Every finding on record at Cupertino Healthcare & Wellness Center

Based on observation, interview, and record review, the facility failed to provide services according to professional standards for five out of five residents (Residents 1, 2, 3, 4, and 5) when social services did not follow up with the psychologist (a mental health professional with a doctoral degree in psychology who focuses on behavior, emotions, and though patterns)/psychiatrist (a medical doctor that focuses on physical and biological causes of mental health) consultation (psych consult - mental health consultation or initial intake meeting) and treatment as ordered by their physician.These failures had the potential to affect Residents 1, 2, 3, 4, and 5's psychosocial needs and behavioral well-being.Findings:1a. Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was admitted to the facility with diagnoses including encounter for attention to ileostomy (a surgical operation that creates an opening [called a stoma] on the abdomen), hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (a type of stroke caused by a blockage in brain blood vessels, resulting in a lack of oxygen and brain cell death) affecting right dominant side (the side of the body that a person prefers, uses more frequently, and is stronger or more skillful with) and other psychoactive substance (any chemical that affects how the brain works and changes a person's mood, awareness, thoughts, feelings or behavior) dependence, in remission.Review of Resident 1's order summary report dated 7/6/2026, it indicated an order dated 2/11/2026 for Psychology/Psychiatrist consult, with follow-up treatment as indicated.Review of Resident 1's clinical record titled Health Status Note, dated 6/19/2026, indicated Resident 1 was an alleged abuser when he struck the resident [Resident 2] with a closed fist on the left face. and was engaged in a verbal altercation after.Review of Resident 1's Social Services (SS) notes, dated 6/19/2026, indicated a psych (psychology/psychiatrist) referral was sent after the incident.During an interview with Resident 1's assigned certified nursing assistant A (CNA A) on 7/3/2026 at 10:28 a.m., CNA A confirmed the altercation that happened between Resident 1 and Resident 2. CNA A stated Resident 1 tried to stop Resident 2 from yelling.During an interview with Resident 1 on 7/31/2026 at 12:28 p.m., Resident 1 stated Resident 2 was a bully, and he hit him.1b. Review of Resident 2's face sheet indicated Resident 2 was admitted to the facility with diagnoses including type 2 diabetes mellitus (DM - a condition which affects the way the body processes blood sugar), unspecified psychosis (a mental state where a person loses touch with reality), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels) and dementia (decline in mental capacity affecting daily function), moderate with agitation (feeling very restless, nervous, or upset).Review of Resident 2's order summary report dated 7/6/2026, it indicated an order dated 6/18/2026 for Psychology/Psychiatrist consult, with follow-up treatment as indicated.Review of Resident 2's clinical record titled, Health Status Note, dated 6/19/2026, indicated Resident 2 was seated on his wheelchair at the hallway, yelling at his CNA and called her some names when Resident 1 punched him on the left side of his face.During an interview with social services director (SSD) on 7/31/2026 at 2:04 p.m., when asked if the psych consult was completed for both Resident 1 and Resident 2 as ordered, SSD stated he could not find the psych consult notes in their system and would ask their medical records director (MRD).During a phone interview with social services B (SS B) on 8/5/2026 at 11:24 a.m., SS B confirmed a psych referral were made for Resident 1 on 6/19/2026 and Resident 2 on 6/18/2026. SS B stated she was not sure if both Residents 1 and 2 were seen for psych consultation.2a. Review of Resident 3's face sheet indicated Resident 3 was admitted to the facility with diagnoses including metabolic encephalopathy (a change in brain function caused by chemical imbalance, illness, organ failure in the body), Marfan syndrome (an inherited genetic condition that affects the body's connective tissue, which is the material that supports, binds, and gives strength to bones, muscles, organs, and blood vessels), and major depressive disorder.Review of Resident 3's order summary report dated 7/6/2026, it indicated an order dated 5/29/2025 for Psychology/Psychiatrist consult, with follow-up treatment as indicated.Review of Resident 3's clinical record titled, Change in Condition, dated 5/18/2026, indicated Resident 3 was an alleged aggressor, when he punched Resident 4 (roommate) to his face.Review of Resident 3's clinical record titled, Multidisciplinary Care Conference, dated 5/27/2026, indicated under social services notes, .Patient can get physically aggressive with other patients. Further review indicated, Non-Pharmacological Interventions in place.Psych Referral.2b. Review of Resident 4's face sheet indicated, Resident 4 was admitted to the facility with diagnoses including cerebral infarction, metabolic encephalopathy, Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and the ability to do simple daily tasks), and adult failure to thrive (a general term for a serious physical and mental decline in older adults).Review of Resident 4's order summary report dated 7/6/2026, it indicated an order dated 5/25/2026 for Psychology/Psychiatrist consult, with follow-up treatment as indicated.Review of Resident 4's clinical record titled, Change in Condition, dated 5/18/2026, indicated Resident 4 was a victim of an alleged abuse when Resident 3 grasped his shirt and punched his face.During an interview with licensed vocational nurse C (LVN C) on 7/3/2026 at 1:06 p.m., LVN C stated Residents 3 and 4 used to be roommates. LVN C further stated that they were separated when Resident 3 punched Resident 4 in the face and Resident 3 did not state the reason why he had to punch Resident 4.During a concurrent interview with SSD and record review of both Resident 3 and Resident 4's order summary report on 7/31/2026 at 2:04 p.m., the SSD confirmed both Residents 3 and 4 had orders for psych consult and treatment. The SSD stated that he was not sure if the psych consult was completed because it was not in their system. The SSD further stated he will check with their MRD.3. Review of Resident 5's face sheet, indicated Resident 5 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe), and unspecified dementia with psychotic disturbance (a mental health event where a person loses touch with everyday reality).Review of Resident 5's order summary report dated 7/6/2026, it indicated an order dated 6/18/2026 for Psychology/Psychiatrist consult, with follow-up treatment as indicated.Review of Resident 5's clinical record titled, Change in Condition Evaluation, dated 6/17/2026, indicated Resident 5 alleged someone hit her but she was unable to describe or identify who did it.During a concurrent observation and interview with Resident 5 on 7/3/2026 at 10:44 a.m., inside Resident 5's room, Resident 5 was on her bed, without signs and symptoms of distress and stated there was a young kid who always hit me. Resident 5 further stated that she did not know the name of the young kid, and she confirmed he (young kid) lived in the facility. Resident 5 stated the young kid was about 23 to [AGE] years old, heavy set, and he was on a wheelchair.During an interview with the director of nursing (DON) on 7/3/2026 at 11:05 a.m., the DON confirmed she was aware of Resident 5's allegation of abuse, and they did not have a resident with the age of 23-[AGE] years of age.During a concurrent interview with SSD and record review of Resident 5's order summary report and SS note dated 6/18/2026 on 7/31/2026 at 2:10 p.m., SSD confirmed there was an order for psych consult and there was a psych referral sent by their SS. SSD stated, she would have to ask their MRD if the psych consult was completed.During a follow up with the facility's MRD related to the psychologist or psychiatrist notes for Residents 1, 2, 3, 4, and 5, the MRD sent an email to this writer dated 8/5/2026, indicated, .As we conducted a deeper review of this matter, we identified that the provider did not see the patients as scheduled. We acknowledge this lapse on our part and have accepted responsibility for the oversight.During a phone interview with SS B on 8/6/2026 at 10:15 a.m., SS B stated they only emailed the providers whenever they requested for their residents' psych consultation. SS B further stated they never called the providers to follow up with their request and to checked if the residents in their referral list were seen or not seen. SS B confirmed she sent out an urgent referral for psych consult for Resident 5, and she never followed up by phone with the providers.During a review of the facility's undated job description titled, Social Service Coordinator, indicated, Ensure the resident's psychosocial and concrete needs are identified and met in accordance with federal, state and company requirements.Communicate needs and plan of care to resident, families, responsible parties and appropriate staff.Participate in the facility's Behavior Management program.

Based on interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three residents (Resident 1) when Resident 1's diclofenac sodium (Brand name is Voltaren, a drug used to treat mild to moderate pain, and helps to relieve symptoms of arthritis such as inflammation, swelling, stiffness, and joint pain) was not available for administration on 2/9/2026 at 5:00 p.m. and 2/10/2026 at 9:00 a.m. This failure had the potential for unrelieved pain, inflammation, and stiffness.Findings:A review of Resident 1's clinical record titled, admission Record, dated 2/5/2026, indicated Resident 1 was admitted to the facility with diagnoses including ankylosing spondylitis (an inflammatory form of arthritis [a general term for diseases that cause inflammation, pain, stiffness, and swelling in one or more joints] that primarily affects the spine [back bone] causing long-term pain and stiffness) of unspecified sites in spine, rheumatoid arthritis (a chronic disease that causes inflammation around the body and commonly presents with pain in the joints), osteoarthritis (the most common form of arthritis, often called wear and tear disease, where the protective cartilage cushioning the ends of bones wears down over time), other chronic pain, arthropathy (a medical term for any disease or abnormality affecting a joint), unspecified.A review of Resident 1's quarterly minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for metal status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact).A review of Resident 1's clinical record, titled, Order Summary Report, indicated an order dated 4/13/2025 of diclofenac sodium 25 milligrams (mg-unit of measurement) to be taken three tablets by mouth two times a day for rheumatoid arthritis.A review of Resident 1's 1/2026 medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), it indicated a code 9, on 2/9/2026 at 5:00 p.m., and code 9, on 2/10/2026 at 9:00 a.m. Further review indicated, code 9 was for Other/See Progress Notes.A review of Resident 1's nursing progress notes dated 2/9/2026, indicated, During medication pass, resident's prescribed diclofenac was unavailable.A review of Resident 1's nursing progress notes dated 2/10/2026, indicated the diclofenac sodium was still unavailable in the morning.During an interview with Resident 1 on 2/18/2026 at 11:30 a.m., Resident 1 stated he missed two doses of his diclofenac sodium. Resident 1 further stated, I badly needed that medication for my rheumatoid arthritis. He also stated the nurses did not give me the medication and they blamed the pharmacy.During an interview with licensed vocational nurse A (LVN A) on 2/18/2026 at 2:05 p.m., LVN A confirmed he did not administer Resident 1's morning dose of diclofenac sodium on 2/10/2026 because it was not available. LVN A stated nurses should order the medication five days before the resident consumed all medications and the pharmacy should have delivered the medication within 24 to 48 hours when ordered.During an interview with the director of nursing (DON) on 2/18/2026 at 3:00 p.m., DON stated nurses should order the medication three days prior to consuming all of it. DON confirmed Resident 1 missed two doses of the diclofenac sodium because the medication was not available.During a follow up interview with DON on 2/18/2026 at 3:57 p.m., DON stated nurses ordered the diclofenac sodium to their pharmacy on 1/26/2026 and 2/5/2026, and the medications were not delivered on time.During a review of the facility's policy and procedure titled, Medication - Administration, date revised 1/1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.

Based on interview and record review, the facility failed to ensure one (Resident 1) out of 6 sampled residents was free from physical abuse when a staff physically hit Resident 1 on the face.This failure resulted in a slap on the right side of the face of Resident 1 by CNA A which was witnessed by CNA B. This failure had the potential to put Resident 1 in psychosocial distress. FINDINGS: A review of Resident 1's medical record indicated an admission date of 10/30/25. Resident 1's diagnoses included but were not limited to muscle weakness, bipolar disorder (a mental health condition that causes extreme mood swings) and fracture of one rib, right side, sequela (residual effect that persists after the acute phase of an illness has resolved). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, indicated a brief interview for mental status score of 5 (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident; a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 1's Nurse's Notes dated 1/3/26 at 10:14 p.m. indicated, Resident is on COC [Change of Condition] monitoring for swelling to the left radial wrist and skin discoloration on the left inner thigh. A review of Resident 1's Nurse's Notes dated 1/4/26 indicated, Received x-ray [an imaging study] results for left wrist.noted with mild degenerative joint disease of the left wrist. A Facility Reported Incident (FRI) sent by the facility to California Department of Public Health (CDPH) received on 1/5/26 indicated, received report that around 215pm a CNA requested assistance from alleged abuser to assist with care for the patient. During providing care, the patient grew agitated and scratched to the left side of the alleged CNA's face. Primary patient's CN A stated that (the) one other CN A was scratched, CN A then slapped the right side of the patient's Face. CN A was immediately removed from the care of the patient . The accompanying Report of Suspected Dependent Adult/Elder Abuse (SOC 341) indicated date/time of incident was 1/4/26 2:15 p.m. A review of eInteract SBAR Summary for Providers dated 1/4/26 15:40 indicated: . Outcomes of Physical Assessment: . Nursing observations, evaluation, and recommendations are: According to the assigned CN A of AM shift, CN A witnessed another CN A who was not assigned to the resident, slap the resident [name of Resident], to the right side of the face, stating a medium slap as the description. Neither soft nor hard. All of this incident occurred while the CN A who abused the resident, tried to help provide a brief change to the resident. Primary Care Provider Feedback:. Monitor for Psychosocial and emotional well being post abuse for 72 hrs. Monitor latent effect on the right face for 7 days During an interview with CNA B on 2/11/26 at 12:22 p.m., CNA B stated that on the day of the incident at around 2:00 p.m. (1/4/26), CNA A was helping her clean and change Resident 1. CNA B stated, CNA A insisted on holding Resident 1's wrist even after telling her not to because it was uncomfortable for Resident 1. CNA B stated Resident 1 was able to free her hands and hit CNA A's face. CNA B then stated she witnessed CNA A hit Resident 1 back in the face and left the room. CNA B also stated, Resident 1 sat up on the bed and was pointing at her wrist to her. A review of CNA A's employee records indicated she was hired on 9/22/25. Her background screening was done on 9/17/25 and her last training on Abuse was during her date of hire on 9/22/25. A review of facility's policy and procedure (P&P) entitled Abuse Prevention and Management revised 5/30/24, the P&P indicated, 1. Definitions .d. 'Physical Abuse' is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. 2. Screening employees, registry, contracted, or temporary agency staff, or students from affiliated academic institutions: a. The facility will screen potential employees for history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.3. Training. a. The facility conducts mandatory staff training programs during orientation, annually and as needed on: . v. understanding resident behavioral symptoms that many increase the risk of abuse and neglect and how to respond. 4. Prevention. d. The Facility identifies corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when:1.A peeled/sliced peaches was beside the red and green bucket at the three-compartment sink tap;2. Two kitchen staff did not perform handwashing/ hand hygiene before and after gloving; and 3. An open box of Almond nondairy beverage was inside the residents' refrigerator with an open date of 12/18/25 and use by date of 12/21/25 and still there on 12/22/25. These failures had the potential to cause food contamination and spread food-borne illnesses to residents who received their food from the kitchen.Findings:1. During a concurrent initial kitchen observation and interview with the Dietary Manager (DM) on 12/16/25 at 10:55 a.m., it was observed in the three-compartment sink tap was a clear square food storage container with peeled /sliced and chopped peaches without cover and left open beside the green and red plastic bucket with chemical solution. Dietary [NAME] (DC) F verified the above observation and stated the peaches should not be placed at the countertop near the red and green bucket because of infection control. The DM confirmed and stated the peeled /sliced and chopped peaches should not be placed beside the red and green bucket because the area is not clean and can cause food contamination.The United States Food and Drug Administration's 2022 Food Code 3-305.14 Food Preparation , indicated Food preparation activities may expose food to an environment that may lead to the food's contamination. Just as food must be protected during storage, it must also be protected during preparation. Sources of environmental contamination may include splash from cleaning operation .2a. During Kitchen observation with the DM on 12/16/25 at 11:02 a.m., DC G picked the kitchen thermometer that fell on the floor then took a new kitchen thermometer without performing hand washing before donning (putting on) new gloves. During a concurrent observation and interview with DC G on 12/12/25 at 11:04 a.m., DC G confirmed he did not perform handwashing before donning a new glove. During an interview with the DM on 12/16/25 at 11:09 a.m., the DM acknowledged DC G did not perform handwashing. The DM stated it can cause infection control.2b. During a concurrent kitchen observation and interview with the DM on 12/19/25 at 8:39 a.m., with Dietary Aide (DA), DA did not perform hand washing before donning a new glove. On further observation DA was observed fixing her hairnet and clothes then proceeded to prepare food with her gloves on. The DA verified she was wearing gloves and did not perform handwashing before donning new gloves. The DM confirmed the DA did not perform handwashing before donning a new glove.The United States Food and Drug Administration's 2022 Food Code 2-301.14 indicated, Food employees shall clean their hands and exposed portions of their arms specified under S2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment . (H). Before donning gloves to initiate a task that involves working with food. (I) After engaging in other activities that contaminate the hands. During a review of the facility's policy and procedure (P&P) titles, Hand Hygiene, revised 9/1/2020, the P&P indicated, The Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water) .II Facility staff follow the hand hygiene procedure to prevent the spread of infections to other staff, Resident, volunteers and visitor. The following situation require appropriate hand hygiene. iv. Before and after food preparation.3. During a concurrent observation and interview with the DM on 12/22/25 at 2:25 p.m., it was observed in NS BB Residents' refrigerator, a box of almond nondairy beverage 32 fluid ounce (fl oz, unit of volume) was labeled with open date 12/18/25 and used by date 12/21/25. The DM stated food that was expired should be thrown on expiration date and it should not be in the refrigerator. The DM further stated it can cause food borne illnessesDuring a review of the facility's policy and procedure (P&P) titles, Food Brought in by Visitors, revised 4/24/25, the P&P indicated, The facility staff will 4. When refrigerated, it will be labeled, dated and discarded after 48 hours if not consumed.

Based on observation, interview, and record review the facility failed to ensure refuse materials (any disposable materials, which include recyclable and non-recyclable materials) were disposed properly when One of two garbage dumpsters were found to be overflowing, and garbage bags were found on the floor outside the containers. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings:During the initial observation at the designated waste area on 12/19/25 at 8:12 a.m., one garbage dumpster was observed to be overflowing. During a concurrent observation and interview on 12/22/25 at 9:00 a.m., accompanied by the Dietary Manger (DM) and Maintenance Director (MD), at the designated waste area, two black plastic bags and cardboard were outside of the dumpster. Both MD and DM confirmed the observation and stated it should be put inside the bins. The MD stated the garbage should be placed inside the dumpster to prevent attracting pests and for infection control. The United States Food and Drug Administration's 2022 Food Code 5-501.110 indicated, Refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. During a review of the facility's policy and procedure (P&P) titles, Waste Management, revised 4/2022, the P&P indicated, To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste.

Based on interview and record review, the facility failed to have a valid copy of a resident's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) when one of 31 sampled residents (Resident 3) had a POLST with no signature and identity of the person who discussed it. This failure had the potential to result in a resident's end-of-life choices not being honored. Findings:A review of Resident 's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/25, indicated that Resident 3 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 00 (scores of 0-7 suggests severe cognitive impairment, 8 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact), which indicate severe cognitive impairment.A review of Resident 3's POLST, undated, indicated that To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant .and (2) the patient or decisionmaker.During a concurrent interview and record review with the Director of Nursing (DON), on 12/19/25 at 3:08 p.m., of Resident 3's POLST, the DON stated the POLST should be completed by the Resident representative and physician will be notified and informed to sign. The DON verified that the POLST was mostly blank without signatures of physician and Resident representative /decisionmaker. The DON further stated it should be completely signed by physician and Resident representative to be valid.The facility's policy titled Physician Orders for Life -sustaining Treatment (POLST), revised date June3, 2020, indicated Policy III. Must be signed by a physician, physician assistant or nurse practitioner, acting under the supervision of the physician and within the scope of practice authorized by law in order to be legally effective; Initiating a POLST, . D. The POLST form must be completed, signed and dated, include the practitioner's medical license number and signed by the resident, or resident's representative or the resident health care decision maker. E. v. POLST form are NOT valid unless signed by an attending physician, physician assistant or nurse practitioner.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Residents 151) had the baseline care plan completed within 48 hours of admission. This failure had the potential for the facility staff not to meet the residents' immediate care needs and safety against adverse events that are most likely to occur right after admission. Findings: 1.Review of Resident 151's Face sheet (a summary document containing a Resident's personal and demographic information, including contact details and medical history) indicated Resident 151 was admitted on 9/5//25 with diagnoses including bradycardia (a slow heart rate), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm ), thrombocytopenia [deficiency of platelets (a small colorless cell fragments in our blood that form clots and stop or prevent bleeding)] and, hypertension (when your blood consistent pushes too forcefully against artery walls forcing your heart to work harder). Review of Resident 151's Baseline care plan dated 9/23/25, indicated the health condition, and medications was not completed. Review of Resident 151's Order Summary Report, dated 9/5/25, indicated an order of Apixaban Oral Tablet 5 milligram (mg. unit of mass), give 1 tablet by mouth two times a day for Atrial Fibrillation. During a record review and interview with Director of Nursing (DON) on 12/19/25 at 3:24 p.m., the DON confirmed the baseline care plan of Resident 151 was incomplete. The DON stated the Baseline care plan should be completed within 48 hours of the resident's admission to monitor what the resident is taking. During a review of the facility's policy (P) titles, Person -Centered Care Planning, revised 4/24/2025, the P indicated,2. Baseline Care Plan a. The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and what assistance with activities of daily living is necessary.

