Every finding on record at Desert Springs Healthcare & Wellness Centre

Based on interview and record review, the facility failed to address abnormal vital signs (basic body measurements that show how well your body works - temperature, heart rate, breathing rate, and blood pressure) and notify the physician, for one of five residents reviewed (Resident 3), when Resident 3 had an elevated heart rate and low blood pressure on multiple days. In addition, there was no documented evidence that the licensed nurse followed up with the resident to assess the resident's status or reassess her vital signs.This failure resulted in a delay in the care and treatment of Resident 3's abnormal vital signs and had the potential to affect Resident 3's overall health condition. Findings:On July 28, 2026, at 9:14 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care and treatment.On July 28, 2026, Resident 3's medical record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included spondylosis, thoracolumbar region (age-related wear and tear in the middle and lower back) and abnormal findings on diagnostic (test or tool used to find out what is wrong) imaging (a way to take pictures of the inside of your body) of other abdominal (stomach area) regions.A review of Resident 3's Minimum Data Set (MDS - an assessment tool), dated July 23, 2026, indicated Resident 3 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 03 (severe cognitive impairment).A review of Resident 3's eINTERACT SBAR (Situation, Background, Assessment, and Recommendation - a simple, four-step communication tool used to share important information) Summary for Providers, dated July 23, 2026, at 1600 (4:00 p.m.) indicated, .change in condition: abdominal/GI status evaluation: nausea and/or vomiting. recommendations: Scopolamine Base Patch (a small, medicated sticker placed behind the ear to stop nausea and vomiting) .monitor qshift (every shift) x72 hrs (for 72 hours) .A review of Resident 3's Weights and Vitals Summary, indicated abnormal vital signs on the following dates and times:-July 23, 2026, at 23:56 (11:56 p.m.): pulse: 109 bpm (beats per minute; normal range 60 to 100);-July 24, 2026, at 06:46 (6:46 a.m.); pulse 102 bpm;-July 24, 2026, at 23:38 (11:38 p.m.): blood pressure: 98/65 mm/Hg (millimeters of mercury- unit of measurement for pressure; normal range 120/80); and pulse: 113 bpm;-July 25, 2026, at 10:14 (10;14 a.m.); pulse 102 bpm;-July 25, 2026, at 13:02 (1:02 p.m.); pulse 102 bpm;-July 25, 2026, at 23:16 (11:16 p.m.): pulse 120 bpm; and-July 26, 2026, at 06:51 (6:51 a.m.); pulse 137 bpm; respiratory 40 breaths/minute (normal range16 to 20)Further review of Resident 3's record indicated there was no documented evidence the abnormal vital signs (blood pressure and pulse rate) on July 23, 24 or 25, 2026, were addressed and the physician was notified. In addition, there was no updated care plan to address the abnormal vital signs after the change of condition on July 23, 24, 25, and 26, 2026.A review of Resident 3's Weights and Vitals Summary, dated July 26, 2026, at 7:10 a.m., indicated, .BP 84/61, P 162, RR 46.temp 100, pulse oximetry 94% room air.A review of Resident 3's eINTERACT SBAR Summary for Providers, dated July 26, 2026, at 7:31 a.m., indicated, .change in condition reported.abnormal vital signs, altered mental status.BP 110/67, P 137, RR 40.temp 97.3, pulse oximetry: 94% room air.mental status evaluation: altered level of consciousness.respiratory status evaluation: labored or rapid breathing.cardiovascular status evaluation: resting pulse greater than 100.neurological status evaluation: altered mental status.recommendations: repeat vital signs, send out if heart rate and RR is the same.A review of Resident 3's Physician Orders, dated July 26, 2026, indicated, .may send out to ER (Emergency Room) . for evaluation and treatment r/t (related to) abnormal vital signs.On July 28, 2026, at 1:28 p.m., an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated the CNAs were responsible for obtaining vital signs at the beginning of every shift and to report to the licensed nurse (LN) if any vitals were out of range. CNA 1 stated the LN was expected to assess the resident and reassess the vitals within 5 minutes.On July 28, 2026, at 4:04 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated when a CNA reports abnormal vitals to the LN, the LN should assess and recheck vitals as soon as possible. LN stated if the vitals were abnormal with LN assessment, the LN should notify the MD (Medical Doctor) and the DON (Director of Nursing). LVN 1 stated the heart rate parameters (normal range) was 60 to 100 bpm. LVN 1 stated if the heart rate was less than 60 or greater than 100 was considered out of normal range. LVN 1 stated on July 25, 2026, at 11;16 p.m., the LN should have rechecked Resident 3's heart rate and if it was still elevated, the physician should have been notified.On July 29, 2026, at 11:03 a.m., during an interview conducted with LVN 4, LVN 4 stated the CNAs obtain the resident's vital signs then enter in the resident's electronic record. LVN 4 stated if the vital signs taken by the CNAs are abnormal, the licensed nurse will re-evaluate the vital signs.On July 29, 2026, at 12:20 p.m., a concurrent interview and review of Resident 3's record was conducted with LVN 2. LVN 2 stated for abnormal out of range vital signs the licensed nurse was expected to assess the resident and recheck the vital signs right away. LVN 2 stated if a resident had a new onset of elevated heart rate, it would be considered a change of condition. LVN 2 stated the LN was expected to complete the change of condition documentation, notify the MD for orders, then update the care plan and notify resident's family. A concurrent review of Resident 3's vital signs, LVN 2 stated the following