor notified, client sent out the ER for evaluation and fluids; 6/13/15 at 2 pm, Notified to send client to ER, was sent to acute care hospital for evaluation. On 6/16/15 at 10 am, the Director of Nurses (DON) and DONI confirmed they had faxed the above referenced note about Client 4's change of condition to MD on 6/12/15, although they could not confirm he received it and therefore they did not receive any new physician's orders [REDACTED]. On 6/16/15 at 3 pm, MD's Receptionist (MDR) stated that their office was closed Fridays and had been for several years. MDR confirmed that faxes received Thursday evening (after closing) or Friday, would not be seen by the MD until they opened up on Monday morning. On 6/16/15 at 3:15 pm, MD confirmed that he did not become aware of Client 4's change of condition (DONI's 6/12/15 1:58 pm change of condition note) until 1:08 pm on 6/13/15, (nearly 24 hours later). Client 4's record showed an MD phone order, dated 6/13/15 at 1:32 pm, to send her to the acute care hospital. On 6/17/15 at 10 am, Licensed Nurse (LN) B stated that she had taken care of Client 4 on 6/12/15 and created the Nurse's Note on 6/12/15 at 2:06 pm. LN B stated that on 6/12/15, she was Absolutely worried about dehydration with Client 4, due to her orthostatic BPs, ongoing urinary tract infection (UTI, bladder infection), and fluid intake problem. LN B stated Client 4 refused all fluids; even the water she typically took with her [MEDICATION NAME] and [MEDICATION NAME]. LN B stated that she had heard about Client 4's [MEDICAL CONDITION] that morning from the Shift Lead Nurse (SLN). LN B stated that she continued to report Client 4's status and ongoing refusal of fluids to SLN throughout her shift on 6/12/15. During an interview and concurrent record and policy review with LN B on 6/17/15 at 1 pm, she confirmed that Client 4's I&O's were not recorded while she suspected dehydration, as per facility policy. On 6/17/15, the admitting physician's History and Physical (H&P) for Client 4 from the acute care hospital, dated 6/13/15, assessment confirmed severe dehydration in her admitting Diagnoses: [REDACTED]. Acute [MEDICAL CONDITION] accompanied severe dehydration. 2. [MEDICAL CONDITION] (low sodium), most likely secondary to dehydration. and showed that, Her overall prognosis remains dismal. (during dehydration, the body can lose both fluid and electrolytes (salt and potassium)). The Urologist (specialist in urinary function) Consulting Physician's report, dated 6/14/15, showed Client 4 was .responding rather nicely to hydration.degree of renal impairment (kidney function). I think the majority of that at this point, is likely due to dehydration and the patient would likely best be served with further observation to see how much renal function improves as she is rehydrated. The report also showed she had been treated with the wrong antibiotic for the urinary tract infection (UTI, bladder infection) during the past week at the facility.I think it is clear that that was not successful in cleaning her infection. On 6/17/15 at 2:45 pm, DONI confirmed she was concerned Client 4 would continue to decline and faxed the note on 6/12/15 (Friday afternoon) to MD to inform him of her change in condition. DONI confirmed she was not aware MD's office was closed on Fridays and that he would not see Client 4's change of condition note and therefore would not be able to give any new physician's orders [REDACTED].