Based on observation, interview, and record review, the facility failed to develop an individualized, resident-centered care plan for two of two residents (Residents 20 and 3) with a sitter (a caregiver who provides companionship and supervision to patients who need constant observation or assistance, often due to medical conditions or behavioral issues that could pose a risk). This failure had the potential not to meet care needs appropriately for Residents 20 and 3. Findings: 1.Review of Resident 20's clinical record titled, admission Record, dated12/19/2025, indicated Resident 20 was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) with agitation (a state of anxiety, or restlessness, often making someone feel tense, irritable, and unable to relax), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and history of falling. Review of Resident 20's quarterly minimum data set (MDS – a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 20's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 0 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview with certified nursing assistant E (CNA E) on 12/16/2025 at 12:38 p.m., inside Resident 20's room, Resident 20 was asleep in bed and CNA E was at bedside. CNA E confirmed she was the sitter for Resident 20 because she was at risk of falling. CNA E stated Resident 20 was ambulatory but due to her confusion, she had history of falling. During an observation on 12/17/2025 at 8:45 a.m., inside Resident 20's room, Resident 20 was asleep in bed, and another certified nursing assistant (CNA) was at bedside. During another observation on 12/18/2025 at 1:51 p.m., at the facility's hallway, Resident 20 was observed walking at the hallway and was assisted by a CNA. During a concurrent interview with the MDS nurse (MDSN) and record review of Resident 20's care plans on 12/19/2025 at 3:54 p.m., MDSN confirmed there was no specific care plan for Resident 20's sitter. MDSN further confirmed Resident 20 had a sitter and was wandering when she was admitted to the facility. MDSN could not state the date they started Resident 20's sitter. The MDSN stated Resident 20's used of sitter should have been care planned when it was initiated. During an interview with the director of nursing (DON) on 12/22/2025 at 11:01 a.m., the DON could not state the date when they started Resident 20's sitter. DON confirmed there was no care plan developed, and it should have been care planned because it was a part of their interventions for Resident 20's risk of falling and elopement. 2. Review of Resident 3's clinical record indicated Resident -- was admitted on [DATE] and had diagnoses including Metabolic Encephalopathy(global brain dysfunction caused by chemical imbalance from an underlying illness) ; Senile degeneration of brain not elsewhere( severe cognitive decline in older adults); Dementia (decline in mental abilities like memory , thinking and reason )in other diseases classified; unspecified severity with agitation (state of anxiety ); Cognitive communication deficit; Major depressive disorder recurrent severe with psychotic symptoms( severe form of ofc depression where intense mood symptoms[sadness, hopelessness] combine with psychosis{break from reality). A review of Resident 's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/25, indicated that Resident 3 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 00 (scores of 0-7 suggest severe cognitive impairment, 8 to 12 suggests moderate cognitive impairment, and 13 to 15 suggest that cognition is intact), which indicate severe cognitive impairment. During a concurrent observation and interview on 12/17/25 at 9:46 a.m., inside Resident 3's room, Resident 3 was asleep with CNA H beside sitting and watching the resident. CNA H stated he was the sitter for Resident 3 because Resident wanders. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) I on 12/18/25 at 12:58 p.m., inside Resident 3's room. CNA H was inside Resident 3's room sitting at bedside. LVN I confirmed Resident 3 has a sitter. Reviewed of Resident 3's Elopement Evaluation dated 8/25/25 with Resident at risk elopement with score of 4.0 on Admission. Reviewed Care Plan - Resident has a wander guard to the right wrist r/t wandering aimlessly. Reviewed goals and intervention: Check functioning of wander guard, check placement of wander guard (right wrist), monitor for episodes of wandering every shift, monitor skin integrity to right wrist. During a concurrent interview and record review with DON on 12/19/25 at 1:21p.m., the DON confirmed Resident 3 had a sitter. The DON stated the Resident has tendency to walk or wander around which might be a risk for elopement. The DON confirmed no care plan for the one on one sitter for the Resident. The DON further stated it should be care planned and it's individualized for each resident. During a review of the facility's policy and procedure titled, NP04 Comprehensive Person-Centered Care Planning, dated 9/7/2023, indicated, The comprehensive care plan must describe the following: i. The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) was provided with appropriate care and services when an enteral feeding was found to be running for more than 24 hours for one (Resident 13) out of 31 sampled residents.This failure had the potential to put Resident 13 at risk for enteral feeding complications such as tube clogging/displacement, fluid overload, abdominal distention and infections.During an observation on 12/16/25 at 9:22 a.m. at Resident 13's bedside, Resident 13 was on the bed with eyes closed and noted rise and fall of the chest. Resident 13 had an enteral feeding bottle with contents below 300 ml (milliliters, a unit of measurement) connected to a running feeding pump (a machine that uses a pump to control the flow, ensuring precise amounts are given over time, often using a bag of special liquid formula, tubing, and a small pump mechanism). The feeding bottle indicated it started on 12/15/25 at 1 a.m.A review of Resident 13's medical record indicated an admission date of 3/22/23. Resident 13's medical diagnoses included gastrostomy status (feeding tube placed through the belly wall directly into the stomach).A review of Resident 13's physician order indicated, Enteral feed: two times a day [brand name 1.5 ] 55 ml/hr [hour] via pump x [times] 20 hrs = 700 ml/24 hrs. OFF @ 1000 and ON at 1400.During an interview on 12/16/25 at 11:15 a.m. with Licensed Vocational Nurse (LVN) A, LVN A stated enteral feeding bottle, and tubing must be changed every 24 hours.During an interview on 12/18/25 at 1:53 p.m. with Licensed Vocational Nurse (LVN) D, LVN D stated enteral feeding bottle should not run for more than 24 hours.During an interview on 12/18/25 at 3:15 p.m. with Registered Nurse (RN) B, RN B stated enteral feeding bottle, and tubing should only be good for 24 hours.The feeding bottle's manufacturer's manual was requested but was not provided.A review of facility's policy and procedure (P&P) entitled, Enteral Tube Management: Gastrostomy Tube-Jejunostomy Tube revised 9/28/23, the P&P indicated, 1. Enteral tubes should be verified for placement and patency prior to intermittent feeding, at every shift, and prior to administering medications, hydration, and nutrition via enteral feeding tubes.

Based on observation, interview, and document review, the facility failed to ensure the daily staffing information was posted in a clear and readable format and in a prominent place readily accessible to residents, staff, and visitors. This failure had the potential to result in staffing misinformation for residents, families, and visitors.Findings:During multiple observations from 12/16/2025 to 12/19/2025, between 8:30 a.m. to 10:30 a.m., at the lobby, nurse station AA (NS AA) and nurse station BB (NS BB), there was no daily staffing information posted. There was no daily staffing information placed on top of the lobby desk or on top of nurse stations AA and BB.During an observation on 12/22/2025 at 9:35 a.m., in the facility's lobby, there was no daily staffing information posted that could easily be seen by visitors or residents.During an observation on 12/22/2025 at 9:39 a.m., in NS AA, there was no daily staffing information posted that could easily be seen by visitors or residents.During a concurrent observation and interview with registered nurse C (RN C) on 12/22/2025 at 9:42 a.m., in NS BB, RN C confirmed they did not have the daily staffing information posting.During a concurrent observation and interview with the director of staff development (DSD) on 12/22/2025 at 9:44 a.m., in NS BB and lobby, the DSD confirmed there was no daily staffing information posted in each nurse station. DSD showed the staffing information written in fine prints and posted behind the facility's check-in kiosk (a digital terminal that allows users to register their arrival and complete related tasks without assistance from staff). The DSD confirmed the daily staffing information could not be seen right away once a visitor entered their lobby and stated she would notify their administrator about it (ADM).During a concurrent observation and interview with the director of nursing (DON) on 12/22/2025 at 10:02 a.m., in the lobby, the DON confirmed the daily staffing information was printed in small prints and stated it was hard to print in larger prints. The DON stated the daily staffing information used to be located on top of the lobby desk.During a review of the facility's policy and procedure titled, Nursing Department - Staffing, Scheduling & Postings, date revised 7/2018, indicated, B. Posting requirementsi. The Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift.ii. Data must be posted as follows:a. Clear and readable format.b. In a prominent place readily accessible to residents and visitors.

Based on observation, interview and record review, the facility failed to ensure accurate account of controlled drugs was maintained and periodically reconciled when Clonazepam (medication used to prevent and treat anxiety disorders, and seizures) was dispensed but was not recorded in the Narcotics Record book for one (Resident 65) out of 31 sampled residents.This failure had the potential for diversion of controlled medications.During a concurrent observation and record review of Station 2 medication cart on 12/16/25 at 11:29 a.m. with Registered Nurse (RN) B, RN B verified Narcotics Record book indicated Resident 65 had 16 remaining Clonazepam pills dated 12/15/25 at 5:20 p.m. RN B also verified Clonazepam blister pack for Resident 65 had 15 pills.A review of Resident 65's physician order indicated Clonazepam 1 MG [milligram, a unit of measurement] give 1 tablet orally two times a day for anxiety m/b [manifested by] continuous yelling, screaming, calling outDuring an interview and record review of Resident 65's medication administration record on 12/18/25 at 2:07 p.m. with the Director of Nursing (DON), the DON verified Clonazepam was administered to Resident 65 on 12/16/25 at 9:00 a.m. The DON stated they should have recorded it in the Narcotics Record book if they took a Clonazepam pill. The DON also stated she was not informed of the incident. The DON stated nurses must report any discrepancies in the Narcotics Record book immediately.During an interview on 12/18/25 at 3:15 p.m. with RN B, RN B stated she went to Resident 65's nurse-in-charge and clarified the Narcotics discrepancy immediately. RN B also stated we must ensure we record every controlled drug taken and administered to residents in the Narcotics Record book. RN B stated it should have been reported to the DON.A review of facility's policy and procedure (P&P) entitled, Controlled Medication Storage effective 8/2014, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.Procedures.E. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately.A review of facility's policy and procedure (P&P) entitled, Using the Brigg's Narcotic Record Book dated 2/2021, the P&P indicated, .Signing out A Narcotic Medication: When a narcotic medication is to be administered, the Licensed Nurse will record the following details:-Date that the medication was signed for-Time-Dose to be used-Amount Remaining-Licensed Nurse Signature.

Based on observation, interview and record review, the facility failed to ensure irregularities were identified during drug regimen review for the medication Lurasidone (an antipsychotic medication, works by rebalancing important natural substances in the brain called dopamine and serotonin to improve thinking, mood, and behavior) for one (Resident 17) out of 31 sampled residents when adequate monitoring for the medication was not done.This failure had the potential to compromise the physical, social, and mental well-being of Resident 17.A review of Resident 17's medical records indicated an admission date of 4/28/25. Resident 17's diagnoses included but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgment, and behavior, often caused by nerve cells in the brain stopping working properly), and bipolar disorder (a mental health condition causing extreme mood swings, shifting between emotional highs [mania or hypomania] and lows [depression], affecting energy, sleep, behavior, and thinking, and disrupting daily life).A review of Resident 17's Minimum Data Set (MDS, an assessment tool), dated 10/30/25, indicated a brief interview for mental status score of 13 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact].A review of Resident 17's Physician Order indicated, Lurasidone HCl [hydrochloride, a chemical substance] Oral tablet 40 MG [milligram, a unit of measurement] Give 1 tablet by mouth in the evening for Bipolar as m/b [manifested by] depressive mood as eb [evidenced by] withdrawn from prior activity. During a concurrent interview and record review of Resident 17's medical chart with the Director of Nursing (DON) on 12/22/25 at 10:48 a.m., the DON verified Resident 17's physician order for Lurasidone and the recent dose increase in November 2025. The DON also verified there was no AIMS (Abnormal Involuntary Movement Scale, a checklist to spot and measure jerky, uncontrollable movements [tardive dyskinesia] in people taking certain medicines, especially antipsychotics, by rating facial tics, tongue movements, limb motions, and how much it bothers the person, using a 0 [none] to 4 [severe] scale for different body parts. ) done for Resident 17 since admission. The DON stated AIMS should have been done for Resident 17.During a concurrent interview and record review of Resident 17's medical chart with the Consultant Pharmacist (CP) on 12/22/25 at 1:18 p.m., the CP verified Lurasidone was started in the facility and not prior to admission. The CP verified Resident 17's dose for Lurasidone was increased from 20 MG to 40 MG in 11/2025. The CP verified there was no AIMS done for Resident 17 since admission. The CP stated there should have been a baseline AIMS for Resident 17. The CP also stated there was an increased risk for EPS (Extrapyramidal Symptoms, involuntary movement problems, like tremors, stiffness, restlessness, or spasms, caused by certain medications, especially antipsychotics, affecting the brain's motor control areas, leading to Parkinson's-like symptoms or other uncontrolled movements) with Resident 17's current dose of Lurasidone. The CP also stated AIMS should have been included in the recommendation in Resident 17's medication regimen review.During a concurrent observation and interview on 12/22/25 at 1:43 p.m. with Resident 17, Resident 17 was on a wheelchair and stated she had lunch. Tremors were noted on Resident 17's both hands.A review of Resident 17's list of diagnoses did not include Parkinson's disease or parkinsonism. A review of facility's policy and procedure (P&P) entitled, Behavior/Psychoactive Medication Management revised on 10/30/25, the P&P indicated, .4. Parameters for use of Anti-psychotic Medications.c. Monitoring and Reporting for Side Effectsi. The resident will be observed and/or monitored for side effects, and adverse consequences, including sedation. An Abnormal Involuntary Movement Scale Assessment (AIMS), should be completed upon admission, every six months, and with increase in dose on all residents that are prescribed Antipsychotic medications. All complications and side effects should be reported to the healthcare practitioner.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:1. Opened eyedrop medications without open and discard date labels, an eyedrop medication past discard date, and an opened Phenytoin Oral Suspension (a medication used for seizures) without open date label were found.2. Insulin pen without opened date label and an expired inhalation solution (medication used to keep airways open and to control and prevent symptoms like wheezing, shortness of breath, coughing and chest tightness) were found.3. Insulin pen without open and discard date was found.These failures had the potential for residents to receive medications with reduced efficacy.1. During a concurrent observation and interview regarding Station 5 Medication Cart on [DATE] at 10:04 a.m. with Licensed Vocational Nurse (LVN) A, the following were identified and verified by LVN A:a. A Latanoprost Eye Drop Medication indicated an open date label of [DATE] and without a discard date label. The packaging indicated, Discard unused portion after 28 days.b. A Latanoprost Eye Drop Medication indicated an opened and discard date label of 11/15-[DATE]. LVN A stated it should have been discarded.c. An opened Bimatoprost Eye Drop Medication did not have an open and discard date labels.d. An opened bottle of Phenytoin Oral Suspension was found without an open date label. LVN A stated opened date should have been indicated on the bottle. 2. During a concurrent observation and interview regarding Station 2 Medication Cart on [DATE] at 11:29 a.m. with Registered Nurse (RN) B, the following were identified and verified by RN B:a. A prefilled insulin pen had no open and discard date. The packaging indicated, Discard unused portion after 28 days.b. An opened inhalation powder indicated an opened date of [DATE] and expiry date of 12/8. 3. During a concurrent observation and interview regarding Station 3 Medication Cart on [DATE] at 11:51 a.m. with Registered Nurse (RN) C, an opened prefilled insulin pen did not indicate an open and discard date. RN C, the open and discard date should be written on the insulin pen. RN C verified the packaging indicated, Discard unused portion after 28 days.A review of facility's policy and procedure (P&P) entitled Medication Storage In The Facility effective [DATE], the P&P indicated, Medications and biologicals are stored, safely, securely, and properly, following manufacturer's recommendations or those of the supplier.M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock.Policy and procedure for Medication Labeling was requested but was not provided.

Based on observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure places all residents who eats food from the facility's kitchen at risk for poor food intake which may compromise their nutritional status. Findings: 1) A review of Resident 8's medical record indicated he was initially admitted on [DATE]. Resident 8's Minimum Data Set (MDS, an assessment tool), dated 10/29/25, indicated he had a BIMS [Brief Interview for Mental Status] score of 15 - cognitively intact. Further review of the medical record indicated Resident 8 was on NAS (no added salt) regular diet. During an interview with Resident 8 on 12/16/2025 at 10:50 a.m., he stated that the facility does not know how to cook chicken. Resident 8 further described the texture of the chicken served at the facility as being [NAME] to rubber. During an observation and concurrent interview on 12/19/25 at 2:00 p.m., three surveyors, along with two Dietary Managers (DMs), conducted a taste test of the food the facility served the residents for lunch that day. The facility's menu indicated the lunch consisted of chicken, pasta marinara sauce, and spinach for regular diet. During the food tasting, all three surveyors agreed that the chicken was tough and dry. A review of the facility's policy and procedure (P&P) titled, DD05 Dining Program, revised 1/30/2025, the P&P indicated, Dining Program is a service organized, staffed and equipped to assure that food service to residents is safe, appetizing, and provides for their nutritional needs. 2) During the test tray observation and tasting with the Dietary Manager (DM) and Regional Dietary Manager (RDM), on 12/19/25 at 1:54 p.m., two test plates in the trays were brought and tasted. One of the test plates contained regular (no modification or restriction) Chicken parmesan, penne with garlic & herbs, and spinach with onions. The second test plate contained pureed chicken, penne pasta, and spinach. The survey team tasted the regular chicken and pureed foods after; the pureed chicken parmesan had a strong burned taste. The RDM verified the taste of pureed chicken has an after taste, the RDM further stated it would follow up on this concern and on improving the taste of these pureed foods. During an interview with the DM and the RDM on 12/22/25 at 1:55 p.m., the DM confirmed the puree chicken was not palatable. The RDM confirmed the texture of the puree chicken is not palatable. During a review of the facility's policy (P) titles, Dining Program , revised 1/30/25, the P & P indicated Dining Program is a service organized, staffed and equipped to assure that food service to resident is safe, appetizing and provides for their nutritional needs.

Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when:1.Housekeeper J (HK J ) did not wear the proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when mopping inside a the room of cohorted (joined together) residents (Resident 62 and Resident 1) who were on contact precautions (extra steps, like wearing of gloves and gown, needed to stop the spread of germs by touch) and enhanced barrier precautions (EBP, an infection control measures in nursing homes to stop the spread of multidrug-resistant organisms [MDROs]), and did not perform hand hygiene upon exit of the room. Resident 62 was on contact precautions for C. Diff [Clostridium difficile, a common, often harmful bacterium that causes severe diarrhea and inflammation of the colon]) and Resident 1 was on enhanced barrier precaution (EBP). 2.Licensed vocational nurse I (LVN I) did not perform hand hygiene (cleaning of hands with soap and water or an alcohol-based sanitizer to remove germs and prevent infections) upon doffing (to take off or remove something) gloves and prior to donning (act of putting on something) a new pair of gloves; and3.Licensed vocational nurse K (LVN K) did not change gloves after touching contaminated gauze wrappers, and the box of gauze during Resident 7's wound treatment, exposed Resident 7's stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure injury/pressure ulcer (PI/PU - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) in the sacrum (a triangular bone just below the lumbar vertebrae) area while cleaning Resident 7's right lower leg wounds, did not clean the surrounding skin of sacrum's stage 4 PI and did not clean the other wounds at the back of Resident 7's right thigh as ordered by the physician.These failures had the potential to compromise resident's health and safety, and spread infections to residents, staff, and visitors.Findings:1.Review of Resident 62's admission Record dated 12/22/2025, indicated Resident 62 was admitted to the facility with diagnoses including paraplegia (paralysis or weakness in the lower body, legs, and sometimes trunk), dorsalgia (pain in the back) and enterocolitis (inflammation affecting both small intestine and large intestine) due to C. diff. [Clostridium difficile - a common, often harmful bacterium that causes severe diarrhea and inflammation of the colon], recurrent.Review of Resident 1's admission Record dated 12/22/2025, indicated Resident 1 was admitted to the facility with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (commonly referred to as stroke), affecting left non-dominant side (the part of the body [like hand, foot or eye] that is less preferred nor used for tasks compared to its paired counterpart, which is the dominant side), dysphagia (difficulty in swallowing) following cerebral infarction, and gastrostomy (or G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) status.Review of Resident 1's Order Summary Report dated 12/22/2025, indicated an order of enhanced barrier precaution (EBP, an infection control measures in nursing homes to stop the spread of multidrug-resistant organisms [MDROs]) due to having a feeding tube.During an observation on 12/16/2025 at 9:48 a.m., in front of Residents 62 and 1's room, the room entrance had a posting indicated that Resident 62 was on contact precaution while Resident 1 who was in B bed was on EBP. HK J was observed mopping inside the room, not wearing proper PPE. HK J was just wearing a facemask, no gown and no gloves on. HK J mopped the floor where Resident 62 was, she moved Resident 62's overbed table without gloves on, touched the privacy curtain, mopped Resident 1's floor, touched Resident 1's overbed table to moved it near the bed, continued mopping to the doorway, and touched the garbage container to move against the wall, still no gown and no gloves on. HK J stepped out of the room, took a long-handled broom, did not perform hand hygiene, and swept the doorway floor. HK J touched the cleaning cart and moved in front of Room CC without hand hygiene.During an interview with HK J on 12/16/2025 at 9:52 a.m., HK J confirmed above observations and stated she did not know Resident 62 was on contact precaution.During an interview with the director of nursing (DON) on 12/22/2025 at 11:03 a.m., the DON confirmed Resident 62 was on contact precaution because Resident 62 was admitted with C-diff. The DON stated the housekeeper should have worn gown and gloves, if resident was on contact precaution, it's our protocol.During a review of CDC's Guideline for Isolation Precautions titled, Precautions to Prevent Transmission of Infectious Agents, dated 11/22/2023, indicated, . for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.C.difficile.During a review of the facility's policy and procedure titled, Hand Hygiene, date revised 9/1/2020, indicated, The following situations require appropriate hand hygiene:.Immediately upon entering and exiting a resident room.2.During a wound treatment observation on 12/19/2025 at 9:27 a.m., inside Resident 7's room, LVN I was observed wearing a new pair of gloves and was about to assist LVN K with wound treatment, but a box of gloves fell on the floor. LVN I removed his gloves, picked up the box of gloves and dropped it on top of a covered garbage container, and donned a new pair of gloves without hand hygiene.During an interview with LVN I on 12/19/2025 at 10:15 a.m., LVN I confirmed above observation, and stated he should have performed hand hygiene prior to donning a new pair of gloves.3.Review of Resident 7's admission Record dated 12/19/2025, indicated Resident 7 was admitted to the facility with diagnoses including pressure ulcer of sacral region, stage 4, chronic peripheral venous insufficiency (a condition where the veins, typically in the legs, have difficulty sending blood back up to the heart), non-pressure chronic ulcer (a long-lasting skin sore [ulcer] that doesn't heal properly and isn't caused by constant pressure) of right lower leg and acquired absence of left leg above knee.During wound treatment observation on 12/19/2025 at 9:38 a.m., inside Resident 7's room, LVN K removed the dressing on Resident 7's right lower leg's non-pressure ulcers, and with the same gloves, removed the old dressing in Resident 7's sacrum area. The wound in the sacrum area was a Stage 4 PI, the wound bed was pink, red in color and had a depth. LVN K started to work on the right lower leg's wounds while the sacrum wound was exposed. LVN K opened the wrappers of each gauze one at a time to moisten with normal saline (NS-sterile saltwater solution) and cleansed each wound with one moistened gauze at a time. LVN K left all the gauze wrappers on top of the overbed table. At 9:49 a.m., with a new pair of gloves, LVN K touched all contaminated gauze wrappers and threw them, opened a wrapper of calcium alginate (a natural, gel-forming substance from seaweed, used in wound dressings to absorb fluid and create a moist healing environment) and started to apply the calcium alginate to the right lower leg wounds, continued to apply dressings to cover the wound, without changing her gloves and no hand hygiene observed. At 9:55 a.m., LVN K went to the treatment cart and took out a box of gauze and placed it on top of the overbed table. LVN K donned a new pair of gloves and touched the box of gauze to take some gauze and started to clean inside the PI wound on Resident 7's sacrum area, without changing her gloves. The surrounding skin of the PI was not cleansed and LVN K packed the wound with calcium alginate and covered with foam dressing. At 10:00 a.m., LVN K proceeded to clean Resident 7's right posterior thigh (at or toward the back or rear of something) scattered open wounds. She cleansed only one open wound with NS then started to apply zinc oxide ointment (a topical medication that acts as a protective barrier for the skin) to all wounds without cleaning them.During an interview with LVN K on 12/19/2025 at 10:20 a.m., LVN K confirmed above observations and stated she should have changed gloves and performed hand hygiene every time she touched a contaminated material or environment. LVN K stated she should have cleansed the PI's surrounding skin prior to application of foam dressing.During an interview with the DON on 12/22/2025 at 10:55 a.m., she stated if needed to change the dressings of resident's multiple wounds, the nurse should take care of one wound at a time to prevent cross contamination. The DON further stated hand hygiene should be performed before donning a new pair of gloves, and nurses should change gloves once they touch a dirty surface. She confirmed wounds should be cleansed as well as their surrounding skin prior to application of any treatment order.Review of Resident 7's order summary report, it indicated a physician's order dated 10/29/2025 to cleanse the right posterior thigh wounds with NS, pat dry, apply the zinc oxide and leave open to air.Review of the facility's policy and procedure titled, Hand Hygiene, date revised 9/1/2020, indicated, Facility staff follow the hand hygiene procedures to help prevent then spread of infections to other staff, Resident, volunteers and visitors.Wearing gloves does not replace the need for hand hygiene.Before donning and after doffing Personal Protective Equipment (PPE).Review of the facility's policy and procedure titled, Dressings - Application, date revised 1/1/2012, indicated, To ensure cleanliness and prevent infection by protecting the skin's surface and to promote resident comfort and wound healing.Wash hands before and after each procedure. Open all dressings to be used. Pour solutions into med (medication) cup as indicated. Reapply non-sterile gloves and proceed with cleansing of wound. Start with inside and move in circular motion away from wound. Gentle cleansing recommended.apply ointments.

Based on interviews, and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when: 1. Licensed vocational nurse A (LVN A) crushed all of Resident 1's morning medications, mixed them with oatmeal, and left them at Resident 1's bedside; and 2. Certified nursing assistant B (CNA B) administered crushed medications, mixed with oatmeal to Resident 1. These failures had the potential to affect Resident 1's care, health, and well-being.Findings:1.Review of Resident 1's clinical record titled, admission Record, dated 9/25/2025, it indicated Resident 1 was admitted to the facility with diagnoses including myocardial infarction (heart attack), paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), chronic systolic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and hypertension (HTN - high blood pressure).Review of Resident 1's annual minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], it indicated Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review indicated Resident 1 was dependent on eating.During an interview with licensed vocational nurse C (LVN C) on 9/25/2025 at 10:40 a.m., LVN C confirmed Resident 1 would take his medications whole by mouth and he had no problem in swallowing. LVN C stated Resident 1 never requested his medications to be crushed and he took them whole with a sip of water. LVN C further stated that if a resident requested for the medications to be crushed, he would not crush them, and would rather call the physician first to get an order, may crush medications, and refer the resident to a speech therapist (ST) as needed.During an interview with registered nurse E (RN E) on 9/25/2025 at 11:38 a.m., RN E confirmed a medication error had happened with Resident 1's morning medications on 9/6/2025. RN E further confirmed LVN A crushed all of Resident 1's morning medications and mixed them with Resident 1's oatmeal. RN E stated some medications like the extended release (ER) should not be crushed because they won't work or would not be the same. RN E further stated Resident 1 was aware that his medications were mixed with his oatmeal and complained about his food tasted bad, and he called FM AA.Review of Resident 1's medication administration record (MAR - a record of medications given), month of September 2025, it indicated the following medications were crushed and administered to Resident 1 on 9/6/2025:a. Amiodarone hydrochloride (a medication that prevents and treats an irregular heartbeat) 200 milligram (mg - unit of measurement) tablet;b. Amlodipine Besylate 10 mg tablet (a medication that lowers blood pressure);c. Aspirin enteric coated (EC - a special coating to resist the stomach's acid and not dissolve until it reaches the small intestine81 mg tablet (an over-the-counter medication used to reduce pain, fever, inflammation and act as a blood thinner);d. Atorvastatin calcium 80 mg tablet (a medication used to lower cholesterol and fats in the blood);e. Clospidogrel bisulfate 75 mg tablet (an antiplatelet drug to prevent blood clots);f. Cyanocobalamin 1000 microgram tablet (a vitamin B12 used to treat and prevent vitamin B12 deficiency);g. Dilantin 30 mg, 2 capsules (brand name for the generic drug phenytoin, an anticonvulsant medication used to control and prevent certain types of seizures);h. Donepezil HCl 10 mg tablet (a medication used to treat symptoms of dementia in people with Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]);i. Folic acid 1 mg tablet (a synthetic B vitamin that helps the body make new cells);j. Isosorbide mononitrate extended release (ER or XR - a medication designed to slowly release the active drug into the body over an extended period of time) 60 mg tablet (a medication used to prevent chest pain);k. Multivitamin one tablet;l. Pantoprazole sodium delayed release 40 mg tablet (a prescription medication that reduces the amount of acid produced in the stomach);m. Levetiracetam 750 mg tablet (an anti-seizure medication used to prevent and control various types of seizures);n. Metoprolol tartrate 100 mg tablet (a medication used to treat high blood pressure);o. Phenytoin sodium extended capsule 100 mg (used to treat and prevent various types of seizures);p. Sennosides 8.6 mg tablet (a medication used to treat constipation); andq. Hydralazine HCl 50 mg tablet (used to treat high blood pressure).During a phone interview with Resident 1's family member AA (FM AA) on 9/25/2025 at 11:53 a.m., FM AA stated Resident 1 called her to complain about his oatmeal tasted, awful. FM AA further stated she learned that LVN A crushed Resident 1's medications and mixed them on his oatmeal. FM AA confirmed that LVN A informed her that she asked CNA B to provide the oatmeal with medications to Resident 1. FM AA stated, the CNA should not give the medications to my dad. FM AA further stated that some of Resident 1's medications should not be crushed.Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation - an assessment tool used to facilitate prompt and appropriate communication of a problem] Communication Form and Progress Note for RNs [registered nurses]/LPN [licensed practical nurse]/LVNs, dated 9/9/2025, it indicated, Resident 1's scheduled morning medications were crushed on 9/6/2025.During a review of the health information platform titled, Drugs.com, dated 3/5/2025, indicated a warning, Enteric-coated products should not be dissolved.or crushed prior to consumption. Damaging the coating allows the medicine to be dissolved by acid in the stomach.Further review of the health information platform titled, Drugs.com, dated 11/23/2025, indicated, Isosorbide Mononitrate Extended-Release Tablets should not be chewed or crushed and should be swallowed together with a half-glassful of fluid.Review of the Pantoprazole: Package Insert/Prescribing Info (information), dated 11/20/2025, indicated, Swallow pantoprazole sodium delayed-release tablets whole, with or without food in the stomach.2.During an interview with certified nursing assistant D (CNA D) on 9/25/2025 at 11:17 a.m., CNA D stated she was not allowed to feed the resident if the food was mixed with medications because she was not a nurse.During an interview with the director of staff development (DSD) on 9/25/2025 at 1:55 p.m., the DSD confirmed CNA B fed Resident 1 with oatmeal mixed with medications on 9/6/2025. The DSD stated CNA's should not be giving medications to residents because that was not in the scope of CNA's practice.During an interview with CNA B on 9/25/2025 at 2:28 p.m., CNA B confirmed she assisted Resident 1 with breakfast on 9/6/2025. CNA B stated when she was about to assist Resident 1 with his breakfast, when LVN A came into the room, crushed Resident 1's medications, mixed them on Resident 1's oatmeal and LVN A left the room. CNA B confirmed Resident 1 took some of the oatmeal with his medications and spit it out. CNA B stated she should not have given the oatmeal with medications to Resident 1.During an interview with the director of nursing on 9/25/2025 at 3:18 p.m., the DON confirmed LVN A crushed Resident 1's medication on 9/6/2025. The DON stated, LVN A asked Resident 1 if he wanted his medication with food. The DON further stated, LVN A misinterpreted Resident 1, she crushed all his medications and mixed them with his food. The DON stated, Unfortunately, the CNA gave the medications mixed with food to Resident 1.During a review of the facility's policy and procedure titled, Medication-Administration, date revised 1/1/2012, indicated, Medications must be given to the resident by the Licensed Nurse preparing the medication.If the resident has difficulty swallowing pills, the Licensed Nurse will notify the physician to discuss the possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.During a review of the lesson plan on one-on-one in-service with CNA B titled, General Inservice, dated 9/8/2025, indicated, C.N.A are not allowed to give medication to residents in nursing home. It is not within c.n.a scope of practice. Further review indicated nurses are responsible for administration of medications to residents.

Based on observation, interview and record review, the facility failed to ensure one (Resident 1) out of three sampled residents was provided needed care and services in accordance with professional standards of practice when Resident 1 did not receive urology (a medical specialty that focuses on the diagnosis and treatment of disorders related to the urinary and reproductive systems) consultation as ordered by the physician. This failure resulted in Resident 1's prolonged use of indwelling urinary catheter [thin, flexible tube inserted into the bladder through the urethra to collect and drain urine] and placed Resident 1 at risk for urinary tract infection and delayed urology evaluation. Findings: A review of Resident 1's clinical record indicated an admission date of 1/17/25 with diagnoses including End Stage Renal Disease (kidneys no longer work as they should to meet the body's needs), Obstructive and Reflux Uropathy, unspecified (urinary tract has a blockage that prevents urine from flowing normally and when urine flows backward from the bladder into the ureters and kidneys instead of flowing down), and Retention of Urine. A review of Resident 1's Physician Order indicated, Indwelling Catheter size (FR#16) with balloon via gravity drainage for obstructive neuropathy ordered on 1/23/25. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview on 4/28/25 at 11:42 a.m. with Resident 1, Resident 1 stated he was not seen by a prostate [accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation] doctor yet and was told to get a prostate doctor once he got discharged without referral. Resident had an indwelling foley catheter. A review of Resident 1's Physician Progress Notes dated 2/26/25 indicated, Refer to SCVMC [a hospital] urology [the medical specialty that deals with the urinary system] for eval [evaluation] . A review of Resident 1's Physician Progress Notes dated 3/18/25 indicated, .awaiting urology apt [appointment] . A review of Resident 1's Physician Progress Notes dated 3/25/25 indicated, failed voiding trial [a test to see if your bladder can empty urine on its own after a catheter is removed]; referred to urology . A review of Physician Progress Notes dated 4/8/25 indicated, .needs urology referral During a concurrent interview and record review of Resident 1's clinical records with the Director of Nursing (DON) on 4/28/25 at 2:42 p.m., the DON verified the urology referral for Resident 1 was ordered on 2/26/25. The DON verified Resident 1 was not seen by a urologist yet. During a concurrent interview and record review of Resident 1's clinical records on 5/13/25 at 1:21 p.m. with the DON, the DON stated urology consult was still pending for Resident 1. During a phone interview on 6/3/25 at 9:49 a.m. with Nurse Supervisor (NS), NS verified he coordinated the order for urology consult for Resident 1. NS also stated it usually took a month or a month and a half to process a referral for consultation. NS stated Resident 1 was discharged on 5/24/25 against medical advice. NS also stated, Resident 1 was not seen by a urologist during his stay in the facility. A review of facility's policy and procedure (P&P) entitled Referrals to Outside Services revised 12/1/2013, the P&P indicated, .III. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents A. For clinical services, a nursing designee will assist the Director of Social Services in locating a provider .

Based on observation, interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice when one (Resident 1) out of three sampled residents was left with their oral medication to be taken unsupervised at bedside and was documented as given without confirmation. This failure resulted in inaccurate documentation of correct time of medication administration and had the potential for a missed dose. Findings: During a concurrent observation and interview on 12/17/24 at 11:39 a.m. with Resident 1 in her room, a medicine cup with two white capsules and a plastic cup of water were noted on her bedside table. Resident 1 stated that her nurse left it there for her to take. At 11:42 a.m., Certified Nurse Aide (CNA) B came in the room and verified the two capsules and stated she will call Resident 1's nurse. Licensed Vocational Nurse (LVN) A came in the room at 11:45 a.m. and confirmed she was Resident 1's assigned nurse and that she left the medications for Resident 1. LVN A stated It's not okay to leave medications at bedside. I should have watched her take her medications. LVN A also stated that the medication was Gabapentin (a medication to treat seizures and/or nerve pain). During a concurrent interview and record review with the Director of Nursing (DON) on 12/17/24 at 3:09 p.m., the DON stated that medications should not be left at bedside without an order for self-administration of medication from the doctor. The DON verified that Resident 1 had no order for self-administration of medication from the doctor. During a concurrent interview and record review of Resident 1's Medication Administration Record with LVN A on 12/17/24 at 3:45 p.m., LVN A verified the latest time stamp for the administration of Gabapentin on 12/17/24 was 11:24 a.m. LVN A confirmed she did not administer Gabapentin at 11:24 a.m. A review of Resident 1's clinical record indicated diagnoses of but were not limited to, Muscle Weakness, Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people) and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Physician Order dated 11/8/24 indicated, Gabapentin Capsule 100 MG [milligram, a unit of measurement] Give 2 capsules by mouth three times a day for nerve pain. A review of facility's Policy and Procedure (P&P) titled, Medication-Administration, revised January 1, 2012, the P&P indicated, .D. Medications must be given to the resident by the Licensed Nurse preparing the medication .IX. Documentation A. The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication or type of the treatment .

Based on interview and record review, the facility failed to ensure sufficient and appropriate social services were provided for two (Resident 7 and Resident 10) out of 12 sampled residents when psychosocial and emotional assessments were not done following a resident-to-resident altercation. This failure had the potential for psychosocial decline of the residents that can affect their overall health. Findings: During an interview on 12/17/24 at 1:47 p.m. with the Social Services Director (SSD), the SSD stated it was her duty to check on residents involved in altercations. The SSD also stated she must check on the residents for three consecutive days after an alleged event except on weekends. The SSD stated, I usually ask them what happened and if they are in pain. I also ask them if they're sad. The SSD also stated the assessment must be documented on the resident's electronic chart. During a concurrent interview and record review with the SSD on 12/17/24 at 2:02 p.m. of Resident 10's and Resident 11's progress notes, the DSD verified Resident 10 had an alleged altercation with Resident 11 on 8/15/24. The progress notes indicated Resident 10 was allegedly tapping Resident 11's legs. The SSD confirmed she had no documentation of psychosocial and emotional assessment for Resident 10 following the incident. The SSD stated, I don't know what happened. During a concurrent interview and record review with the Social Services Director (SSD) on 12/17/24 at 2:12 p.m. of Resident 5's and Resident 7's progress notes, the DSD verified that on 9/3/24, Resident 5 allegedly grabbed Resident 7's left wrist and kicked Resident 7's left ribs. The DSD verified there were no social services documentation of psychosocial and emotional assessment for Resident 7 following the alleged incident. During an interview with the Director of Nursing (DON) on 12/17/24 at 3:09 p.m., the DON stated there must be a 72-hour psychosocial status check done by the social services and must be documented on the resident's chart. A review of facility provided Job Description for Social Services Coordinator indicated, Principal Responsibilities Clinical/ Administrative .Assess the psychosocial, mental and emotional needs of residents . .Communicate needs and plan of care to resident, families, responsible parties and appropriate staff .

Based on observation, interview, and record review, the facility failed to ensure facility staff honored one of two residents (1) preferences when the social services assistant (SSA) did not assist Resident 1 to choose another physician. This failure had the potential to compromise resident rights. Review of Resident 1's Admission Record (part of the medical record that documents patient information) indicated he was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Ankylosing Spondylitis of the Spine (an inflammatory arthritis affecting the spine and large joints). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/12/24, indicated the resident was cognitively intact (mental process used to think, learn, remember, reason, pay attention, and ultimately, comprehend information and turn it into knowledge). During an interview, on 9/11/24, at 11:30 a.m., with the SSA, SSA stated Resident 1 asked to switch physicians about two months ago. SSA stated she thought she told the director of nurses about it. SSA stated she was not aware of what happened after that. During a subsequent interview, on 9/11/24, at 11:49 a.m., with the SSA, SSA acknowledged residents have the right to change doctors. SSA stated she did not know the procedure for switching physicians and she thought the DON handled it. SSA stated she did not follow up after that. Review of the facility's policy and procedure titled, Designation of Attending Physician, revised January 1, 2012, indicated To ensure that the resident is able to exercise his/her right to choose a personal Attending Physician .residents of the Facility have the right to choose a personal Attending Physician .the Facility helps the resident exercise his/her choice in finding another Attending Physician.