should have been reported to the physician as a change of condition:-July 23, 2026, at 2356, heart rate 109 bpm; and-July 24, 2026, at 2338, blood pressure 98/65 mmHg, and heart rate 113 bpm.On July 29, 2026, at 4:05 p.m., a concurrent interview and review of Resident 3's record was conducted with the Director of Nursing (DON). The DON stated the expectation for the LN would be to check the resident and recheck the vitals as soon as possible. The DON stated if the vital signs continue with abnormal readings, the LN was expected to notify the physician, for further orders. The DON verified there was no documented evidence that the LN rechecked Resident 3's vitals or documented a progress note on Resident 3's status. The DON stated the LN should have reassessed Resident 3's vital signs and condition then notified the physician for the following dates:-July 23, 2026, at 23:56: pulse: 109 bpm.-July 24, 2026, at 23:38: blood pressure: 98/65 mm/Hg; and pulse: 113 bpm; and-July 25, 2026, at 23:16: pulse 120 bpm.The DON verified that on July 25, 2026, at 23:16, Resident 3's pulse was 120 bpm and the LN did not recheck or report all shift. The DON stated this resulted in Resident 3's vital signs worsening and became critically abnormal requiring the resident to be transferred to the hospital for further evaluation.A review of the facility's policy and procedure titled, P-NP23 Change in Condition, review date August 25, 2022, indicated, .it is the responsibility of the person who observes the change to report the change to the Licensed Nurse.the Licensed Nurse will assess the change of condition.determine what nursing interventions are appropriate.before notifying the physician.the Licensed Nurse must observe and assess the overall condition.utilizing a physical assessment and chart review.notification to the physician will include a summary of the condition change and an assessment of the resident's vital signs and system review.focusing on the condition and/or signs and symptoms.for which the notification is required utilizing a SBAR format.licensed nurse will document the following.date, time, and pertinent details of the event and the subsequent assessment in the medical record.the time the physician was contacted.the time the family/responsible person was contacted.update the care plan to reflect the resident's current status.a licensed nurse will communicate any changes.required interventions to the care team.

Based on observation, interview, and record review, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH) and local authorities within the mandated timeframe of the facility's knowledge of the allegation, for two of five residents reviewed (Residents 1 and 5), when Resident 1 was observed touching Resident 5 inappropriately at the patio and hallway. The facility was made aware of the allegation of sexual abuse on July 25, 2026. This failure to report an alleged sexual abuse to CDPH resulted in delayed investigation of abuse and delay implementation of appropriate action which increased the risk of further abuse for Resident 5 and other residents in the facility.Findings:On July 28, 2026, at 9:14 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving an abuse allegation.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and psychosis (a mental state marked by a disconnection from reality, where a person has trouble telling what is real and what is not).A review of Resident 1's H&P (History and Physical) Note, dated February 6, 2026, indicated the resident was not capable to make decisions.A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated June 22, 2026, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8 (severe cognitive impairment). A review of Resident 1's Progress Notes, dated July 26, 2026, at 9:31 a.m., which indicated, .Sexually inappropriate behavior, and gets physically aggressive with staff.May send to Behavioral Health.On July 28, 2026, at 12:18 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 1 was observed touching Resident 5 inappropriately in his private area, in the hallway on July 26, 2026. The DON stated this incident was witnessed by the treatment nurse and was reported to her. The DON stated it was not reported to CDPH because it was consented and Resident 1 and Resident 5 were noted on the patio often, touching each other. The DON stated there was no concern of sexual abuse between Resident 1 and Resident 5. A concurrent record review was conducted with the DON. The DON stated Resident 1's BIMS score was 08 and Resident 5 BIMS score was 07, indicating moderate cognitive impairment. The DON stated the residents were able to answer some questions appropriately and would be able to consent the touching.Resident 5's medical record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses of myocardial infarction (occurs when blood flow to a part of the heart muscle abruptly decreases or stops, causing tissue death).A review of Resident 5's MDS, indicated the resident has a BIMS score of 7 (severely cognitive impairment).On July 28, 2026, at 2:21 p.m., during an interview with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she observed Resident 1 and 5 sitting on their wheelchair side by side around the corner near Nursing Station 2 on July 25, 2026, and Resident 1's right hand was down Resident 5's pants, touching his private area. LVN 3 stated she started to wheel Resident 1 away from Resident 5. LVN 3 stated she reported it to the DON that same day and was told she was going to file a report for mental health evaluation for Resident 1.On July 28, 2026, at 3:01 p.m., Resident 5 was observed resting in bed laying on his left side. In a concurrent interview, Resident 5 stated he has never had an encounter with another resident that touched him inappropriately in any private area without his consent. On July 28, 2026, at 3:04 p.m., the DON and the Administrator (ADM) stated Resident 1 does not have the capacity to make decisions. They stated LVN 3 witnessed Resident 1 touching Resident 5 and wheeled Resident 1 away and the resident tried to hit LVN 3. The ADM stated Resident 5 would remember sometimes and sometimes would not remember. The ADM stated the abuse process was not initiated because both residents were both consensual and had notified Resident 1's representative about the situation between Residents 1 and 5. Resident 1's record was concurrently reviewed with the DON and the ADM, stated the IDT (Interdisciplinary Team - a group of healthcare professionals) notes did not document any sexual behavior or touching was discussed with the resident representative.On July 29, 2026, at 2:38 p.m., during a concurrent interview and review of Residents 1 and 5's records conducted with the ADM and the DON, they stated Residents 1 and 5 were in and out with mental capacity, however, they were both consenting during the times when Resident 1 was touching Resident 5. The ADM and the DON stated Residents 1 and 5's relationship was never discussed with Resident 1's family. The ADM stated both residents are vulnerable to any form of abuse.A review of the facility's policy and procedure titled, Abuse-Reporting & Investigations, revised date March 2018, indicated, .to protect the health, safety, and welfare of facility residents .by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported .thoroughly investigated .the facility will report all allegations of abuse .as required by law and regulations to the appropriate agencies .the facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated by .suspicion of crimes .allegations of abuse, neglect, mistreatment, exploitation or reasonable suspicion of a crime .to be reported to the Administrator or designated representative .immediately when the Administrator receives the report of an incident or suspected incident of resident abuse .the Administrator or designated representative will initiate an investigation immediately .upon receiving allegations of sexual abuse .the Administrator or designated representative .will notify the Attending Physician to promptly examine the resident .immediately notify law enforcement .the administrator conducting the investigation will interview individuals .who may have information relevant to the allegation or suspected crime .notification of outside agencies of allegations of abuse caused by a resident with dementia diagnosed by a physician .the administrator will notify within 2 hours .by telephone .CDPH, the Ombudsman and law enforcement .the administrator will send a written .SOC341 report .to the Ombudsman .Law Enforcement .and CDPH Licensing and Certification within 2 hours

Based on observation, interview, and record review, the facility failed to investigate an allegation of sexual abuse, for two of five residents reviewed (Residents 1 and 2), when Resident 1 was observed crying and touching her private area while pointing at Resident 1's room on July 25, 2026.This failure resulted in a delay in the investigation of an alleged sexual abuse involving Residents 1 and 2, and placed Resident 2 at risk for further abuse. Findings:On July 28, 2026, at 9:14 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving an abuse allegation.On July 28, 2026, at 10:02 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed sitting at the side of her bed, wearing personal clothing, preparing to brush her teeth. In a concurrent interview with Resident 2, Resident 2 stated the following:- admitted to the facility from hospital due to a fall at home;- Approximately three days ago that she was in the bathroom, when a large woman in a wheelchair came into the bathroom from an adjoining door, and she had never seen the other woman at the facility before;- The other woman said to her, what are you doing in here? This is a woman's bathroom;- The other woman started grabbing her buttocks and crotch area and that the other woman was very big and strong and she was not very steady;- The other woman would not stop and she was fighting her off and trying to get away;- She was upset and crying hysterically and the staff heard her crying and five staff members came to her room trying to calm her down; and- Resident 2 stated she was moved to another room immediately. Resident 2 stated since the incident, the facility staff has not mentioned the incident to her again. Resident 2 was observed crying and tearful during the interview and stated it was an unpleasant memory.On July 28, 2026, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses presence of left artificial hip joint (a person has previously had left hip replacement surgery) and anxiety disorder (a feeling of fear, worry, or nervousness about what might happen.)A review of Resident 2's Minimum Data Set (MDS - an assessment tool), dated July 7, 2026, indicated Resident 3 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 08 (moderate cognitive impairment).Further review of Resident 2's record indicated there was no documented evidence of the alleged incident that occurred or Resident 2's behavior on July 25, 2026. In addition, the was no monitoring of the resident's psychosocial status or updated care plan to address Resident 2's behavior of crying.On July 28, 2026, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses dementia (loss of memory and thinking skills that gets in the way of daily life) and psychosis (a medical condition where a person loses touch with reality.)A review of Resident 1's H&P (History and Physical) Note, dated February 6, 2026, indicated the resident was not capable to make decisions.A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated June 22, 2026, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8 (severe cognitive impairment). A review of Resident 1's Progress Notes, dated July 26, 2026, at 9:31 a.m., which indicated, .Sexually inappropriate behavior, and gets physically aggressive with staff.May send to Behavioral Health.On July 28, 2026, at 12:18 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the following:- When there was a change in a resident's behavior, it would be considered a change of condition;- The licensed nurse (LN) was expected to assess the resident, notify the physician, the family and the DON;- The LN should document a change of condition/SBAR (Situation, Background, Assessment, and Recommendation - a simple, four-step communication tool used to share important information) summary in the resident's medical record then follow up with the resident for 72 hours to monitor their behavior and update the care plan;- Certified Nursing Assistant (CNA) 2 reported to Licensed Vocational Nurse (LVN) 4 that Resident 2 was crying because she was in the bathroom and a female came in the bathroom;- Resident 2 did not provide any further information about why she was crying;- Resident 1 was interviewed and stated she was helping Resident 2 pull up her pants. The DON stated the staff moved Resident 2 to another room so she could feel better; and- The DON or ADM did not further investigate why Resident 2 was crying because there were no concerns at the time and Resident 2 stopped crying after she was moved to another room.On July 28, 2026, at 3:31 p.m., during an interview with CNA 2, CNA 2 stated she responded to a call light of Resident 2 on July 25, 2026, and saw the resident crying. CNA 2 stated Resident 2 was trying to explain that the lady over and over while the resident was touching her briefs. CNA 2 stated Resident 2 could not find the words to explain and stated she was in the restroom and the lady and kept pointing at her room door. CNA 2 stated she reported it LVNs 1 and 4. On July 28, 2026, at 4:04 p.m., during an interview with LVN 1, LVN 1 stated CAN 2 reported to her and LVN 4 that Resident 2 was crying and did not why. LVN 1 stated she and LVN 4 went to Resident 2's room and asked the resident why she was crying and the resident stated something happened in the resident's bathroom. LVN 1 stated she was in and out of the resident's room during the conversation with Resident 2.On July 29, 2026, at 11:03 a.m., during an interview with LVN 4, LVN 4 stated Resident 2 was crying and reporting that another resident rushed her out of the bathroom and she felt embarrassed. LVN 4 stated she went to ask Resident 1 and was told that she wanted to use the bathroom and Resident 2 was using the same bathroom. LVN 4 stated she reported to the DON and was advised for a room change.On July 29, 2026, at 3:38 p.m., during a follow up interview with the DON, the DON stated she and the ADM did not investigate further, did not interview reporting CNA (CNA 2), did not interview Resident 2. The DON stated they should have investigated further as Resident 1 had history and ongoing sexually inappropriate behavior. The DON stated Resident 2 should have been monitored after she had a change of condition/behavior. A review of the facility's policy and procedure titled, Abuse-Reporting & Investigations revised date March 2018, indicated, .to protect the health, safety, and welfare of facility residents .by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported .thoroughly investigated .the facility will report all allegations of abuse .as required by law and regulations to the appropriate agencies .the facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated by .suspicion of crimes .allegations of abuse, neglect, mistreatment, exploitation or reasonable suspicion of a crime .to be reported to the Administrator or designated representative .immediately when the Administrator receives the report of an incident or suspected incident of resident abuse .the Administrator or designated representative will initiate an investigation immediately .upon receiving allegations of sexual abuse .the Administrator or designated representative .will notify the Attending Physician to promptly examine the resident .immediately notify law enforcement .the administrator conducting the investigation will interview individuals .who may have information relevant to the allegation or suspected crime .notification of outside agencies of allegations of abuse caused by a resident with dementia diagnosed by a physician .the administrator will notify within 2 hours .by telephone .CDPH, the Ombudsman and law enforcement .the administrator will send a written .SOC341 report .to the Ombudsman .Law Enforcement .and CDPH Licensing and Certification within 2 hours A review of the facility's policy and procedure titled, P-NP23 Change in Condition, review date August 25, 2022, indicated, .it is the responsibility of the person who observes the change to report the change to the Licensed Nurse.the Licensed Nurse will assess the change of condition.determine what nursing interventions are appropriate.before notifying the physician.the Licensed Nurse must observe and assess the overall condition.utilizing a physical assessment and chart review.notification to the physician will include a summary of the condition change and an assessment of the resident's vital signs and system review.focusing on the condition and/or signs and symptoms.for which the notification is required utilizing a SBAR format.licensed nurse will document the following.date, time, and pertinent details of the event and the subsequent assessment in the medical record.the time the physician was contacted.the time the family/responsible person was contacted.update the care plan to reflect the resident's current status.a licensed nurse will communicate any changes.required interventions to the care team.