Based on interview and record review, the facility failed to ensure finger stick blood sugar (FSBS, a blood sugar test performed by piercing the skin via fingerstick to draw blood onto a chemically active disposable test-strip) levels were checked for one of three residents (Resident 1) when the order from the General Acute Care Hospital (GACH) for Resident 1 to have FSBS two times a day was not carried out after Resident 1 was transferred to the facility. This failure resulted in Resident 1 to experience severe low blood sugar (below 54 mg/dL (milligrams per deciliter, a unit of measure for concentration of substance in a specific amount of fluid)), which led to his admission to an intensive care unit (ICU, a GACH unit for patients with life-threatening injuries and illnesses) for treatment. Findings: Review of Resident 1's Admission Record indicated he was admitted to the facility from a General Acute Care Hospital, on 10/26/2022, with diagnoses of dementia (a condition characterized by loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes (a disease of which the body is not able to take up sugar into its cells and use it for energy). Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 11/2/2022, indicated his cognition was moderately impaired. Review of Resident 1's Skilled Nursing Facility (SNF) Orders that the General Acute Care Hospital sent to the facility, dated 10/26/2022, indicated Resident 1 had orders for Glucagon (an emergency medicine used to treat hypoglycemia, a condition in which your blood sugar (glucose) level is lower than the standard range of 70 to 100 mg/dL) 1 mg reconstituted solution inject subcutaneously (under the skin) as needed for hypoglycemia and FSBS two times a day. Review of Resident 1's physician order at the facility lacked indication for FSBS two times a day for Resident 1. During an interview with the director of rehabilitation (DOR) on 1/27/2023 at 3:50 p.m., she stated, on 11/2/2022, when she provided care to Resident 1 that day, Resident 1 complained of feeling cold. The DOR stated she provided blankets to Resident 1, but Resident 1 still complained of being cold, and he looked cold. So, she checked Resident 1's SpO2 (SpO2, the percentage amount of oxygen in the blood, of which the normal range would be 92% to 100%) and it was below 90%. She reported it to the licensed nurse. Review of Resident 1's Change in Condition Evaluation, dated 11/2/2022 at 2:51 p.m., indicated Resident 1 had fluctuating blood pressure, his hands were cold, his left fingers were purple and his SpO2 could not be obtained. Extra blankets were provided to Resident 1, and the physician ordered oxygen 2 LPM (liters per minute, a measure of air flow velocity) via nasal cannula (NC, a medical device to provide supplemental oxygen to people who have lower oxygen levels) as needed for comfort. Review of Resident 1's Health Status Note, dated 11/2/2022 at 10:06 p.m., indicated Resident 1 still had cold hands, and his SpO2 could not be obtained. Review of Resident 1's Health Status Note, dated 11/3/2022 at 5:23 p.m., indicated Resident 1 became lethargic, and the physician ordered to send Resident 1 to the emergency room (ER) via 911 emergency medical service ambulance. Review of Resident 1's Health Status Note, dated 11/3/2022 at 10:05 p.m., indicated at approximately 5:30 p.m., Resident 1's fingers were too cold, and SpO2 still could not be obtained. Paramedics (healthcare professionals who respond to emergency calls for medical help outside of a hospital) came to pick up Resident 1 and stated Resident 1's FSBS was below normal level. Review of Resident 1's Ambulance Record, dated 11/3/2022, indicated Resident 1 presented with hypoglycemia, altered mental status, somnolence (abnormal drowsiness), and shortness of breath. His skin was dry and cold. Resident 1's respiratory rate was slow and shallow, and his lung sounds were diminished bilaterally (both sides). Resident 1's blood pressure was 182/100 mmHG (millimeters of mercury, a measure pressure), which increased to 216/113 mmHG, and his pupils were non-reactive to light (an abnormal condition, because the pupils of a person's eyes normally change in size when exposed to light). A SpO2 sensor placed on Resident 1's ear showed his SpO2 was 78% while he was on 1-6 LPM of oxygen, and his blood sugar was 24 mg/dL. After 250 milliliters (ml, a metric unit of volume) of dextrose 10% (a medicine used to elevate blood sugar level) was intravenously (IV, by way of a person's vein) administered to Resident 1, his blood sugar was 32 mg/dL, and there was no improvement in Resident 1's mental status and breathing. So, bag-valve-mask (BVM, an airway apparatus used to cover the patient's nose and mouth and begin ventilating the lungs mechanically by squeezing a reservoir of oxygen or air) ventilations with 10-25 LPM of oxygen were started. Review of Resident 1's Emergency Department Provider Note, dated 11/3/2022, indicated Resident 1 presented with altered mental status, respiratory depression, and hypoglycemia. Resident 1 was ill-appearing and somnolent. His blood pressure was 224/164 mmHG. After one dose of dextrose 50% (used in emergency care to treat hypoglycemia) was administered to Resident 1, his blood sugar level still ranged from below 15 to 31 mg/dL, so two more doses of dextrose 50% were given. After three doses of dextrose 50% were administered, Resident 1 was able to open his eyes, but he was obtunded (a lethargic state, in which the patient has a lessened interest in the environment, slowed responses to stimulation and tends to sleep more than normal with drowsiness in between sleep states), had difficulty breathing and needed bagging. Resident 1 was intubated (to insert a tube into a person or a body part, especially the windpipe for ventilation), put on a ventilator (a machine that helps a person breathe), and admitted to the ICU. During an interview with licensed vocational nurse A (LVN A) on 1/24/2023 at 5:45 p.m., she stated she admitted Resident 1 and transcribed Resident 1's physician orders. LVN A reviewed Resident 1's Skilled Nursing Facility (SNF) Orders that the General Acute Care Hospital sent to the facility and confirmed Resident 1 had an order for FSBS two times a day. LVN A stated she did not see the order and did not carry it out. During an interview with Resident 1's physician on 1/27/2023 at 3:30 p.m., she reviewed Resident 1's Skilled Nursing Facility (SNF) orders and confirmed Resident 1 had the order for FSBS two times a day, but the order was missed; therefore, it was not carried out. Resident 1's physician agreed that, since Resident 1 had a Glucagon order, he should have the FSBS checked; otherwise, the staff would not know if Resident 1 had hypoglycemia. During an interview with the director of nursing (DON) on 1/27/2023 at 5 p.m., she reviewed Resident 1's Skilled Nursing Facility (SNF) Orders and confirmed Resident 1 had the order for FSBS two times a day, but the order was missed and not carried out. The DON also agreed that since Resident 1 had a Glucagon order, he should have the FSBS checked; otherwise, the staff would not know if Resident 1 had hypoglycemia. Review of the facility's undated job description, LVN Staff Nurse, indicated General Duties and Responsibilities: . Clinical: . Receives and transcribes orders accurately from attending/alternate physician. Review of the facility's Handbook for Long Term Care Medical Directors and Providers, Attending Physician Role and Responsibilities, dated 12/2021, indicated Roles and Responsibilities of the Nursing Home Attending Physician: 1. Provide competent, safe medical care to residents under their care with relevant age-appropriate medical and/or geriatric principles. 2. Orders are related to medically necessary items and services.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided as ordered, timely, accurately, and safely for three of 26 sampled residents (Residents 29, 75, and 82) and four residents (Residents 26, 69, 123 and 327) as evidenced by: 1. Medications ordered by the physician were not available in the medication cart for administration to Residents 29, 82, 123, and 327. The nursing staff did not re-order and receive pain medication from the pharmacy timely for Residents 123 and 327, resulting in the residents suffering from the pain. Resident 29 did not receive his daily sevelamer (a [MEDICATION(S)] binder, medication to control high blood level of phosphorus, a mineral found in food, in people with kidney disease who are on [CONDITION(S)]) for more than two months; and the nursing staff documented sevelamer given to the resident without actually giving the medication. The nursing staff did not notify the physician when the medication was not available to give to Resident 29. Resident 82 did not receive his inhalers (to treat breathing problems), [MEDICATION(S)] (medication to help prevent recurrence of certain liver problems), and [MEDICATION(S)] (nerve pain medication) as ordered; and the nursing staff did not notify the physician when the medications were not available to give to Resident 82. These failures resulted in Residents 123 and 327 suffering from pain; Resident 82 suffering from asthma ([CONDITION(S)] disease of the airways to the lungs) attacks and potential for worsening of his other medical conditions; and the potential for Resident 29 to suffer from high [MEDICATION(S)] concentration in the blood. 2. Random controlled medication (those with high potential for abuse and addiction) use audit for three out of three residents (Residents 75, 123, and 327) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications. 3. During the medication pass observation, one of four nurses prepared and was about to administer medications for two residents (Residents 26 and 69) at the same time. This failure had the potential for medication errors due to the resident mix-up; and 4. Four of four opened emergency kits (E-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced in a timely manner as in accordance with the facility policy and procedures (P&P). This failure had the potential for the residents not receiving emergency medications, if needed, in a timely manner. Findings: 1a. During the medication pass observation with licensed vocational nurse (LVN) B on 7/19/21 at 9:45 a.m., Resident 123 was observed on a wheelchair outside in the hallway, near LVN B's medication cart. Resident 123 requested to have his [MEDICATION(S)] (a controlled medication for pain) with his morning medications. LVN B looked through the medication cart and said he could not locate the [MEDICATION(S)] for Resident 123. He said the resident asked for it earlier that morning for the pain level of 6 (moderate pain; using the Numeric Rating Scale; scoring range, 0-10; 0 = no pain, 10 = worst pain possible). On 7/19/21 at 9:50 a.m., LVN B was observed administering the morning medications to Resident 123 but there was no [MEDICATION(S)] given. During an interview on 7/19/21 at 9:57 a.m., Resident 123 stated he requested the [MEDICATION(S)] earlier that morning. He pointed to his left shoulder and stated he had a pain level of 9 (severe pain) on his left shoulder. A review of Resident 123's medical record indicated he was admitted to the facility with diagnoses including left shoulder pain. The physician's Progress Notes, dated 6/22/21, indicated: Left shoulder pain OA [[CONDITION(S)] - type of arthritis that occurs when flexible tissue at the ends of bones wears down]. The medical record indicated a physician's order, dated 6/9/21, for [MEDICATION(S)] 5-325 mg (combination of [MEDICATION(S)] 5 mg and acetaminophen 325 mg) 1 tablet every 6 hours as needed for moderate pain. A review of Resident 123's Minimum Data Set (MDS, an assessment tool), dated 6/25/21, indicated Resident 123 had the Brief Interview for Mental Status (BIMS, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1, which is the lowest score, to 15, which is the highest score) score of 13, indicating the resident had intact cognition. During a follow-up interview on 7/19/21 at 11:46 a.m., with LVN B, he stated the physician's order for [MEDICATION(S)] was changed from one tablet every 8 hours as needed, to every 6 hours as needed on 6/9/21 but no one informed the pharmacy. He said the last tablet was used last night on 7/18/21. He said he called the pharmacy this morning, the pharmacy told him that they could not refill the [MEDICATION(S)] until they talked with the doctor and would not authorize the use of the E-kit. LVN B said he did not have the [MEDICATION(S)] to give to the resident. He offered to give Tylenol but the resident refused. During an interview with LVN E on the following day, on 7/20/21 at 12:03 p.m., she stated the facility had not yet received the [MEDICATION(S)] for Resident 123. During an interview with the assistant director of nursing (ADON) on 7/20/21 at 12:12 p.m., she stated she in-serviced the nursing staff to request refills for medications when they had five days' worth of medications on hand for routine and for as-needed medications based on pattern of use. She stated the facility ran out of the [MEDICATION(S)] for Resident 123 because the nursing staff failed to request the refill and follow-up with the pharmacy timely and did not report to her when they were running low on [MEDICATION(S)]. During a telephone interview with the pharmacy staff (PS) on 07/21/21 at 4:18 p.m., PS said the pharmacy delivered 30 [MEDICATION(S)] tablets for Resident 123 on 6/25/21, and the facility made a refill request for [MEDICATION(S)] on 7/13/21, but the pharmacy had been trying to get the clarification for the direction change but was not successful until 7/20/21 (day of survey). There was no documented evidence the nursing staff followed up the pharmacy during from 7/13 to 7/19/21 to ensure they received the [MEDICATION(S)] timely. The ADON confirmed this during the interview on 7/20/21 at 12:12 p.m. as described above. 1b. On 7/20/21 at 8:31 a.m. in the presence of LVN C in the hallway of Nursing Unit 6, Resident 327 was overhead crying in her room. She sobbed out loud and said, Hurts too much! On 7/20/21 at approximately 8:35 a.m., LVN C was observed opening and taking one tablet of [MEDICATION(S)] 5-325 mg from the controlled medication E-kit. He said he was waiting for the pharmacy to deliver the [MEDICATION(S)] for Resident 327. On 7/20/21 at 8:45 a.m., LVN C was observed administering the [MEDICATION(S)] to Resident 327 while she was crying and twisting her body in pain. She said her pain level was a 10 out of 10 (severe pain); and the pain was burning in my knees . Hurts so much! During a concurrent observation and interview with Resident 327 on 7/20/21 at 8:48 a.m., she was observed turning and twisting in pain, crying, and apologizing for crying. She said the pain was too much, burning on her left leg. She said she usually got her [MEDICATION(S)] around 7 a.m. and said if she did not get it on time, then the pain just builds up. A review of Resident 327's medical record indicated a physician's order, dated 7/14/21, for [MEDICATION(S)] 5-325 mg, 1 tablet every 6 hours as needed for severe pain. During an interview with LVN C on 7/20/21 at 11:01 a.m., he said it was his first time working in this unit. He did not know what happened to the [MEDICATION(S)] for Resident 327. He said he could not find it this morning, that the last [MEDICATION(S)] tablet was used last night by the night-shift nurse. During an interview with the ADON on 7/20/21 at 12:12 p.m., she said the night nurse gave the last dose at 3 a.m. but did not document it on the MAR, and also did not report that was the last dose. She said the staff did not request the refill from the pharmacy timely, therefore, the medication was not available for the resident, causing the delay in administration. On 7/19/21, a review of Resident 327's medical record indicated she was admitted to the facility, on 7/14/21, with diagnoses including [CONDITION(S)] (common, potentially serious bacterial skin infection) of right lower limb, [CONDITION(S)] of left lower limb, lumbago with sciatica (pain radiating along the sciatic nerve, which runs down one or both legs from the lower back), and unspecified open wound on right knee and right lower leg. Her MDS, dated [DATE], indicated she had a BIMS score of 15, indicating she had intact cognition. During a follow-up interview with Resident 327 on 07/21/21 at 3:49 p.m., she said she lived in a van and fell when she missed a step, something punctured her legs, and woke up in pain following the accident. She was hospitalized prior to being admitted to the facility. The resident was observed with three covered wounds on both legs: two on her right leg and one on the lower part of the left leg. She said yesterday (7/20/21) she received the [MEDICATION(S)] two hours after she requested it and by the time she got it the pain had already set in, and was in pain the whole day, more in the wound on the left leg. She again said the pain level was 10 out of 10, and it was burning the skin off my bone. It was excruciating! She said she received more [MEDICATION(S)] later in the afternoon, but it messed up her schedule and she was in pain the entire day. She said the nurse had to bring her the commode (a portable toilet) to use at the bedside last night because she was debilitated by the pain. Normally she would be able to use the restroom all by herself. 1c. During a medication pass observation on 7/20/21 at 9:36 a.m. with LVN C, he prepared medications for Resident 29 in Nursing Unit 6. He was looking through the medication cart and said he could not find two medications. LVN C said he could not find the sevelamer 0.8 gram (unit of measurement), which was scheduled to be given daily at 9 a.m. He said he looked everywhere, including the medication room, but could not find it. During a review of Resident 29's medical record, it indicated he was admitted to the facility on [DATE], with diagnoses including end-stage renal disease ([CONDITION(S)], a longstanding kidney failure). It showed the resident had been receiving [CONDITION(S)] (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) three times per week since admission. The MDS, dated [DATE], indicated he had a BIMS score of 15, indicating the resident had intact cognition. A review of Resident 29's medication orders included an order dated 4/29/21, for sevelamer (brand name: [MEDICATION(S)]) 0.8 gram (gm, unit of weight) powder packet, give 1 packet (0.8 gram) via G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) daily for [CONDITION(S)]. A review of the Prescribing Information (detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for sevelamer, revised 7/21, indicated it is a [MEDICATION(S)] binder which works by binding with the [MEDICATION(S)] (or phosphorous, found in food) in the gastrointestinal tract and thus decreasing the phosphorous absorption in the blood. During a follow-up interview the following day with LVN C, on 07/21/21 at 10:18 a.m., he said the facility had not yet received the sevelamer for Resident 29. A review of Resident 29's July 21 MAR indicated sevelamer was scheduled to be given daily at 9 a.m. It showed LVN C circled the MAR entry on 7/20 and 7/21/21 for sevelamer administration. On the back of the MAR, LVN C wrote, Sevelamer 0.8 gm waiting delivery. MD made aware on 7/20 at 9 a.m. and 7/21/21 at 9 a.m. During another interview with LVN C on 7/21/21 3:14 p.m., he said he had not received the sevelamer yet. He said he called the physician who said to monitor the resident for any changes and to give when available. A review of LVN C's Progress Notes, documented on 7/21/21 at 8:45 p.m., indicated in part, Patient missed 2 doses of Sevelamer 0.8 gr [grams]. MD made aware and per MD to monitor for s/s [signs and symptoms] of distress. Spoke with [[CONDITION(S)] nurse' (DN) name] from [[CONDITION(S)] center name] [CONDITION(S)], and per [DN's name] to resume medication as ordered, she will inform the [CONDITION(S)] MD, and labs will be done this week . During a telephone interview with PS on 07/21/21 at 4:18 p.m., she said the pharmacy record showed the pharmacy delivered 14 packets (14-day supply) of sevelamer for Resident 29 on 4/30/21, and another 14 packets today (7/21/21). On 7/21/21, a review of Resident 29's May to July 21 MARs indicated the nursing staff documented they had been administering the sevelamer almost every day in May except on 5/1 to 5/4/21 (MAR entries were left blank); every day in June except there were 9 days (on 6/7 - 6/9; 6/14, 6/18, 6/19, 6/21, 6/26, and 6/27) where the staff circled their initials without explanation on the back of the MAR; and every day in July except 7/20 and 7/21/21 (where LVN C had circled MAR entries indicating the medication not available.) On 7/22/21 at 9:15 a.m., the consultant pharmacist (CP) provided the dispensing record for Resident 29's sevelamer. It indicated the pharmacy dispensed 14 packets on 4/30/21, and another 14 packets on 7/21/21 (day of survey). During an interview with LVN G on 7/22/21 at 10:55 a.m., she said she believed Resident 29 received his medications through the facility's pharmacy only. She said any time the medication was not available, the nursing staff was to follow up with the pharmacy and make a circle around their initials on the MAR to indicate the medication not given. She said they were supposed to write on the back of the MAR the reason, such as medication not available or resident refused, whenever the medication was not given. She said she noticed the nursing staff just circled the MARs and were not writing the reason on the back of the MAR for all the residents. During an interview with Resident 29 on 7/22/21 at 11:10 a.m., he said he was not familiar with sevelamer. He said the staff usually did not tell him what they gave him. He said he thought he had been getting his medications every day. Resident 29 confirmed he had been getting his medications through the facility only; there were no family members or other sources where his medications might have come from. During an interview with the CP on 7/22/21 at 11:20 a.m., she said she reviewed Resident 29's medical record and confirmed he had been receiving medications through the facility's pharmacy and no other sources. CP confirmed from 4/30 to 7/19/21, a period of 80 days, the pharmacy only delivered 14-day supply of sevelamer for Resident 29. She said, They probably document without giving the medication. During a concurrent interview and review of Resident 29's medical record with ADON on 7/22/21 at 1:32 p.m., she said 14-day supply for sevelamer sent on 4/30/21 only lasted until mid-May. She said that meant nursing staff signed the MAR but the medication was not available to give from mid-May to 7/19/21, a period of more than two months. ADON could not find any documented evidence, such as in the nursing progress notes, indicating the medication was not available. She said, Sometimes it is written on the back of the MAR but I checked, there were no notes. She said she could not find evidence that the nursing staff followed up with the pharmacy and informed the physician when the medication was not available. During an interview with Physician A on 7/22/21 at 2:26 p.m., she said she was only informed of the sevelamer not available for Resident 29 yesterday or today. She confirmed the nursing staff did not inform her the medication was not available in the past. When asked what clinical effect this would have on the resident, she said not giving the daily sevelamer could cause the resident to have increased phosphorous level in the blood, and symptoms such as nausea and lethargy (lack of energy). She said the phosphorous level in the blood could be corrected by [CONDITION(S)] unless the resident refused [CONDITION(S)]. Physician A confirmed the resident had refused [CONDITION(S)] in the past. A review Physician A's Progress Notes, dated 7/22/21, indicated, Recent discovery [resident] was not getting sevelamer packet phosphorous slightly elevated. During a telephone interview with the [CONDITION(S)] nurse (DN) on 7/23/21 at 8:22 a.m., she said she was only informed of the resident missing sevelamer for two days. She said the resident was receiving his nutritional supplement from the feeding formula (dietary supplement given via G-tube), so she was not too concerned. She said the resident will have another lab on 7/26/21 during his [CONDITION(S)] visit. A review of Resident 29's Nutrition Profile Report (Monthly), dated 7/1/21, indicated Resident 29 had the following phosphorous levels (normal level: 2.4 - 5.1 milligram/deciLiter (unit of measurement)): Date: Phosphorous level: 5/4/21 6.6 5/12/21 5.6 5/27/21 5.5 6/4/21 8.5 6/8/21 6.2 6/14/21 5.4 6/23/21 6.8 During an interview on 7/26/21 at 8:34 a.m. with the ADON, she said she will send the phosphorous level from Resident 29's 7/26/21 lab draw when it became available. During a follow-up email communication post survey, on 7/28/21 at 5:50 p.m., the Administrator indicated the lab draw for Resident 29, scheduled on 7/26/21, was canceled. Therefore, there was no laboratory report for the phosphorous level. 1d. On 7/23/21, a review of Resident 82's medical record indicated he was admitted to the facility with diagnoses including acute respiratory (breathing) failure, asthma, chronic obstructive pulmonary ([CONDITION(S)], chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs), and [CONDITION(S)] of liver (chronic liver damage from a variety of causes leading to scarring and liver failure) with ascites (accumulation of fluid in the abdomen cavity, causing abdominal swelling). The record showed Resident 82 had routine scheduled paracentesis (a procedure used to remove excess fluid from the abdominal cavity) due to fluid build-up from the liver [CONDITION(S)]. A review of Resident 82's MDS, dated [DATE], indicated he had a BIMS score of 15, indicating he had intact cognition. A review of Resident 82's medical record indicated the following medication orders: 1) [MEDICATION(S)] 550 mg, 1 tablet twice daily for [CONDITION(S)] (loss of brain function when a damaged liver does not remove toxins from the blood), dated 3/28/21. 2) [MEDICATION(S)] (a combination of two short-acting medications given via inhalation for use in patients with [CONDITION(S)]), inhale 1 puff orally four times daily for asthma, dated 3/28/21. 3) [MEDICATION(S)] 300 mg, 2 capsules by mouth twice daily before meals for [CONDITION(S)] (chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain), dated 4/19/21. A review of Resident 82's July 21 MAR indicated the resident had not been receiving [MEDICATION(S)] from the morning of 7/20 through 7/23/21 A review of the nursing progress notes, dated 7/20/21 at 2 p.m., indicated, [MEDICATION(S)] medication not available. Another progress notes, dated 7/21/21, indicated, . [MEDICATION(S)] missing. ADON will follow up with [Pharmacy A]. During an interview with LVN G on 7/23/21 at 10:54 a.m., she said the facility did not have [MEDICATION(S)] for the resident for four days, from 7/20 to 7/23/21. She said Resident 82 usually did not refuse any medications except for his stool softeners. On 7/23/21, a review of Resident 82's May 21 MAR indicated the following: 1) The MAR indicated the [MEDICATION(S)] was scheduled daily at 9 a.m. and 5 p.m. It showed the nursing staff circled their initials (meaning medication not given) 12 times, not consecutively, for the 9 a.m. [MEDICATION(S)] administration on 12 different days (on 5/2, 5/6, 5/9, 5/10, 5/12-5/15; 5/17, 5/18, 5/25, 5/26, and 5/28). On the back of the MAR, there were only 5 entries, on 5/5, 5/10; 5/13, 5/17, and 5/18 that indicated, [MEDICATION(S)] not available. 2) The MAR indicated the [MEDICATION(S)] was scheduled to be given 4 times daily at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. It showed the staff circled their initials on the [MEDICATION(S)] administration on the 9 a.m. and 1 p.m. entries on 5/23 and 5/24; and four times each day on 5/29 through 5/31/21. This indicated Resident 82 did not receive his [MEDICATION(S)] doses entirely for 3 days from 5/29 to 5/31/21. There were only two entries on the back of the MAR, both dated 5/31/21, where it indicated, [MEDICATION(S)] No Med Awaiting for Pharmacy. 3) The MAR indicated the [MEDICATION(S)] was scheduled to be given twice daily at 9 a.m. and 5 p.m. It showed the staff had 8 circled MAR entries on 10 different days (on 6/10, 6/12, 6/15, 6/18, 6/19, 6/21, 6/23, 6/24, 6/29, and 6/31) during the 9 a.m. administration and once on the 5 p.m. administration (on 6/15). There were only 3 entries on the back of the MAR (on 6/10, 6/18 and 6/31) indicating [MEDICATION(S)] not available and No medication awaiting for pharmacy. A review of the June 21 MAR indicated the following: The MAR indicated Resident 82 did not receive all four daily doses of [MEDICATION(S)] inhaler 12 days continuously from 6/2 to 6/13/21, and another 3 continuous days from 6/16 to 6/18/21. The nursing staff circled the initials on each MAR entry on these days (60 circled MAR entries). Additionally, on four other days: 6/19, 6/21, 6/23, and 6/26, the resident only received two doses where the staff circled the MAR twice each of these days (8 circled MAR entries). Out of the 68 times the staff circled the MAR entries, there were only 4 documentations on the back of the MAR, dated 6/2, 6/3, 6/7, and 6/13/21, that indicated, [MEDICATION(S)] Not available. There were no other explanations why the resident did not receive the [MEDICATION(S)]. A review of the July 21 MAR indicated the following: The MAR indicated the resident did not receive his twice-daily [MEDICATION(S)] from 7/20 to 7/23/21 (4 days). During an interview with Resident 82 on 7/23/21 at 11:15 a.m., he said he had not been getting his medications regularly, especially the inhalers for his breathing problems. Resident 82 was observed wearing the oxygen tubing through the nasal cannula (through the nose). He said the facility had been having issues getting his medications from his pharmacy (Pharmacy A). He said there were days he did not receive his inhalers, and experienced asthma attacks, once a day, when he did not receive his inhalers. When asked to describe the symptoms, Resident 82 said he had shortness of breath and tightness in the chest. He said he did not inform the facility staff about his asthma attacks and said, What's the use? There's nothing they can do. During an interview with on 7/23/21 at 3:15 p.m. with ADON, she verified the circled MAR entries as described above. She said the nursing staff were to document on the back of the MAR the reason why they circled the MAR entries. She explained the resident's family member (FM) used to get his medications from Pharmacy A and bring them to the facility, but she had moved out of the state three to four months ago, and the facility had difficulties with access to the resident's pharmacy account to re-order medications for him. She said she had arranged for the nursing staff to pick them up from Pharmacy A when they ran low of his medication supply. She said the facility had a lot of changes in nursing staff and the use of registry nurses, they did not re-order or follow up on medication supplies when running low. She said, They were supposed to let us know when they have about 5 days left but did not follow up that's why we ran out. During another interview with ADON on 7/26/21 on 8:20 a.m., she said the nursing staff received Resident 82's [MEDICATION(S)] on 7/25/21. She confirmed he did not receive his [MEDICATION(S)] for 5 days, from 7/20 to 7/24/21, a medication needed for his liver disease. During a concurrent interview and record review on 7/26/21 at 2:45 p.m. with ADON, she reviewed Resident 82's medical record and said there were no documented evidence the nursing staff followed up on the unavailability of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], neither was there documentation they informed the physician when the medications were not available to give in May and June. ADON said, Yes, they should have informed the doctor. A review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy, effective date April 2008, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medication five days in advance of need to assure an adequate supply is on hand. A review of the facility's Physician's Order Medical Records Manual, revised 8/20/2020, indicated, Supplies and medications required to carry out the physician's order will be requisitioned [demanded or acted upon]. A review of the facility's P&P titled Medication Administration-General Guidelines, effective October 2017, indicated, Medications are administered in accordance with written orders of the attending physicians. It also indicated, The individual who administers the medication dose records the administration on the resident's MAR . At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. A review of the facility's Medication-Administration Nursing Manual - General, dated 1/1/2012, indicated, Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back of the MAR, noting the time and reason the medication was held. A review of the facility's undated policy titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY indicated, In the event that a medication is not available at the time it is due for administration owing to any of the . reasons . Facility must document unavailability of medication on the patient's chart. Facility must inform the physician immediately regarding the unavailability of medication. 2. The Controlled Drug Records (CDRs) for 3 random residents (Residents 75, 123, and 327) receiving as-needed controlled medications were requested for review during the survey. a. A review of Resident 327's medical record indicated a physician's order, dated 7/14/21, for [MEDICATION(S)] 5-325 mg, 1 tablet every 6 hours as needed for severe pain. On 7/20/21, a review of the CDR for Resident 327's [MEDICATION(S)] indicated from 7/15 to 7/20/21, the nursing staff signed out of the CDR 18 times (18 tablets), but only documented on the [DATE] times to indicate they were given to the resident. The following were signed out but not documented: 7/16 at 3 a.m., 7;30 a.m., 1:30 p.m., and 7:30 p.m.; 7/17 at 1:40 a.m.; 1:30 p.m., and 7:30 p.m.; 7/18 at 3 a.m., 1:30 p.m. and 7:30 p.m. This resulted in 10 [MEDICATION(S)] tablets unaccounted for. During an interview with ADON on 7/20/21 at 12:12 p.m., she said the nursing staff gave a dose at 3 a.m. that morning but did not document on the MAR. During a concurrent interview and record review with ADON on 7/22/21 at 3:29 p.m., she verified the number of [MEDICATION(S)] removed but not documented on the MAR. She said the nurses were supposed to document on the MAR and also write on the Pain Assessment Flow Sheet the reason and the re-assessment of the resident after an hour. ADON verified they were not documented on the back of MAR, on the flow sheet, or in the nursing progress notes, they were given to the resident. b. During a review of Resident 75's medical record, it indicated she had a physician's order, dated 3/29/21, for [MEDICATION(S)] 5-325 mg 1 tablet every 6 hours as needed for pain. A review of the CDR for Resident 75's [MEDICATION(S)] indicated from 7/4 to 7/17/21, the nursing staff signed out of the CDR 25 times (25 tablets), but only documented 22 times. Those removed on 7/7/21 at 6 a.m., 7/9/21 at 8 a.m., and 7/10/21 at [illegible time] were removed but not documented on the MAR, or the pain flow sheet to indicate they were given to the resident. During a concurrent interview and record review on 7/22/21 at 1:43 p.m., with ADON, she verified the above finding. She could not find documented evidence to indicate they were given. ADON verified three [MEDICATION(S)] tablets for Resident 75 were unaccounted for. c. A review of Resident 123's medical record indicated a physician's order, dated 6/9/21, for [MEDICATION(S)] 5-325 mg 1 tablet every 6 hours as needed for moderate pain. A review of the CDR for Resident 123's [MEDICATION(S)] indicated the nursing staff removed the [MEDICATION(S)] on 7/2/21 at 3 p.m. and 7/4/21 at 3 p.m. but did not document on the MAR to indicate they were given to the resident. They were also not documented on the pain flow sheet. During a concurrent interview and record review on 7/22/21 at 1:43 p.m., with ADON, she verified this finding. She acknowledged two tablets for Resident 123's [MEDICATION(S)] were unaccounted for. During a review of the facility's Pain Management Nursing Manual, revised 11/2016, it indicated, The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR) . After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour . Nurses will complete the Pain Flow Sheet for residents receiving PRN [as-needed] pain medication to evaluate the effectiveness of the medication regimen. A review of the facility's P&P titled Controlled Medications, dated April 2018, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR). The information included the date and time of administration, amount administered, signature of the nurse administering the dose, and the initials of the nurse administering the dose on the MAR. 3. During the medication pass observation on 7/19/21 at 4:10 p.m. with LVN D, she entered Residents 26 and 69's shared room with a small cup of medications and a 6-ounce cup of water in each hand (two cups in each hand). She was asked to stop and explain the medication administration process. She said she prepared the medications for both residents and was about to give each of them their medications at the same time. She acknowledged preparing and administering medications for two residents at the same time had the potential for medication errors due to resident mix-up. LVN D said she normally prepared medications for one resident at a time. During an interview on 7/20/21 at 12:45 p.m., with the ADON, she said nurses were supposed to prepare and administer medications for one resident at a time to avoid medication errors. A review of the facility's Medication-Administration Nursing Manual - General, dated 1/1/2012, did not address the preparation and administering medications for multiple residents at the same time. A review of the Long Term Care AdviseERR, Volume 5 Issue 12 December 2017, the Institute for Safe Medication Practices (ISMP), a non-profit patient safety organization with recognized natio