Based on observation, interview, and record review, the facility failed to ensure wound care and management were implemented according to the facility's policy and procedure and national guidelines, for two of three residents reviewed (Residents 1 and 2), when:1.For Resident 1, the pressure injury (PI - a localized damage to the skin and underlying tissue caused by constant pressure, usually over a bony prominence) on the sacrococcyx (tail bone) area was not properly assessed. In addition, the treatment for Resident 2's PI on bilateral buttocks was not appropriate according to the facility's treatment protocol; and2.For Resident 2, infection control measures were not implemented while providing wound care. These failures had the potential for delayed wound healing and placed the resident at risk for further complications such as infection and worsening of the wound.Findings:On April 13,2026, at 9;15 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue.1.On April 13, 2026, Resident 1's record was reviewed. A review of Resident 1's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included heart failure and protein-calorie malnutrition (a potentially life-threatening condition caused by an inadequate intake of protein, calories (energy), or both).A review of Resident 1's care plan, dated March 2, 2026, indicated, .has actual impairment to skin integrity of the Sacrococcyx r/t (related to) admitted with unstageable pressure injury.Goal.The resident's (sic) will have no complications r/t unstageable pressure injury through the review date.Interventions.Follow facility protocols for treatment of injury.Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection.Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.A review of Resident 1's Skin Check, dated March 2, 2026, indicated a skin assessment to the sacrococcyx area (tail bone) with stage 3 pressure injury (a deep, crater-like wound that extends completely through the skin layers into the underlying fatty tissue), measuring 3 cm (centimeters - unit of measurement) by 4 cm by 0.1 cm.A review of Resident 1's Skin Check, dated March 2, 2026, indicated a skin assessment to the sacrococcyx area (tail bone) with unstageable pressure injury (PI - a severe wound where the true depth is hidden by dead tissue [slough or eschar]), measuring 5 by 5 by 0.1 cm, 100% slough, moderate exudate.A review of Resident 1's Skin Check, dated March 9, 2026, indicated the following skin assessments:- sacrococcyx area, unstageable PI, with measurement of 5 by 5 by 0.1 cm, 40% granulation, 30% slough, and 30% eschar;-left gluteus (buttocks), stage 2 PI (a shallow, open wound with a moist, shiny pink or red base, a blister or an abrasion/scrape), with measurement of 2 by 2 by 0.2 cm., pink wound base; and- right gluteus, stage 2 PI with measurement of 3 by 2 by 0.2 cm., pink wound bed.A review of Resident 1's Skin Check, dated March 17, 2026, indicated the following skin assessments:-right gluteus, stage 2 PI, with measurement of 2 by 2 by 0.1 cm, pink wound bed;-left gluteus, stage 2 PI, with measurement of 2 by 2 by 0.1 cm, pink wound bed; and-sacrococcyx, unstageable PI, with measurement of 6 by 6 by 3 cm. undermining (tissue destruction under the intact edges of a wound, creating a hidden pocket or cave beneath the skin) measuring 2 cm at 9 o'clock to 3 o'clock; 40% granulation, 20% slough (total of 70%).Further review of Resident 1's Skin Check, dated March 17, 2026, indicated there was no description of the wound status of the 40% of the wound bed at the sacrococcyx unstageable wound.On April 13, 2026, at 10:45 a.m., during an interview with the Treatment Nurse (TN), the TN stated Resident 1 was admitted to the facility with an unstageable wound on the sacrococcyx area. The TN stated the wound care nurse practitioner (NP) assessed the sacrococcyx and the bilateral buttocks wounds as one wound.On April 13, 2026, at 1 p.m., during a concurrent interview and record review with the TN, the TN stated he does not stage the PI and waits for the wound care specialist to stage and assess the wounds, and he was not aware of what guidelines to follow when assessing the wound. The TN stated he should have assessed the wound on Resident 1's sacrococcyx area as Stage 4 (a severe, full-thickness wound where skin and underlying tissue are destroyed, exposing muscle, tendon, joint, or bone), when the wound presented with granulation tissue (a fresh, pink or dark red, moist, and slightly bumpy tissue that grows from the base of the wound for wound healing). The TN stated the skin assessment on Resident 1's sacrococcyx area, on March 17, 2026, was incomplete as it did not indicate 40% of the remaining part of the wound bed.On April 13, 2026, at 2 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated the licensed nurses should be able to stage the PI, and not to wait for the wound care specialist to make the assessment. The DON stated she had to research what criteria or guidelines to use when staging wounds/P1. The DON stated the treatment of a barrier cream on Resident 1's stage 2 PI on bilateral buttocks was not appropriate as the resident is incontinent in urine and bowel.On April 20, 2026, at 11 a.m., the wound NP was interviewed. The wound NP stated the wound on Resident 1's sacrococcyx area should have been staged as 4 and not unstageable on March 17, 2026, as the muscle and bone were exposed to the wound. The wound NP stated the treatment for the stage 2 PI on bilateral buttocks should have been covered with a foam dressing instead of barrier cream and left open to air.A review of the facility's policy and procedure titled, Skin Integrity Management, revised June 27, 2024, indicated, .A Licensed Nurse will complete a skin evaluation then there is a change in skin integrity.A Licensed Nurse will complete the skin evaluation weekly.Consultation from a wound care physician may be obtained upon an order from the attending physician.Licensed Nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis.A review of the facility's document titled, Quick Reference - Topical Wound Care, indicated the following:-Stage 2 PI; wound treatment of Dermafilm (a transparent, flexible hydrocolloid [a flexible, moisture-retentive material which contains gel-forming agents) wound dressing used to treat non-infected, low-exuding wounds and shallow ulcers); and-Stage 4 PI; full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed.2.On April 13, 2026, at 11:15 p.m., an observation of wound care on Resident 2's wound on bilateral legs being provided by the TN. The TN was observed to do the following:-The TN applied gloves, cut off gauze bandage and removed xeroform dressing and left leg were directly placed on the pillow; no clean field was placed under the left leg;-cleansed the left leg with normal saline, removed gloves and performed hand hygiene and applied new gloves;-cut the new xeroform dressing with the same scissors used to remove the dirty bandage without disinfecting it; applied the dressing to the left leg wound and wrapped it with kerlix gauze (a type of stretchable, 100% woven cotton medical bandage featuring a unique crinkle-weave pattern);-removed the old gauze dressing from the right leg with the same scissors used for the left leg; and followed the same process of wound care on the left leg.A review of Resident 2's Face Sheet, record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke).A review of Resident 2's Order Summary Report, included a physician's order, dated April 7, 2026, which indicated.Cleanse venous ulcers (a slow-healing sore typically found on the lower leg, usually near the ankle) to bilateral shins with normal saline, pat dry, apply xeroform to open areas, cover with non-stick gauze wrap with kerlix secure with tape.On April 13, 2026, at 1 p.m., during a concurrent interview and record review with the TN, the TN stated he should have provided a clean area for dressing removal and another for redressing the wounds when he performed wound care to Resident 2. The TN stated he should have disinfected the scissors before using it to a clean/sterile dressing.According to the web article titled, What does Infection Control and Prevention Mean in Wound Care? published by the Wound Care Education Institute, dated April 2, 2024, .Infection control practices are crucial to prevent complications in wounds. By following steps like these, you can reduce the risk of infection and promote successful wound healing.changing gloves after assessing a wound and before applying a clean dressing.moving from clean to dirty.Don't mix clean and dirty.Seeing patients with multiple wounds can quickly create a dirty, disheveled workspace.work areas should be free of used, dirty supplies and materials before place a clean, dry dressing.According to the web article titled, Infection Prevention During Wound Care, published by the California Department of Public Health, indicated, .Reusable wound care equipment should be cleaned and disinfected prior to reuse.Surfaces in the treatment area that may have been contaminated should be cleaned and disinfected.