Based on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards for seven of 26 sampled residents (Residents 98, 50, 59, 117, 125, 33 and 74) when: 1. Certified nursing assistant S (CNA S) transferred Resident 98 from bed to wheelchair without assistance from another staff member; 2. Staff did not implement a landing pad (soft mat placed on the floor next to the bed to prevent injury from falls) for Resident 98 as indicated in the care plan; 3. For Residents 98, 50 and 59, the facility did not complete a Morse Fall Risk Assessment after the residents fell ; 4. CNA X did not provide extensive (staff provide weight-bearing support) toileting assistance for Resident 117; 5. The facility failed to ensure Resident 125 had a person-centered fall care plan; 6. The facility did not implement dycem (a type of non-skid mat) on Resident 33's wheelchair as indicated in the care plan; and 7. The activity director (AD) did not communicate Resident 74's desire to smoke in a timely manner. Failure to provide transfer assistance from more than one staff member resulted in Resident 98's fall with pain and injuries to the left knee and right index finger. Failure to implement a landing pad increased Resident 98's risk for injury in the event of a fall. Failure to complete Morse Fall Risk Assessments after falls had the potential to compromise the facility's ability to anticipate and implement interventions to prevent future falls for Residents 98, 50 and 59. Failure to provide extensive toileting assistance resulted in Resident 117's right knee injury with pain. Failure to ensure Resident 125 had a person-centered fall care plan had the potential to increase her risk for falls and injury. Failure to implement dycem on Resident 33's wheelchair increased her risk for further falls from the wheelchair. Failure to communicate Resident 74's desire to smoke had the potential to compromise the facility's ability to plan and implement interventions to ensure the resident smoked safely. Findings: 1. Review of Resident 98's medical record indicated he had the diagnoses of acquired absence of left leg below knee (left leg was amputated [surgically removed] below the knee), [CONDITION(S)] (a disorder involving excessive body fat that increases the risk of health problems), type 2 diabetes mellitus with diabetic [CONDITION(S)] (nerve damage that most often occurs in the legs and feet), and history of falling. Review of Resident 98's Minimum Data Set (MDS, an assessment tool), dated 3/5/21, indicated he had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicated the resident was cognitively intact). The MDS indicated Resident 98 weighed 271 pounds, had impaired range of motion (movement of a joint) in one lower extremity (leg, ankle and foot), and was not steady during surface to surface transfers. The MDS further indicated Resident 98 was totally dependent (required full staff performance) and required assistance from two or more people for transfers. Review of Resident 98's fall risk care plan, dated 3/24/21, indicated he was at risk for falls due to several factors, including limited mobility, poor balance, decreased endurance, [CONDITION(S)], left BKA (below-the-knee amputation), and history of falls. Review of Resident 98's Activity of Daily Living (ADL) care plan, dated 3/6/21 indicated, Resident performance: Transfer- total assist of 2 person. The care plan further indicated it was the role of nursing and the nursing assistant to provide Resident 98 with total assist of two people for transfers. During an interview with Resident 98 on 7/22/21 at 8:27 a.m., he stated he once fell while transferring from his bed to his wheelchair. He could not remember the date of the fall. Resident 98 explained that one staff member was helping him transfer from bed to wheelchair and he fell because the staff member just couldn't do it. Resident 98 stated he sustained a wound on his leg as a result of the fall. Review of Resident 98's situation, background, assessment, recommendation (SBAR, a tool used to communicate information to the resident's doctor), dated 5/24/21, indicated Resident 98 had a witnessed fall. The SBAR indicated, CNA was assisted resident transferring from bed to wheelchair, resident's legs were weak and resident was sliding on the floor. CNA got help and moved resident up to the wheelchair. CNA reported it to LN [licensed nurse], LN came to check, resident's index finger nail almost came off, as resident explained, It came back while I tried to push my hands against the ground and I was knee[l]ing on the ground. A small skin tear was on resident's left knee. Resident complained of pain on his knee at 6/10 [pain scale ranging from 0 to 10, with 0 indicating no pain and 10 indicating the worst pain imaginable], pain medication was given with good effects. The SBAR further indicated the nurse initiated treatment on Resident 98's fingernail and left knee. Review of Resident 98's Physician's Telephone Order, dated 5/25/21 indicated, Abrasion wound on left knee, [NAME][n]se with NS [normal saline], pat dry app[l]y antibiotic ointment daily and PRN [as needed] cover with band aid for 14 days then reassess. During an interview with the director of rehab (DOR) on 7/22/21 at 2:00 p.m., she explained that physical therapy (PT) had started working with Resident 98 on 5/5/21, and that his PT program was still ongoing. The DOR reviewed Resident 98's Physical Therapy Treatment Encounter Notes, dated 5/14/2020 to 5/24/21, and stated that around the time of Resident 98's fall on 5/24/21, he required moderate assistance (per DOR, this meant the therapist performs about 50% of the work) and a sliding board (flat slab of metal, plastic or wood used to transfer the resident from one surface to another) for transfers. The DOR explained that this type of transfer assistance was provided by PT staff, but should not have been provided by the CNAs because the PT staff had not trained the CNAs how to transfer Resident 98 with a sliding board. The DOR stated the CNA should have used a Hoyer lift (machine used to transfer the resident from one surface to another) and two person assistance to transfer Resident 98 from the bed to the wheelchair. During an interview with CNA S on 7/22/21 at 4:59 p.m., he confirmed he was the one transferring Resident 98 when the resident fell on [DATE]. CNA S stated he was helping Resident 98 transfer from the bed to the wheelchair using a sliding board. According to CNA S, Resident 98 slid to the wheelchair, was in the wrong position, and fell on the floor. CNA S confirmed he was the only staff member assisting Resident 98 during this transfer. He also confirmed he never received training from the therapy department on how to transfer Resident 98 using a sliding board. CNA S explained that nobody told him how many people were needed to transfer Resident 98. He also explained the facility did not have a system to communicate to the CNAs how much assistance the residents needed. During an observation on 7/26/21 at 10:32 a.m., Resident 98 was asked which finger was injured when he fell on [DATE]. Resident 98 showed his right index finger. During this observation, approximately two months after the fall, Resident 98's right index fingernail had still not completely grown back. 2. Review of Resident 98's SBAR, dated 3/24/21, indicated he was found sitting on the floor next to his bed on 3/24/21 at 6:00 a.m. According to the SBAR, Resident 98 stated he was sliding out of the bed . Review of Resident 98's fall risk care plan, dated 3/24/21 indicated, For actual fall on 3/24/21: Provide landing pad. During observations on 7/22/21 at 9:26 a.m., 10:03 a.m., 10:40 a.m. and 10:53 a.m., Resident 98 was lying in bed. There was no landing pad on the floor next to his bed. During an observation and concurrent interview with CNA T on 7/22/21 at 11:05 a.m., Resident 98 was lying in bed. There was still no landing pad on the floor next to his bed. CNA T stated she was not aware Resident 98 was supposed to have a landing pad. During an interview with the Minimum Data Set nurse (MDSN) on 7/23/21 at 9:19 a.m., she confirmed that while Resident 98 was in bed, the landing pad should have been on the floor next to the bed. Review of the facility's policy titled Fall Management Program, revised 3/13/21 indicated, The facility will implement a Fall Management Program that supports providing an environment free from fall hazards. 3. Review of Resident 98's SBAR, dated 3/24/21, indicated he was found sitting on the floor next to his bed at 6:00 a.m. Review of Resident 50's SBAR, dated 7/3/21, indicated her roommate yelled for help after noticing Resident 50 was on the floor. Review of Resident 59's SBAR, dated 11/23/21, indicated he was found on the floor at around 7:00 a.m. During an interview and concurrent record review with the MDSN on 7/22/21 at 8:47 a.m., she reviewed Resident 98's medical record and confirmed the facility did not complete a Morse Fall Risk Assessment after he fell on [DATE]. The MDSN confirmed the Morse Fall Risk Assessment should be done after each fall. During an interview and concurrent record review with the MDSN on 7/23/21 at 7:57 a.m., she reviewed the medical records for Residents 50 and 59. The MDSN confirmed the facility did not complete Morse Fall Risk Assessments after Residents 50 and 59 fell on [DATE] and 11/23/2020, respectively. Review of the facility's policy titled Fall Management Program, revised 3/13/21 indicated, A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed. 4. Review of Resident 117's medical record indicated she had diagnoses including a history of falling, [CONDITION(S)] accidents ([CONDITION(S)]/stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function), right hand, right shoulder, right hip contractures (hardening of muscles and other tissues causing rigidity to the joints) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). Review of Resident 117's MDS, dated [DATE], indicated she was cognitively intact. The MDS also indicated her balance was not steady when moving from seated to standing position and she needed staff assistance during surface-to-surface transfers, such as toileting. Review of Resident 117's SBAR, dated 6/11/21, indicated Resident 117 bumped and twisted her knee when transferring from the toilet to a wheelchair. During an interview on 7/19/21 at 9:30 a.m., Resident 117 stated CNA X, who helped her on 6/11/21, was not her regular CNA and CNA X did not know how to provide care for her. Resident 117 further stated she heard a popping sound from her knee during the transfer. During an interview and concurrent record review with the ADON on 7/22/21 at 9:50 a.m., the ADON reviewed Resident 117's paper and electronic medical records and stated she could not provide a care plan to address the incident that occurred on 6/11/21. She also stated the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) did not meet to discuss this incident. The ADON further stated the IDT should have met to discuss the root cause of the incident and should have reviewed Resident 117's care plan. During an interview and concurrent record review with the ADON on 7/22/21 at 10:00 a.m., the ADON reviewed Resident 117's paper and electronic medical records and stated her care plan indicated she needed extensive assistance in performing activities of daily living (ADLs) such as toileting and dressing. The ADON stated Resident 117's cognition was intact and she was able to communicate her needs with no episodes of refusing or resisting assistance with ADLs. During an interview with Resident 117 on 7/22/21 at 10:05 a.m., she stated she was sent to the hospital in June 21 due to unbearable pain 9 days after she was toileted without the assistance she needed. During an interview and concurrent record review with the MDSN on 7/23/21 at 4:13 p.m., she reviewed Resident 117's medical records and stated Resident 117 had a history of multiple falls on 4/21/2020, 7/12/2020, 9/18/2020 and 12/4/2020. The MDSN further stated Resident 117 was at high risk for falls and needed extensive assistance in performing ADLs, such as toileting and dressing, due to right hand, right shoulder and right hip contractures. During an interview with CNA X on 7/26/21 at 2:53 p.m., she stated she was not the regular CNA for Resident 117 and provided supervision and set up only (oversight and no weight bearing support) during toilet use. CNA X explained that when toileting Resident 117 on 6/11/21, she wheeled the resident to the bathroom in a wheelchair and locked the brakes. CNA X stated she stayed behind Resident 117's wheelchair and the resident used the grab bar and stood up on her own. According to CNA X, she only helped Resident 117 pull down her pants and incontinent briefs. CNA X stated she did not receive any instructions on how to toilet Resident 117. Review of Resident 117's SBAR, dated 6/20/21 indicated, Resident stated pain on right knee is unbearable. Stated 7/10 pain on pain scale. Review of Resident 117's physician order, dated 6/20/21, indicated send to acute hospital emergency department (ED) for further evaluation and treatment. Review of the acute hospital ED notes, dated 6/20/21 indicated, Patient .presents with R [right] leg pain. States occurred during transfer 1 week ago, gradually increasing pain which prompted her visit to the ED. In the ED was found to have periprosthetic distal R femoral fracture [right knee fracture associated with an orthopedic implant]. 5. Review of Resident 125's medical record indicated she had diagnoses including muscle weakness and major depressive disorder. Review of Resident 125's fall risk assessments dated 4/23/21, 7/4/21 and 7/8/21 indicated she was at high risk for falls. Review of Resident 125's MDS dated [DATE], 4/5/21 and 6/28/21, indicated her cognition (ability to remember, judge and use reason) was severely impaired and she required the assistance of one person for activities of daily living (ADLs) such as bed mobility, locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor), dressing, eating, toileting, transfer and personal hygiene. During an interview and concurrent record review with the ADON on 7/22/21 at 10:03 a.m., she reviewed Resident 125's fall care plan, both hard copy and computer, and confirmed that the initial fall care plan was not updated since it was initiated on 11/3/2020, and revised on 5/3/21. During an interview and concurrent record review with the MDSN on 7/22/21 at 2:59 p.m., she reviewed Resident 125's fall care plan and confirmed the initial fall care plan was not updated since it was initiated on 11/3/2020, revised on 5/3/21. She stated the initial fall care plan interventions were not person-centered because the care plan indicated staff would orient Resident 125 to new environment each time changes are made and provide education to the resident regarding special care needs. She further stated the care plan should have been updated every time Resident 125 fell , every three months when the MDS assessment was done, and as needed. 6. Review of Resident 33's face sheet (document that summarizes a resident's information) indicated she was admitted to the facility with a diagnosis including dementia with behavioral disturbance (mental disorder caused by brain disease or injury that affects behavior). Review of Resident 33's SBAR, dated 2/26/21, indicated Resident 33 was found sitting on the floor when Resident 33 slipped down from her wheelchair . Review of Resident 33's IDT meeting notes, dated 3/1/21, indicated new interventions for Resident 33's fall on 2/26/21 included to apply non-skid mat on the wheelchair. Review of Resident 33's care plan, dated 3/1/21, indicated actual fall on 2/26/21 and to apply dycem to minimize sliding from wheelchair. During an observation and concurrent interview with CNA L on 7/22/21 at 1:55 p.m., Resident 33 was in the wheelchair and sitting on a foam pad with a linen cover. CNA L was asked if Resident 33 had a dycem pad on. CNA L confirmed Resident 33 did not have a dycem pad on. 7. Review of Resident 74's face sheet (document that summarizes a resident's information) indicated he was admitted to the facility with a diagnosis including [CONDITION(S)] (loss of movement and sensation in lower part of body). Review of Resident 74's safe smoking assessments, dated 8/8/2020 and 1/24/21 respectively, indicated he was not a smoker. Review of Resident 74's MDS dated [DATE], indicated he had a BIMS score of 15, meaning he was cognitively intact. During an observation and concurrent interview with Resident 74 on 7/19/21 at 10:10 a.m., Resident 74 had a green lighter on his bedside table. Resident 74 stated he smoked once in a while. During an interview with CNA N on 7/20/21 at 7:43 a.m., CNA N stated Resident 74 was not a smoker. During an observation and concurrent interview with Resident 74 on 7/20/21 at 8:43 a.m., Resident 74 showed he had two cigarettes. Resident 74 stated the last time he smoked was yesterday and staff knew he smoked in the patio. Resident 74 stated he kept the lighter and cigarettes with him and smoked once a day. During an interview with licensed vocational nurse M (LVN M) on 7/21/21 at 1:59 p.m., LVN M stated she was not aware Resident 74 smoked. During an interview with the activity director (AD) on 7/21/21 at 2:12 p.m., she stated she had not seen Resident 74 smoking and he was not on the smokers list. According to the AD, her activity assistant informed her on 7/20/21 that Resident 74 expressed his desire to smoke again. The AD confirmed her department did not communicate to the licensed nurse upon learning about Resident 74's desire to smoke on 7/20/21. During an interview with the ADON on 7/22/21 at 2:18 p.m., the ADON acknowledged there should have been timely communication between the activity department and nursing to facilitate Resident 74's smoking in a safe manner. Review of the facility's policy titled Smoking by Residents, dated 1/2017 indicated, It is the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents.