Based on observation, interview, and record review, the facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer's specifications, when one of two medication refrigerators was identified with documented temperature readings below the normal range on multiple days in September 2025. This failure had the potential for residents to receive ineffective medications which could result in the residents not receiving the full benefit of the medications, leading to further health complications.Findings:On September 15, 2025, at 11:28 a.m., during a concurrent observation and interview at nursing station 1 with Registered Nurse (RN), a medication refrigerator was inspected. The refrigerator temperature was observed on the thermometer to be 28 degrees Fahrenheit (F, a temperature measurement) and contained the following medications:- Afluria (influenza vaccine) injectable suspension;- Tuberculin PPD (test agent used in the diagnosis of tuberculosis [a respiratory disease]) vial; and- various types of insulin (injectable medication used to treat diabetes [abnormal blood sugar]) including insulin lispro, human insulin, and insulin glargine.On September 15, 2025, at 11:28 a.m., during a concurrent observation of the medication refrigerator and interview with the RN, she confirmed that 28 degrees F is within freezing range and that medications should be stored between 36 to 46 degrees F, according to the facility's policy and procedure. The RN noted the Afluria carton label stated, Do not freeze, and explained that medications stored at freezing temperatures are no longer viable and must be replaced.On September 15, 2025, at 11:45 a.m., during an interview and record review of the medication refrigerator temperature log for September 2025, the RN stated that evening (3 p.m. to 11 p.m.) and overnight (11 p.m. to 7 a.m.) nursing staff were expected to document the refrigerator temperature. The RN acknowledged the temperatures were documented as below 36 F (out of range) during the PM shift on the following dates: - September 1, 2025: 35 degrees F; - September 7, 2025: 31 degrees F; - September 8, 2025: 32 degrees F; - September 9, 2025: 32 degrees F; - September 10, 2025: 34 degrees F; and - On September 12, 2025: 34 degrees F.In a concurrent interview with the RN, the RN stated the nursing staff needed to adjust the thermostat inside the refrigerator and should report to maintenance if temperature had not returned to normal range when the medication refrigerator was out of range.On September 15, 2025, at 11:48 a.m., during a concurrent interview and record review, the RN reviewed the facility's maintenance log and stated there was no documented evidence the maintenance staff was contacted and no documented corrective actions were taken when the nursing station 1's medication refrigerator was below 36 degrees F (out of range) on the above dates.On September 15, 2025, at 11:49 a.m., during a concurrent observation of the nursing station 1 medication refrigerator and interview with the RN, the medication refrigerator temperature was observed on the thermometer to be 28 degrees F for the second time and the RN confirmed the temperature was still in the freezing range.On September 16, 2025, at 12:05 p.m., during a concurrent interview and record review of the medication refrigerator temperature logs and maintenance logs, for September 1 to 12, 2025, with the Director of Nursing (DON). The DON stated nursing staff were expected to check the medication refrigerator temperature twice a day during the PM shift and NOC shift. The DON stated the expected temperature range for the medication refrigerator should be between 36 to 46 degrees F and confirmed freezing temperature was 32 degrees F or less. The DON stated the expectation was for nursing staff to have adjusted the setting in the refrigerator, rechecked temperature after 15 minutes, and if the temperature was not corrected then nursing staff should have notified maintenance, if the medication refrigerator temperature was out of range. A review of the facility's policy and procedure titled, Medication Storage in the Facility, revised date February 2020, indicated, .Medications requiring refrigeration are kept in the refrigerator at temperatures between 2 degree C (36 degree F) and 8 degree C (46 degree F) with a thermometer to allow temperature monitoring . A review of the PI for Tuberculin PPD, dated October 2021, retrieved from DailyMed (a public website maintained by the U.S. Food and Drug Administration), indicated, Store at 2 to 8 degree C (35 to 46 degree F). Do not freeze. Discard product if exposed to freezing.A review of the PI for insulin lispro injection solution, dated September 2023, retrieved from DailyMed, indicated, Storage and Handling .Do not freeze and do not use if it has been frozen .Not In-Use (Unopened) Refrigerated (36 degree F to 46 degree F [2 to 8 degree C]).A review of the PI for human insulin injection solution, dated November 2022, retrieved from DailyMed, indicated, Storage and Handling .Do not freeze .Do not use if it has been frozen .Not In-Use (Unopened) Refrigerated (36 degree F to 46 degree F [2 to 8 degree C]).A review of the PI for insulin glargine injection solution, dated June 2023, retrieved from DailyMed, indicated, Store unused Insulin Glargine in a refrigerator between 36 degree F and 46 degree F (2 degree C and 8 degree C]. Do not freeze. Discard Insulin Glargine if it has been frozen.A review of an article titled Storage of Insulin, by the Institute for Safe Medication Practices (ISMP, a nationally recognized medication safety organization) dated 2025, indicated, Safety Tips for Storing Insulin.Do not keep insulin in places that freeze. Never store insulin products in a freezer. If insulin is frozen, do not use even after thawing. Freezing temperatures will breakdown the insulin and then it will not work well to lower your blood sugar.A review of the Prescribing Information (PI, manufacturer's instructions) for Afluria (flu vaccine) injectable suspension, dated March 2025, provided by the facility indicated, Store refrigerated at 2-8 degree Celsius [C, a temperature measurement] (36-46 degree F). Do not freeze. Discard if product has been frozen .