Based on interview and record review, the facility failed to ensure pain control was monitored and reviewed to effectively manage one of three residents' pain, when: (1) The licensed nurse (LN) did not assess post-medication pain level for Resident 3 on 7/11, 7/14, 7/15, and 7/16/19; (2) The physician was not notified when Resident 3's pain was 8/10 (severe) for three consecutive days prior to hospitalization ; (3) The physician order [REDACTED]. to 7/9/19 to evaluate Resident 3's pain management. This failure resulted in Resident 3's increased pain during activities of daily living (ADLs, routine aspects of self-care). Resident 3 was transferred to the acute hospital for uncontrolled hip and back pain on 7/17/19. Findings: 1. Review of Resident 3's clinical record, indicated Resident 3 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 3's minimum data set (MDS, resident tool assessment) dated 6/17/19, indicated Resident 3 was cognitively intact and required extensive assistance with one-person physical assist during ADLs. During an interview with Resident 3 on 8/15/19 at 6:12 p.m., Resident 3 stated he screamed in pain because his back hurt so much he cannot move much with his bad back. Resident 3 stated there were times staff had not given his pain medication. Resident 3 had to yell to ask for his pain medication and a lot of times staff gave him his pain medication six hours late. In a concurrent interview with certified nursing assistants C and D (CNAs C and D) on 8/20/19 at 11:00 a.m., they stated Resident 3 expressed a lot of pain while assisting him during bathing, turning and repositioning. CNA D stated every time they had approached Resident 3, he was always yelling out in pain even if he was not touched. Review of Resident 3's Medication Administration Record [REDACTED]. However, the times [MEDICATION NAME] was given to Resident 3 were not specified. Review of Resident 3's pain assessment flow sheet dated 7/2019, indicated Resident 3 was not assessed for pain level after licensed nurse gave his [MEDICATION NAME] on 7/11, 7/14, 7/15, and 7/16/19, three days prior to his hospitalization . During an interview with licensed vocational nurse [NAME] (LVN E) on 8/20/19 at 1:00 p.m., LVN [NAME] confirmed there was no pain level assessment done after [MEDICATION NAME] was given to Resident 3; when the LNs should have reassessed to determine the effectiveness of the pain medication. Review of Resident 3's pain care plan dated 6/10/19, indicated Assess pain medication and treatments for effectiveness. Review of the facility's undated policy and procedure,Pain management, indicated B. Nurses will complete the Pain Flow Sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen. 2. Review of Resident 3's Medication Administration Record [REDACTED]. Review of Resident 3's progress notes did not show the physician was notified on those days to report pain had not been relieved with current pain medication. During an interview with LVN [NAME] on 8/20/19 at 1:10 p.m., LVN [NAME] stated the pain scale of 8/10 every shift showed Resident 3 was in severe pain and his current pain medication was ineffective. LVN [NAME] acknowledged there was no documentation in the clinical record that physician was notified which the LNs should have done. Review of the facility's undated policy and procedure, Pain management, indicated D. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician and IDT for a review of medications. 3. Review of Resident 3's physician order [REDACTED]. On 6/15/19, [MEDICATION NAME] 5/325 mg 1 tablet po Q 4 hours PRN (as needed) for moderate pain (Pain 4-7/10) was discontinued. Review of Resident 3's pain assessment flow sheet dated 7/2019, indicated [MEDICATION NAME] 5/325 mg was given for severe pain as needed on 6/27/19 at 12:30 a.m., 7:10 a.m., and 12:30 p.m., and on 6/28/19 at 1:30 a.m. and 9:40 a.m. instead of [MEDICATION NAME] 10/325 mg. During an interview with LVN [NAME] on 8/20/19 at 1:00 p.m., LVN [NAME] confirmed that Resident 3 received the wrong dose of medication and stated he should have received [MEDICATION NAME] 10/325 mg on 6/27 and 6/28/19 because [MEDICATION NAME] 5/325 mg was already discontinued on 6/15/19. Review of the facility's undated policy and procedure, Pain management, indicated [NAME] The licensed Nurse will administer pain medication as ordered . 4. Review of Resident 3's weekly summaries for the period of 6/10/19 to 7/17/19, there were no weekly summaries completed for the period of 6/17/19 to 7/9/19 to evaluate resident's pain management. During an interview with LVN [NAME] on 8/20/19 at 1:15 p.m., LVN [NAME] acknowledged the lack of weekly summaries for the period of 6/17/19 to 7/9/19, and stated they were missed. Review of Resident 3's emergency department (ED) notes dated 7/17/19, indicated patient presents with a chief complaint of right hip pain. States that his pain started a week ago and occurs only when he attempts to sit up or walk about. States that he came in today because the pain was unbearable while working with physical therapist this morning .He has been taking [MEDICATION NAME] for this pain and it has relieved his pain from 10/10 to 8/10 . Review of the facility's undated policy and procedure, Pain management, indicated B. The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary .

Based on observation, interview and record review, the facility failed to prevent the development, worsening and recurrence of a pressure ulcer (localized damage to the skin and/or underlying tissue as a result of long-term pressure) for one of eight sampled residents (Resident 111) when: 1. Nurses did not provide [MEDICATION NAME] (preventive) skin treatments as ordered; 2. Staff did not provide snacks as ordered; 3. Nurses did not provide pressure ulcer treatments as ordered; 4. Staff did not turn and reposition the resident every two hours; and 5. Staff put diapers on the resident when it was not necessary. These failures resulted in the development, worsening, and recurrence of Resident 111's right buttock Stage 3 (full-thickness loss of skin involving damage to tissues under the skin; fat is visible) pressure ulcer. Findings: During an interview with the wound treatment nurse (WTN) on 4/6/19 at 11:06 a.m., he stated Resident 111 had a Stage 3 pressure ulcer on her right ischium (right buttock). The WTN stated Resident 111's pressure ulcer was in-house acquired (developed in the facility). The WTN explained Resident 111's pressure ulcer closed at one point, but opened back up again. During a wound treatment observation and concurrent interview with the WTN on 4/9/19 at 11:17 a.m., Resident 111 had an open area on the right buttock. The WTN measured the open area and stated it had a size of 1 centimeter (cm, unit of measurement) by 0.6 cm by 0.1 cm. Review of Resident 111's clinical record indicated she was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Review of Resident 111's Minimum Data Set (MDS, an assessment tool), dated 5/16/18, indicated she did not have pressure ulcers, but she was at risk for developing them. The MDS also indicated Resident 111 required extensive assistance (staff provide weight-bearing support) with bed mobility (moving in bed) and transfers. The MDS further indicated Resident 111 was always incontinent (has no voluntary control) with bowel movements. Review of Resident 111's Skin care plan, dated 7/1/13 and revised on 8/15/18, indicated she was at risk for skin breakdown and pressure ulcer formation due to impaired mobility, incontinence, decreased sensation of the skin, and thin and fragile skin. Review of Resident 111's record indicated she had a physician's orders [REDACTED]. Review of Resident 111's Medication Administration Record [REDACTED]. Review of Resident 111's activities of daily living (ADL) flowsheets for the same three months indicated the documentation for nourishment was blank except for 6/2/18 and 6/7/18. Review of Resident 111's record indicated she had a physician's orders [REDACTED]. Review of Resident 111's treatment administration record (TAR) indicated from 4/1/18 to 6/10/18, this treatment was not provided 72 times. Review of Resident 111's record indicated she also had a physician's orders [REDACTED]. Review of Resident 111's treatment administration record (TAR) indicated from 4/1/18 to 6/10/18, this treatment was not provided 62 times. Review of Resident 111's Weekly Skin Problem Progress Report indicated on 6/11/18, she was noted to have a 4 cm by 5 cm skin tear on the right buttock. Resident 111 had a physician's orders [REDACTED]. Further review of the Weekly Skin Problem Progress Report, indicated Resident 111's right buttock skin tear gradually decreased in size and had a measurement of 1.2 cm by 1.2 cm by 0.1 cm on 8/22/18. However, on 8/29/18, the Weekly Skin Problem Progress Report, indicated Resident 111's right buttock skin tear changed to a pressure ulcer. The documentation did not specify the stage of the pressure ulcer and did not specify measurements. Review of Resident 111's TAR indicated on 8/30/18, the treatment for [REDACTED]. Further review of the TAR, indicated this treatment was not provided from 9/1/18 to 10/3/18 (33 days). Review of the wound doctor's notes, dated 9/5/18, indicated the wound on Resident 111's right buttock declined and had a measurement of 3 cm by 5 cm by 0.5 cm. The wound doctor's notes also indicated the wound had 55% granulation (healing surface of a wound), 30% slough (dead tissue separating from living tissue), and 15% eschar (thick crust or scab). The wound doctor's note had an order indicating Resident 111's right buttock wound was to be cleansed with NS, apply a nickel thick layer of santyl, cover with moist gauze and dry dressing every day and as needed. The note also indicated the treatment, Zinc Barrier Cream 20% or greater - Cleanse area. Pat dry well. Apply Every Shift and PRN. Further review of the TAR, indicated for the entire month of 9/2018, zinc oxide was applied to Resident 111's right buttock once a day and not every shift as indicated in the wound doctor's order. Review of the wound doctor's notes, dated 9/12/18, indicated Resident 111's right buttock wound declined again. The notes indicated Resident 111's right buttock wound was a Stage 3 pressure injury and had a measurement of 7 cm by 3.5 cm by 0.5 cm. The notes also indicated the wound had 40% granulation, 50% slough, and 10% eschar. Review of Resident 111's Weekly Pressure Injury/Ulcer Progress Report, indicated on 3/6/19, her right buttock pressure ulcer resolved. Review of Resident 111's situation, background, assessment, recommendation (SBAR, a communication tool) communication form, dated 3/13/19, indicated her right buttock pressure ulcer reopened. Review of Resident 111's ADL flowsheets indicated from 5/1/18 to 1/31/19, the documentation for bed mobility was blank 93 times which did not include the dates Resident 111 was out of the facility. Further review of the ADL flowsheets, indicated there was no documentation indicating how often the CNAs turned Resident 111 in bed. During an interview with certified nursing assistant S (CNA S) on 4/11/19 at 7:17 a.m., she stated Resident 111 required total care and was not able to turn and reposition herself in bed. CNA S stated Resident 111 needed to be turned every 2 hours, but confirmed there was no documentation indicating how often the resident was actually turned. CNA S stated Resident 111 did not have normal urination and bowel movements and everything is from the bags. CNA S stated Resident 111 had a bag on her right abdomen to collect urine and a bag on her left abdomen to collect stool, but the CNAs continued to put diapers on Resident 111 when they got her out of bed. Review of Resident 111's clinical record indicated as of 1/2/19, she had a [MEDICAL CONDITION] (surgical opening in the abdomen for the passage of stool) and a [MEDICATION NAME] (surgical opening in the abdomen for the passage of urine). Review of Resident 111's wound doctor's notes from 2/13/19 to 3/6/19 indicated, Related to Wound Status - Patient Unable to Comply .diaper tight Review of the wound doctor's note, dated 3/13/19, indicated Resident 111's right buttock Stage 3 pressure ulcer reopened and had a measurement of 0.6 cm by 0.2 cm by 0.1 cm. The wound doctor's note, dated 3/27/18, indicated Resident 111's right buttock Stage 3 pressure ulcer worsened again and had the measurements of 1 cm by 0.5 cm x 0.1 cm. During an interview and concurrent record review with the WTN on 4/11/19, he acknowledged Resident 111's record indicated she did not receive snacks as ordered for the months of 5/2018, 6/2018 and 7/2018 and stated nutritional status could affect skin integrity. The WTN confirmed from 4/1/18 to 6/10/18, Resident 111's TAR indicated the treatments of applying periguard to both gluteal folds and applying zinc oxide to the right buttock were not provided as ordered. He stated these treatments were [MEDICATION NAME] and if they were not done, it could contribute to wound development. The WTN stated if wound treatments were not documented, it meant they didn't happen. The WTN stated about 50% of the time when making rounds, he had seen Resident 111 in the same position for more than two hours. He stated Resident 111 should be turned no less than every two hours and not doing so could increase her risk for pressure ulcers. The WTN also stated, although he had instructed the CNAs not to do so, they continued to put diapers on Resident 111. He stated there was no need for Resident 111 to wear diapers because she had a [MEDICAL CONDITION] and [MEDICATION NAME]. Further, the WTN stated diapers were an additional source of friction and could cause worsening in skin issues. The facility's policy, Pressure Injury and Skin Integrity Treatment, revised 8/12/16, indicated pressure injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The policy further indicated the tolerance of soft tissue for pressure may be affected by nutrition and the residents' diet should contain adequate calories, nutrients and fluids to support wound healing. The policy also indicated, Treatments to pressure injuries and other skin integrity problems will be provided as ordered by the physician. Treatments administered will be documented on the Treatment Administration Record.

Based on interview and record review, the facility failed to prevent accidents for two of ten sampled residents (Residents 61 and 94) when staff did not provide supervision to prevent falls and did not develop and/or implement resident-centered interventions to prevent future falls. These failures resulted in Resident 61's fall with left collarbone fracture (break) and Resident 94's multiple falls with injury. Findings: 1. Review of Resident 61's clinical record indicated he was admitted on [DATE], and had the [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and history of falling. Review of Resident 61's Minimum Data Set (MDS, an assessment tool), dated 3/5/18, indicated he had a brief interview for mental status (BIMS) score of 10 (a score of 8 to 12 indicates moderate cognitive impairment) and required extensive assistance (staff provide weight-bearing support) for transfers and toileting. The MDS also indicated Resident 61 was not steady and was only able to stabilize with staff assistance for surface to surface transfers. Review of Resident 61's fall risk evaluations from 2/23/18 to 2/21/19 indicated scores ranging from 14 to 23 (a score of 10 or higher represents high risk). Review of Resident 61's fall risk care plan, dated 6/14/15, indicated he was at risk for falls due to balance problems, use of [MEDICAL CONDITION] medications (medications capable of affecting the mind, emotions and behavior), unsteady gait (walking) and poor safety awareness. Some interventions on the care plan included keeping the resident's call light within reach, reminding the resident to use the call light, and encouraging the resident to ask for assistance with his needs. Review of Resident 61's situation, background, assessment, recommendation (SBAR, a communication tool) communication form, dated 2/23/18, indicated he had an unwitnessed fall and was noted with a two by five centimeter (cm, unit of measurement) bruise on the left side of his abdomen. Review of Resident 61's interdisciplinary team (IDT, staff from different disciplines who work to together to plan and provide care) notes dated 2/26/18 indicated on 2/23/18, Resident 61 had an unwitnessed fall at 10:00 a.m. The IDT notes indicated Resident 61 transferred himself unassisted from wheelchair to bed and slid on the floor. The IDT notes and the 2/23/18 post-fall short term care plan indicated the interventions of reminding Resident 61 not to transfer unassisted, educating him regarding safety awareness, reminding him to use his call light when needing help, and checking the resident frequently for his needs. Review of Resident 61's Medication Administration Record [REDACTED]. According to the MAR, from 9/1/18 to 1/17/19, Resident 61 got up unassisted over 400 times. There were no new fall interventions added to Resident 61's care plan from the time he fell on [DATE] until he fell again on 1/17/19. Review of Resident 61's MDS, dated [DATE], indicated he had a BIMS score of 6 (a score of 0 to 7 indicates severe cognitive impairment) and required extensive assistance for transfers, walking, and toileting. The MDS also indicated Resident 61 was not steady and was only able to stabilize with staff assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfers. Review of Resident 61's SBAR communication form, dated 1/17/19, indicated he was found in his bathroom at 6:30 p.m. yelling for help. He was lying on his left side next to the toilet bowl. According to the SBAR communication form, Resident 61's left hand was swollen, he complained of pain, and he was sent to the emergency room (ER) for further evaluation and treatment. Review of Resident 61's IDT notes dated 1/18/19 indicated on 1/17/19 at 6:30 p.m., Resident 61 called for help and was found in his bathroom lying on his left side next to the toilet bowl. His left hand was swollen and he complained of 9/10 pain. The IDT notes further indicated, Resident was out of balance when he stood up (after) using the restroom. He mostly forget to call when he wants to go to the restroom. At 7pm, he was transferred to the ER for further eval (evaluation) & treat (treatment). Review of Resident 61's post-fall short term care plan, dated 1/17/19, indicated the last time the certified nurse assistant (CNA) saw him prior to the fall was at 5:00 p.m. (one and a half hours before the fall). The care plan indicated the last time the nurse saw Resident 61 prior to the fall was at 5:30 p.m. (one hour before the fall). Review of an After Visit Summary from the acute hospital, dated 1/17/19, indicated Resident 61 had a closed (no puncture of the skin) nondisplaced (bone maintains normal alignment) fracture of acromial end of left clavicle (broken left collarbone). During an interview with licensed vocational nurse H (LVN H) on 4/9/19 at 10:08 a.m., he stated Resident 61 frequently tried to get up and go to the bathroom on his own. When asked what it meant to check the resident frequently for his needs, LVN H stated staff should visualize Resident 61 every 15 to 30 minutes. LVN H reviewed Resident 61's 1/17/19 post-fall short term care plan and acknowledged the documentation indicated the CNA last saw the resident an hour and a half before the fall and the nurse last saw him an hour before the fall. During an interview with the assistant director of nursing (ADON) on 4/9/19 at 10:22 a.m., she confirmed Resident 61 would try to get up unassisted to use the bathroom. The ADON stated when staff reminded Resident 61 not to get up by himself or to use his call light, he would not remember to do so. The ADON stated providing reminders to Resident 61 was not an appropriate intervention because he would not remember. During a follow-up interview with the ADON on 4/9/19 at 12:42 p.m., she reviewed Resident 61's record and confirmed the only interventions added to the care plan after he fell on [DATE] were to remind the resident not to transfer unassisted, remind him to use his call light when needing help, and frequently check him for his needs. The ADON confirmed the facility did not add any other fall interventions until the next time he fell on [DATE]. She acknowledged other interventions needed to be in place. The ADON stated the intervention of frequently checking Resident 61 for his needs was too vague and should have specified how often staff was supposed to check on him. The ADON added that all residents should be checked frequently for their needs. The ADON acknowledged Resident 61's care plan interventions were not resident-centered and were not tailored to his needs. During an interview with LVN O on 4/10/19 at 6:49 a.m., he confirmed he was Resident 61's nurse when he fell on [DATE]. LVN O explained he heard Resident 61 yelling for help and saw him in the bathroom lying on his side and his left hand was swollen. LVN O stated Resident 61 was sent to the hospital and he had a fracture. LVN O stated Resident 61 had a long history of taking himself to the bathroom without assistance. He explained even though staff kept reminding Resident 61 to use his call light to ask for assistance, he did not remember to do so. When asked what it meant to check the resident frequently for his needs, LVN O stated staff should check on Resident 61 every 15 to 30 minutes. 2. Review of Resident 94's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED].(pain [MEDICATION NAME] more than 12 weeks) and history of falling. Review of Resident 94's MDS, dated [DATE] and 7/9/18, indicated he required extensive assistance with transfers and toileting. The MDS also indicated Resident 94 was not steady and only able to stabilize with staff assistance for surface-to-surface transfers. Review of Resident 94's fall risk evaluations from 2/20/18 to 3/22/19 indicated scores ranging from 12 to 24 (a score of 10 or above represents high risk). Review of Resident 94's fall risk care plan, dated 10/3/17, indicated he was at risk for falls due to limited mobility (ability to move freely and easily), poor balance, lack of awareness, cognitive deficit (impaired mental processes), decreased endurance, unsteady gait and history of falls. Review of Resident 94's non-compliant care plans, dated 2/12/18 and 2/26/18, indicated he would not use his call light even after staff ask him to do so, would stand up unassisted and not call for help, would transfer independently despite explanation of risks, and would stand up to use the urinal (a bottle to urinate into) without assistance. Review of Resident 94's IDT notes dated 3/19/18 indicated on 3/16/18 at 2:00 a.m., Resident 94 was found on the floor face down in front of the bathroom. He was noted with a skin tear on his left eyebrow. The IDT notes indicated the intervention of bowel and bladder tracking (monitoring urination and bowel movement patterns) from 12:00 a.m. to 4:00 a.m. for three days then re-evaluate. There was a follow-up entry on the IDT notes written on 3/26/18 that indicated to continue bowel and bladder tracking. This was not a new intervention, as bowel and bladder tracking every hour was already on Resident 94's fall risk care plan as of 3/12/19. Review of Resident 94's Bowel and Bladder Tracking Form, indicated the facility completed bowel and bladder tracking from 3/19/18 to 3/21/18, but there was no documentation that the tracking was continued as specified on the IDT notes. Review of Resident 94's IDT notes dated 4/16/18 indicated on 4/13/18 at 3:10 p.m., Resident 94 was found lying in the bathroom and had a laceration (a deep cut) and skin tear on his right upper eyelid. The IDT notes also indicated Resident 94 continued to be non-compliant with using his call light and continued to get up without assistance despite reminders. The IDT notes and the 4/13/18 post-fall short term care plan indicated the interventions of reminding Resident 94 to use his call light when needing assistance to the bathroom, reminding him he had a bedside commode (a movable toilet), offering assistance to the commode or bathroom, and checking him frequently for his needs. These were not new interventions. During an interview with the ADON on 4/10/19 at 12:33 p.m., she reviewed Resident 94's record and confirmed there were no new interventions added after he fell on [DATE]. The ADON stated providing reminders to Resident 94 was not an appropriate intervention. She also stated the intervention of frequently checking the resident was not specific and should be done for all residents. The ADON confirmed there was no documentation to show how often staff checked on Resident 94. Review of Resident 94's IDT notes dated 5/15/18 indicated on 5/14/18 at 1:40 p.m., Resident 94 was found on the floor near his bed due to trying to get up unassisted and walk to the bathroom. He was noted with a right eyebrow laceration with approximate size of 2.5 centimeters (cm, unit of measurement). Resident 94 was sent to the acute hospital for further evaluation and treatment. The IDT notes and the 5/14/18 post-fall short term care plan indicated the interventions of reminding Resident 94 to use his call light when needing to use the toilet, explaining the risks and benefits of being non-compliant with getting up unassisted, and offering toileting as needed. These were not new interventions. During an interview with the ADON on 4/10/19 at 12:33 p.m., she confirmed there were no new interventions added after he fell on [DATE]. The ADON stated when a resident falls, a new intervention should be added and the intervention should be resident-centered and obtainable. Review of an After Visit Summary from the acute hospital, dated 5/14/18, indicated Resident 94 was diagnosed with [REDACTED]. The summary further indicated Resident 94 required stitches. Review of Resident 94's IDT notes dated 5/21/18 indicated on 5/20/18 at 9:30 a.m., Resident 94 was found on the floor near his bathroom after he stood up without assistance. Resident 94 was noted with right nostril bleeding. The IDT notes and the 5/20/18 post-fall short term care plan indicated the interventions of reminding Resident 94 not to get up unassisted and to use his call light, reminding him about the risks and benefits of getting up unassisted, checking him frequently for his needs, and getting him up on the wheelchair daily to attend activities. Review of Resident 94's SBAR communication form, dated 9/16/18, indicated he refused to be assisted back to bed and when the CNA turned away to empty the urinal in the toilet, the resident suddenly lost his balance and hit footboard of bed before landing on the floor. Resident 94's IDT notes dated 9/18/18 indicated on 9/16/18, the resident lost his balance as the CNA disposed urine in the toilet. The IDT note indicated Resident 94 hit his head on the footboard when he lost his balance trying to go back to bed, had a skin tear on the right eyebrow that needed stitches, and was transferred to the acute hospital. Resident 94's 9/16/18 post-fall short term care plan indicated the intervention of staying beside the resident until he is completely on the bed. During an interview with the ADON on 4/10/19 at 12:33 p.m., she stated it was not safe to leave Resident 94 unattended while he was standing. She stated the CNA should have assisted the resident back to bed, assisted him to sit on a chair, or asked another staff member to watch the resident before going to empty the urine in the toilet. The ADON stated the CNAs should not take their eyes off Resident 94 while he is standing. Review of an After Visit Summary from the acute hospital, dated 9/16/18, indicated Resident 94 was diagnosed with [REDACTED]. The after visit summary further indicated Resident 94 required stitches. Review of the facility's policy, Fall Management Program, revised 11/7/16, indicated The IDT will initiate, review, and update resident fall risks and Plan of Care at the following intervals: admission, quarterly, annually, upon significant change of condition identification, and post fall as needed. The policy indicated following each resident fall, the licensed nurse will update, initiate or revise the plan of care. The policy further indicated that a resident who sustains multiple falls may require more frequent observation of activities and whereabouts. Review of the facility's policy, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.

Based on interview and record review, the facility failed to protect three of three residents (Residents 1, 2, and 3) from unwanted touching of their breasts and private area by another resident (Resident 4). This failure caused Resident 1 to feel dirty and violated, Resident 2 cried when interviewed about the incident, and Resident 3 had anxiety over the incident. Findings: Review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS, an assessment tool), dated 12/8/18, indicated she had a brief interview of mental status (BIMS) score of 15 which meant she was cognitively intact (alert and oriented x 3). Review of Resident 1's Progress Notes dated 12/22/18, indicated she reported she was out on the smoking patio on 12/17/18 when Resident 4 grabbed her breast and put his hand down her pants. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare providers who work together toward the same goal to provide the best care or outcome for a patient) Note dated 12/24/18, indicated she reported the incident on 12/22/18 because Resident 4 kept asking her out and she had been trying to hide from him. The IDT note also indicated she did not report the incident at the time it occurred because she was ashamed and embarrassed. The IDT note also indicated she reported she was having trouble sleeping because of the incident. Review of Resident 1's Nurse's Notes dated 12/22/18 indicated she was assessed for any injuries, her treating physician was notified, and she was sent to the emergency room for further evaluation and came back with no new orders. Resident 1's Situation, Background, Assessment, Recommendation (SBAR, notes to help nurses with effective communication by verbalizing problems about patients to the doctors) Note, dated 12/22/18, indicated the California Department of Public Health (CDPH), the ombudsman, and the police were notified on 12/22/18. The police came to the facility, arrested Resident 4, and took him to jail 12/22/18. Review of Resident 1's Psychiatric Evaluation dated 12/27/18, indicated she was having difficulty sleeping because she kept seeing Resident 4's face and she felt dirty and violated. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS, dated [DATE], indicated she had a BIMs score of 15 which meant she was cognitively intact (alert and oriented x 3). Resident 2's Progress Notes, dated 12/2/18, indicated she reported Resident 4 grabbed her breast and put his hand down her pants shortly after she was admitted in 2/2018. Review of Resident 2's IDT Notes, dated 12/24/18, indicated she reported Resident 4 touched her breast shortly after her admission in 2/2018. Resident 2 was assessed for injuries, her treating physician was notified, but she refused to go to the emergency room for further evaluation. Review of Resident 2's SBAR Note, dated 12/24/18, indicated Resident 2 was on monitoring for emotional distress. Reported that 1 resident tried to put his arm inside her pants and touched her breast. During an interview on 12/24/18 at 11:30 a.m., Resident 2 cried and stated she was out on the smoking patio having a cigarette shortly after she was admitted in 2/2018 when Resident 4 grabbed her breast and attempted to put his hand down her pants. Review of Resident 3's admission record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS dated [DATE], indicated she had a BIMS score of 15 which meant she was cognitively intact (alert and oriented x 3). Review of Resident 3's Progress Notes, dated 12/22/18, indicated the police spoke to her and she reported Resident 4 grabbed her breast about one month ago. The progress notes also indicated she told Resident 4 to stop and there have been no further incidents and she was assessed for any injuries. Review of Resident 3's SBAR, dated 12/22/18, indicated Resident 4 grabbed her breast about a month ago. Review of Resident 3's Psychiatric Evaluation, dated 12/27/18 indicated she claimed she was sexually harassed and her anxiety was triggered recently d/t the incident that the same said male resident sexually harassed another female resident. During an interview on 12/24/18 at 11:15 a.m., Resident 3 stated on or about 11/1/18, she was out on the smoking patio having a cigarette when Resident 4 grabbed her breast. She stated she reported the incident to a nurse. Review of Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His MDS, dated [DATE], indicated he had a BIMS score of 15 which meant he was cognitively intact (alert and oriented x3). Review of Resident 4's Care Plan, dated 7/3/17, indicated he was accused of inappropriately touching a female resident. His Care Plan, dated 7/25/17, indicated he was accused of inappropriately touching a female resident. Review of Resident 4's IDT Note, dated 7/3/17, indicated he was accused of touching the breasts of a female resident. He denied the allegation and was advised to stay away from the resident. On 7/11/17, the police spoke to him about the incident. He denied touching the other resident's breasts. On 7/12/17, the female resident asked him to apologize for touching her breasts. He refused and denied touching her. During a telephone interview on 2/25/19 at 10 a.m. with the detective who was handling the case of Resident 4, she stated Resident 4 is still in jail and will be arraigned on 3 separate counts of sexual abuse and his plea hearing is set on 3/22/19.

Based on interview and record review, the facility failed to implement the occupational therapy's (OT's) discharge summary recommendation to provide contact guard assist (CGA, having one or two hands on the resident's body)/minimum assist (Min A, staff performs about 75 percent of the work and the resident performs 25 percent of the work) with toileting for one of three sampled residents (Resident 1) when Resident 1 had her fourth fall on 10/7/18 while she was trying to use the bedside commode by herself, and she fell to the floor. This resulted in Resident 1 sustaining an acute subchondral [MEDICAL CONDITION] femoral head (broken or dislocated left hip) and two skin abrasions (wounds caused by rubbing or scraping) and swelling on the right side of her back. Findings: Review of Resident 1's face sheet indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's MDS, dated [DATE], indicated her brief interview for mental status (BIMS) score was 15 (a score of 13-15 indicates the resident is cognitively intact). Further review of the MDS, dated [DATE], in section G (MDS section that assesses the need for assistance for activities of daily living and altered gait (manner of walking)), indicated Resident 1 was unable to walk. Section G also indicated Resident 1 was not steady when moving from a seated to a standing position and during surface to surface transfers. Review of Resident 1's OT's discharge summary note, dated 2/16/18, indicated, CGA/Min A for toilet transfer, Min A for clothing mgmt. (management). Review of Resident 1's fall assessments dated 1/17/18, 2/24/18, 2/26/18, 6/18/18, and 10/7/18 indicated she was a high risk for falls. Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a communication tool) dated 2/24/18 at 4:00 p.m., indicated Resident 1 had a claimed fall on 2/24/18 after she used the bedside commode in her room. Review of Resident 1's SBAR dated 2/26/18 at 2:50 a.m., indicated Resident 1 tried to go to the bathroom unassisted and was found lying on the floor. Review of Resident 1's SBAR dated 6/18/18 at 11:45 a.m., indicated Resident 1 fell on [DATE] after she used the bedside commode in her room. Review of Resident 1's SBAR dated 10/7/18 at 5:30 a.m., indicated, Resident 1 tried to use the bedside commode unassisted, fell and was found lying on the floor at her left side. Resident 1 was transferred to an acute care hospital. During an interview with Resident 1 on 11/16/18 at 2:00 p.m., she stated it took very long, sometimes more than 40 minutes for a staff member to come and answer her call light. Resident 1 further stated that staff members are not checking on her regularly if she needed to use the bedside commode. The reason why she kept on falling was, because she needed to get up by herself because no staff member was available to assist her to use the commode in spite of using the call light and calling loudly to the staff for help. During a telephone interview with certified nursing assistant A (CNA A) on 11/16/18 at 2:48 p.m., CNA A stated he was assigned to Resident 1 on the day of the incident and he was aware that Resident 1 could not walk by herself and needed limited assistance with one person assist when using the bedside commode. During an interview with licensed vocational nurse B (LVN B) on 11/16/18 at 2:10 p.m., LVN B stated she was Resident 1's regular nurse and she was aware that Resident 1 needed a one-person standby assist when using the bedside commode due to her high risk for fall and Resident 1 was using oxygen continuously. During a telephone interview with LVN C on 12/6/18 at 9:03 a.m., she stated she was assigned to Resident 1 on the day of the incident and she was aware of Resident 1's high risk for fall. LVN C further stated Resident 1 needed limited one-person assistance when using the bedside commode due to poor safety awareness and episodes of bladder incontinency. During an interview and concurrent MDS record review with the minimum data set coordinator (MDSC) on 10/26/18 at 9:22 a.m., the MDSC stated Resident 1 needed extensive assistance with toileting and transfers as per assessment on 5/31/18, 8/13/18, and 10/20/18. During an interview and concurrent record review with the rehab therapy director (RTD) on 10/26/18 at 10:41 a.m., she stated Resident 1 had a fall on 10/7/18 and needed extensive assistance with toileting and transfers all the time. The RTD further stated before the fall on 10/7/18, Resident 1 used a bedside commode and needed supervision with one person assist at her side for safety reason as indicated in the OT discharge summary note dated 2/16/18. Review of Resident 1's acute hospital progress note, dated 10/7/18, indicated Resident 1 was a [AGE] year-old who had avascular necrosis (interruption of blood supply to the bone) and an acute subchondral [MEDICAL CONDITION] femoral head due to a mechanical fall and was scheduled for surgery on 10/7/18. However, after a discussion between the orthopedic doctor and Resident 1's family member, the surgery was rescheduled for 11/5/18.

Based on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 9) received appropriate care to prevent a pressure ulcer (skin injury caused by unrelieved pressure that results in damage to the underlying tissues). The facility failed to update Resident 9's Braden scale (a tool to predict pressure ulcer risk) and failed to implement a different kind of intervention to prevent a pressure ulcer. This failure resulted in Resident 9's left inner heel with stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). Findings: A review of Resident 9's clinical record indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 9's Minimum Data Set (MDS, an assessment tool) dated 10/9/16, indicated the resident had impaired cognition, required assistance with bed mobility, transfer, hygiene and bathing. The MDS also noted he was at risk for the development of a pressure ulcer. Resident 9's MDS for 12/2016 was not completed. During an interview with the MDS coordinator (MDSC) on 1/17/17 at 1:40 p.m., she stated Resident 9's quarterly assessment was scheduled on 12/15/16 and it was not completed A review of Resident 9's admission assessment dated [DATE] indicated under skin integrity, he had skin discoloration on the left hand and left forearm, multiple skin rashes on the right and left forearms, and skin redness on the resident's buttocks. Resident 9 had no pressure ulcer on the left inner heel upon admission. A review of Resident 9's Braden scale dated 9/11/16, indicated he was at mild risk for developing a pressure ulcer. Resident 9's Braden Scale for 12/2016 was not updated. A review of Resident 9's skin care plan dated 9/11/16, indicated the resident was at risk for a pressure ulcer related to impaired mobility, cognitive impairment, and fragile skin. The interventions to prevent pressure ulcer included repositioning with care rounds and referral to the registered dietitian (RD) if needed. A review of Resident 9's weekly pressure ulcer progress report dated 1/9/17, indicated he had developed a blister (it was raised on the skin which contains clear liquid and that was caused by injury or rubbing against something) on his left inner heel, which measured approximately three centimetera (cm, unit in measurement) length and three cm in length. The interventions for preventing pressure ulcer were floating heel (the heels were off the bed) and heel protector. During an observations on 1/17/17 at 3 p.m., 1/18/17 at 3:35 p.m., and 1/19/17 at 8:00 a.m., Resident 9 was lying on his back and his left inner heel rested on his bed with no heel protector. During an interview with licensed vocational nurse A (LVN A) on 1/18/17, at 3:30 p.m., she stated she was the assigned charge nurse when Resident 9 developed a blister on his left heel with stage II pressure ulcer on 1/9/17. LVN A stated Resident 9 was always in bed and got his blister from his bed. During an observation and interview with licensed vocational nurse B (LVN B) on 1/18/17, at 3:35 p.m., she confirmed Resident 9 was lying on his back. The left inner heel pressure ulcer rested on the bed with yellowish color around the dressing, and Resident 9's bed linen had yellow circle color drainage from his left inner heel pressure ulcer. She stated Resident 9 should have been repositioned and the left inner heel stage II pressure ulcer should have been floating when he was in bed. During an interview and record review with the assistant director of nursing (ADON) on 1/18/17, at 3:45 p.m., she stated she was not aware of Resident 9's left inner heel pressure ulcer. She stated Resident 9 developed his left inner heel stage II pressure ulcer from his bed and nursing staff should have repositioned Resident 9 when he was in bed. The ADON confirmed Resident 9 was a high risk for developing a pressure ulcer. He was immobile, and it was an avoidable pressure ulcer. She also stated there was no interdisciplinary (IDT, team members from different departments involved in a resident's care) notes, the Braden scale was not updated, and there was no RD referral. During wound care observation and interview with treatment nurse I (TN I) on 1/18/17, at 8:50 a.m., Resident 9's left inner heel pressure ulcer was observed with slough and dry black blood in the wound bed area. TN I stated Resident 9's left inner heel pressure ulcer had increased in size, and measured approximately 5.5 cm in length and 4.8 cm in width. TN I confirmed Resident 9 had no heel protector and he should have it. A review of the facility's policy titled, Pressure Injury Prevention dated 8/12/16, indicated to provide interventions for residents identified as high risk for developing a pressure ulcer. A risk assessment (Braden Scale) for a developing pressure ulcer will be completed in a timely manner. The nursing staff will implement interventions identified in the care plan based on individual risk factors. Nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care.

Based on observation, interview, and record review, the facility failed to ensure adequate assistance to prevent accident and injuries for one of 25 sampled residents (Resident 19). The facility failed to assist the resident to the bedside commode, and failed to implement a different kind of intervention in response to Resident 19's frequent falls. These failures resulted in Resident 19 sustaining a bump on the left side of her eye and a left clavicle fracture. Findings: Review of Resident 19's clinical record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set (MDS, an assessment tool) dated 7/6/16, indicated the resident had impaired cognition (mental process), required assistance for bed mobility, transfer, and toileting. There were no MDS's in 10/2016 and 1/2017. Review of Resident 19's Fall Risk assessment dated [DATE], indicated she had a score of 14. A score of 10 or above represents a high risk for falls. Review of Resident 19's Fall Risk Prevention and Management care plan dated 5/19/16, indicated Resident 19 had a risk for fall related to her history of falls and unsteady gait (abnormal walking). The interventions to prevent falls included placing the call light within reach, remind the resident to use the call light, provide an environment which minimized hazards over which the facility has control, and encourage the use of a front wheel walker. Review of Resident 19's cognitive loss care plan dated 5/19/16, indicated Resident 19 had a period of forgetfulness, short term memory loss and poor judgment. Review of Resident 19's situation background assessment recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) dated 9/19/16, indicated the resident had an unwitnessed fall when she was found on the floor next to her bed. This resulted in a skin tear on the back of the head and a skin tear on her right hand. Review of Resident 19's post fall short term care plan dated 9/19/16, indicated the incident occurred when Resident 19 wanted to use the bedside commode. The intervention to prevent falls was to place the resident on bladder assistance (assist to the bathroom) every two to three hours. There was no evidence Resident 19 was placed on bladder assistance every two to three hours. Review of Resident 19's bowel and bladder assessment and interventions dated 7/6/16, indicated the resident would proceed with a retraining program. There was no bowel and bladder assessment in 10/2016. Review of Resident 19's post fall interdisciplinary (team members from different department involved in a resident's care) assessment dated [DATE], indicated the resident lost her balance during transfer. The intervention to prevent falls was to remind the resident to use the call light for needs, and encourage her to move slowly when changing position. Review of Resident 19's SBAR dated 10/22/16, indicated the resident had an unwitnessed fall when the resident used the bedside commode, lost her balance and fell . Resident 19 complained of pain, dizziness, a lump was noted on the back of the head, and the resident was sent to an acute hospital. Review of Resident 19's Fall Risk assessment dated [DATE], indicated she had a score of 14. A score of 10 or above represents a high risk for falls. Review of Resident 19's acute hospital [DIAGNOSES REDACTED]. Review of Resident 19's post fall interdisciplinary assessment dated [DATE], indicated the resident tried to use the bedside commode, lost her balance and fell . The intervention to prevent a fall included to monitor orthostatic hypotension (decrease in blood pressure) upon return from the acute hospital. There was no evidence the resident was monitored for orthostatic hypotension. Review of Resident 19's SBAR dated 10/25/16, indicated the resident had an unwitnessed fall. When the resident fell , the resident complained of dizziness, and a bump on the left side of her left eye. The resident was sent to an acute hospital. Resident 19's acute hospital [DIAGNOSES REDACTED]. Review of Resident 19's post fall interdisciplinary assessment dated [DATE], indicated the resident got up from bed, forgot to use the call light, tried to use her bedside commode but lost her balance and fell . The intervention to prevent a fall included to remind the resident with each contact to call for assistance, educate regarding the risk, and consequence of doing an independent transfer. Review of Resident 19's SBAR dated 1/9/17, indicated the resident had an unwitnessed fall when she was found sitting on the floor with a right shin (lower extremities) abrasion (scrape). Review of Resident 19's post fall interdisciplinary assessment dated [DATE], indicated the resident rolled off the edge of the bed. The intervention to prevent a fall was to put a floor mat at the resident's bedside. Review of Resident 19's Fall Risk Prevention and Management care plan dated 11/30/16, indicated Resident 19 had a risk for fall related to history of falls, decreased endurance and medications, e.g., Propranolol (blood pressure medication), Dilantin (for seizure), and Melatonin (medication to control the sleep and wake cycle). During an observation and interview with licensed vocational nurse J (LVN J) on 1/20/17 at 8:05 a.m., Resident 9 was lying on her bed, with the bedside commode nearby. The call light was bent to the other side of the bedside table. LVN J confirmed Resident 19's call light was not within reach and she could not call for assistance. LVN J also stated Resident 19 had no floor mat. During an interview with the director of nursing (DON) on 1/20/17 at 2:35 p.m., she stated Resident 19 was a high risk for falls related to her confusion and forgetfulness. The resident required assistance for transfer and toileting. The DON stated the interventions should have been implemented and new interventions should have been developed to prevent falls. She also stated Resident 19 should have been referred to therapy related to her frequent falls. The DON acknowledged there was no bowel and bladder training every two to three hours, there was no weekly summary from 9/21/16 to 10/26/16, no monitoring for orthostatic hypotension, no floor mat and the call light should have been within reach. Review of the facility's 11/7/2016 policy, Fall Management Program, indicated the facility will implement a fall management program which supports and provide an environment free from hazards. The licensed nurse and interdisciplinary team (IDT, team members from different department involved in a resident's care) will develop a plan of care according to the identified risk factors and root cause. The licensed nurse will evaluate the resident's response to the plan of care during weekly summary evaluation and will update the care plan as necessary.

Based on observations, interviews, and record reviews, the facility failed to provide and maintain nutritional status to one out of twenty six sampled residents (Resident 2), when: 1. The food that the resident liked to eat including cultural food preferences were not assessed. were not considered and provided to Resident 2 resulting significant weight loss. The resident lost 10 pounds from January to May 2012 and had 25 pound weight loss from June to November 2012. 2. The facility failed to identify the problem of Res. 2's ill-fitting dentures, develop and implement interventions to address problem so the resident can chew his food better with less or no discomfort during meals. 3. The facility failed to develop and implement interventions to address Res. 2's depression. This could potentially result to resident's lack of appetite or decreased interest in food. 4. The facility failed to follow physician's orders [REDACTED]. Foreign bodies (including food and fluids) may be aspirated into the nose, throat and lungs on inspiration). FINDINGS: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - an assessment tool) dated 9/21/06 revealed Section AB, 8. Language, Primary language 3b Cantonese. The most recent MDS dated [DATE] revealed he had clear speech, was able to express himself, and was able to understand others. 1. During an interview with the Charge Nurse (CN 1) on 11/29/12 at 1 P.M., he stated that Resident 2 was not eating well, has dementia and diabetes. He further stated that Resident 2 spoke mostly "Mandarin" some English, and the staff used a "communication board" to talk to Resident 2. During a review of the Vital Signs and Weight Record dated 1/12 to 11/12, revealed monthly weights as follows: Date Weight 1/10/12 174 lbs 2/16/12 172 lbs 3/8/12 172 lbs 4/9/12 168 lbs 5/9/12 164 lbs 6/14/12 160 lbs 7/6/12 140 lbs 8/8/12 138 lbs 9/10/12 139 lbs 10/9/12 140 lbs 11/8/12 135 lbs During a meal observation in the Dining room area located on the first floor on 11/30/12 at 11:40 A.M., Resident 2 was sitting on a wheelchair, was prepared with bib in place, eating by himself. Resident was served fortified, regular, no concentrated sweets (NCS) diet. He had the following food on his tray: chili beans, 1 glass of milk, a slice of cornbread, a cup of vegetable soup, a cup of vegetable salad, and a cup of coffee. Review of Meal Intake Record (MIR) on 11/30/12 showed that Resident 2 took 50% of food on the tray. During a review of Resident Care Plan Nutrition and Hydration (RCPN and H) revised 7/11/12, revealed the following: 1.The following problems/needs were identified on 7/11/12: Decreased food intake; depression/depressive DO (disorder); 2.The Goal: the Resident will have no significant weight changes of 5% or more x 30 days x 3 months; 3. Approach: Other (specify: Honor food preferences; Dietary consult as needed; adm. diet as ordered; monitor for signs and symptoms of dehydration; notify MD immediately During an interview with Charge Nurse (CN 2) on 12/3/12 at 11:15 A.M., she was asked what food does Resident 2 liked to eat. She stated "Oh! he likes Chinese food. He eats better with Chinese food. If he likes the food, he will eat more". When asked who knew about Resident's food preferences, CN 2 stated " all of us knows he likes Chinese food." During a phone interview with the Resident 2's Responsible Party (RP) on 12/3/12 at 11: 25 A.M., the RP stated, "I don't know why he is losing weight. When we take him out on weekends to eat, he finishes his food. He likes Chinese food.". He also added that he had requested dentures from Social Worker (SW 2). During an interview with CN 1 on 12/3/12 at 1:10 P.M., when he was asked to show evidence that Resident 2's food preferences was honored as written in the RCPN and H form, revised date 7/11/12, he stated that Resident 2 was given "cup-o noodles" and banana as supplement. He further stated that family brought in Chinese food , "every time the son takes him out, he eats Chinese food, he eats a lot". CN 1 was not aware if Chinese food was part of Resident 2's menu. CN 1 reported that Resident 2 was sent to the emergency room "today for rectal bleed". During an interview with the Dietary Service Supervisor (DSS 1) on 12/3/12 at 2:45 P.M., she was asked if she talked to Resident 2 about his food preferences. DSS 1 stated Resident 2 did not speak English well, "it is hard", she also admitted that she did not use the communication board to talk to Resident 2. She acknowledged that she did not discuss food preferences with the RP. When asked if Chinese food is served in the facility, DSS 1 stated that Chinese porridge is served in the facility as part of the menu but not to Resident 2. The only intervention given to Resident 2 was adding banana and cup-o- noodle. She also acknowledged that care plan for Resident 2 did not identify or address the twenty pound weight loss on 6/14/12 to 7/6/12. DSS 1 was asked to provide the menus served to Resident 2. Review of clinical record titled "Fall Menus" for the months of October and November 2012, showed no evidence of honoring cultural food preferences for Resident 2. DSS 1 also gave a copy of card profile that listed only the food that Resident 2 "dislikes' to eat but did not list the food that Resident 2 "likes" to eat. During an interview with the Nursing Supervisor (NS 1) on 12/3/12 at 3 P.M., she was asked if she was aware of Resident 2's food preferences. She stated "we know", Resident 2 is given "cup-o-noodle", the family brought in food, and the family took Resident 2 to dine out. When asked if Resident 2 would likely eat better if Chinese food is offered in the facility menu, she stated "yes". During an interview with the RD on 12/4/12 at 1:30 P.M., she acknowledged that she did not talk to the RP for Resident 2 about cultural food preferences, thought "it was assessed" by the prior RD before taking over the case. She acknowledged that the cup-o-noodles would not be sufficient to meet the caloric requirement of the resident. She also stated that she was not aware of the denture issue and had not attended any IDT meeting. During a phone interview with the Family Nurse Practitioner (FNP 1), primary provider for Resident 2, on 12/5/12 at 10:30 A.M., she stated that Resident 2 was still in hospital for "hemorrhoids". She stated that Resident 2 liked certain food, preferred Chinese food and she encouraged the family to bring food for Resident 2. 2. During a review of Progress Notes dated 1/8/12, indicated that Resident 2 had ill- fitting dentures. During an interview with SW 2 on 12/4/12 at 2 P.M., she verified that the Progress Notes dated 1/8/12 was written by the Dentist who evaluated Resident 2 on 1/8/12. She acknowledged that Resident 2 had an ill-fitting denture. She stated that she attended the Interdisciplinary Team meeting (IDT) but problem with the ill-fitting dentures was never brought up: SW 2 thought it was not an issue. During a concurrent interview with Certified Nurse Assistant (CNA 2) on 12/4/12 at 2:20 P.M., he stated that Resident 2 had "discomfort with dentures". He added that Resident 2 ate without dentures and sometimes with dentures but "pushes it away" when offered. 3.The care plan dated 7/11/12 was reviewed with NS 1 on 12/3/12 at 3 P.M., Depression was identified as a problem in the care plan but no appropriate interventions were developed or implemented to address the problem. During an interview with DSS 1 on 12/3/12 at 2:45 P.M., she stated that Resident 2 was doing good prior to wife getting sick but after his wife's condition "deteriorated" a year ago, Resident 2 became depressed. 4. During review of recap physician's orders [REDACTED]." During a lunch observation on 11/30/12 at 11:45 A.M., Resident 2 was observed coughing continuously when he took the vegetable soup and drank the coffee. CN 2 came at 1 P.M., spoonfed Resident 2 with the remaining chili beans on his plate about 2 spoonfuls and CN 2 left the dining area. During an interview with the Director of Nursing (DON) on 12/4/12 at 9:40 A.M., he was asked to interpret/explain the above order. DON stated that before carrying the order, he recommends an evaluation by a Speech Therapist, educating the CNAs and Licensed Nurses (LNs). When asked what he expect staff to do, DON stated that LN has to supervise CNA while feeding the resident. CNA to be with resident at all times till resident finish meals. During an interview with CNA 2 on 12/4/12 at 2:20 P.M., he stated that during meals, he prepared Resident 2, opens the tray and informed Resident 2 that meal is "here". He stated that Resident 2 ate by himself. Review of facility's Policy and Procedure titled Evaluation of Weight & Nutritional Status, Policy No.-DD-01, version No.1.0, Date revised; January 01, 2012 s stated the following: Policy, II. Definitions C. "Avoidable" - The resident did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: (2) define and implement interventions that are consistent with residents needs, goals and recognized standards of practice (3) monitor and evaluate the impact of interventions (40 revise interventions as appropriate Procedure II. Nutritional Assessment C. The Dietician's assessment may include but is not limited to: v. possible dental problems vii. Resident likes and dislikes III. Clinical Evaluation A. In connection with the assessments mentioned above, the Registered Dietitian and the IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including the following: ix. chewing and swallowing problems xi. relevant conditions and diagnosis

Based on observation, interview and record review, the facility failed to ensure that the resident ' s environment was free of accident hazards by failing to maintain water temperature in the bathrooms in Rooms 1 and 2 within acceptable range of 105 to 120 degrees Farenheit. This condition placed the 4 of 32 sampled residents (Res. 11, 18, 27 and 31) at risk for 3rd degree burns due to scalding. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. There were unsecured television monitors in five resident rooms that created a potential safety hazard in the event of a resident, or a passer-by bumping into the bedside tables and night stands. Findings: During the initial tour on 9/14/10 at 11:15 AM at Station 1, Room 1's bathroom was checked. The water temperature from the faucet was very hot to the touch and steam was observed after running the water for about 1-2 minutes. Room 1 was a semi-private room with 2 residents in the room. The Maintenance Supervisor was notified. The water temperature was 136 degrees F (Fahrenheit). Room 2's bathroom was checked at 11:20 AM. This was also a semi-private room with 2 residents. The water temperature from the faucet was also 136 degrees F. During an interview the Maintenance Supervisor on 9/14/10 at 11:25 AM stated that Rooms 1 and 2 were the closest to the main water heater tank. He stated that he was responsible for monitoring the temperature of the water and he keeps a log to track the weekly water temperature in the hand sinks and showers in the facility." During an interview the charge nurse for Station 1 on 9/14/10 at 1:00 PM stated that the Resident 11 in room 1A needs total assistance from staff for bathing and hygiene. The Resident 18 in Room 1B was able to go to the bathroom with assistance from staff. The Random Resident 27 in room 2A was able to walk to the bathroom, but was confused at times. Random Resident 31 in rooom 2B was a hospice patient and needed total assistance from staff. Review of water temperature log showed that the temperature reading was 120 degrees for for Rooms 1 and 2 for the following dates: 6/12/10, 8/6/10, 8/13/10, 8/27/10, and 9/3/10. Review of an undated facility policy and procedure, titled "Water Supply, Plumbing and Water Heating System" revealed that, "It is the policy of this facility to maintain a clean, adequate water supply, to properly maintain fixtures and plumbing in good operation condition, and to maintain a water heating system to ensure clean, hot water at the correct temperature for both patient and facility use as prescribed by law... Regulations require that hot water temperature be maintained at no less than 105 degrees F (40.5 degrees Centigrade) and not more than 120 degrees F (48.8 degrees Centigrade) for all hot water used by patients." According to Federal Guidelines from the State Operations Manual, "Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Temp Time Required for a 3rd Degree Burn to Occur 155?F 68?C 1 sec 148?F 64?C 2 sec 140?F 60?C 5 sec 133?F 56?C 15 sec 127?F 52?C 1 min 124?F 52?C 3 min 120?F 48?C 5 min 100?F 37?C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. o First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. Immediate jeopardy was declared on 9/14/10 at 1:15 AM, after identifying Rooms 1 and 2 bathrooms had water temperatures from the faucets in the sink at 136 degrees Fahrenheit. The Administrator and Director of Nursing were notified. The Administrator went to Room 1 immediately and rechecked the temperature in the faucet, using his thermometer and found it to be 136 degrees. The following corrective measures were implemented by the facility: 1. After determining which water heater zone fed the affected area, the water was immediately dumped by turning on the valve at the bottom of the tank, to eliminate the source of the hot water. 2. Faucets in the affected resident areas were also turned on to drain hot water from the pipes. 3. After the water was found to be running cool, the valve and faucets were closed, the regulator adjusted to 116 degrees to allow it to recover. 4. After 20 minutes the water to the resident areas were re-checked by the facility staff and found to be within acceptable limits. 5. Maintenance staff was instructed to do random check of water temperature to resident areas in the two other water heater zones in the facility. 6. The maintenance person who comes on duty at 7 AM the following day was instructed to check the water temperatures in all water heater zones at that time, when the temperature is at its peak prior to showers. 7. Maintenance staff was to check and document water temperature in resident areas throughout the facility on a no less than weekly basis. 8. Maintenance Director and Administrator will monitor water temperatures and records on an ongoing basis to assure compliance. On 9 /14/10 at 3:35 PM, the surveyors rechecked the water temperatures in Rooms 1 and 2 and other resident rooms throughout the facility after corrective actions were implemented. The water temperature in Rooms 1 and 2 were found to be 105 degrees Fahrenheit. Random water temperatures in other resident rooms were also within acceptable range. The Administrator was informed that the immediate jeopardy was lifted on 9/14/10 at 4:00 PM. During an observation on 09/17/10 at 9:50 AM in resident rooms 2, 17, 25, 51 and 95 there were flat screen television monitors next to resident's bed that were not secured to night stand, or bed side tables. In interview, the maintenance staff acknowledged the potential hazardous condition and stated: "We will secure the monitors with Velcro."