Based on observation, interview, and record review, the facility failed to ensure clean linens (pillows) were handled and stored in a manner that prevented the spread of infection, when clean pillows were observed improperly stored in an area designated for soiled materials.This deficiency had the potential to cause harm by placing residents at risk for contamination from microorganisms.FindingsOn September 18, 2025, at 12:25 p.m., during a tour of the laundry area, multiple clean pillows wrapped in a clear plastic bag, were found stacked in the soiled area of the laundry. The plastic bag of clean pillows were observed tied in one knot but with open areas to escape in and out of the bag.On September 18, 2025, at 12:27 p.m., an interview was conducted with the Laundry Director (LD). The LD stated they did not have room to store the clean pillows. The LD acknowledged that keeping pillows in the soiled area of the laundry room could pose an infection control issue. On September 18, 2025, at 12:29 p.m. an interview was conducted with the Plant Manager (PM). The PM stated the pillows were not fully covered and could cause contamination. A review of the facilities policy and procedure titled, Laundry - Supply & Storage, dated January 1, 2012, indicated, .separate room for the storage of clean linen and soiled linen.separate linen carts labeled.Soiled or Clean Linen, constructed o f washable materials which shall be laundered or suitable cleaned as needed to maintain sanitation .A record review of the facilities policy and procedure titled, Soiled Laundry & Bedding, dated September 2016, indicated, .facility staff handle soiled laundry and bedding in a manner that prevents gross microbial contamination of the air and those handling the linen.washable pillows are laundered in hot water when soiled before exchange between residents.

Based on interview and record, the facility failed to ensure, for one out of one resident reviewed in the care planning process (Resident 7), was involved in the care planning process when Resident 7 was not notified of the gradual dose reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) for the medication Depakote (medication used to treat bipolar disorder [ mental health condition that causes extreme mood swings]).This failure resulted in Resident 7 feeling suppressed when changes were made to her plan of care without her knowledge, involvement, or consent. As a result, this violated Resident 7's right to be involved in her care and provide informed consent. Findings:On September 16, 2025, at 11:25 a.m., Resident 7 was interviewed. Resident 7 that her Depakote dosage was reduced from twice a day to once a day two weeks ago. Resident 7 stated she feels different and more suppressed since then. Resident 7 stated she did not know why no one asked her about how she was coping with the change.On September 18, 2025, Resident 7's medical record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses including bipolar disorder and major depressive disorder (mental illness).A review of Resident 7's Minimum Data Set (MDS - a clinical assessment tool), dated July 14, 2025, indicated Resident 7 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact).A review of Resident 7's IDT (interdisciplinary team - a group of healthcare professionals) PROGRESS NOTES - BEHAVIOR MANAGEMENT, dated August 30, 2025, indicated Resident 7 was recommended for GDR of Depakote to give .Divalproex Sodium Tablet Delayed Release 250 MG (milligram - unit of measurement) Give 1 tablet by mouth in the morning for Bipolar .Resident 7's Medical Orders were also reviewed. Resident 7's previous order of Depakote was discontinued on August 30, 2025, and indicated .Divalproex Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day for Bipolar .On September 18, 2025, at 2 p.m., Resident 7 was interviewed. Resident 7 stated her plan of care was not clear and that she was not involved in meetings regarding dose reduction or changes in the Depakote. Resident 7 stated she was not aware of the change in Depakote and that the staff could not explain why her second daily dose Depakote was discontinued. Resident 7 stated that she has been asking when her psychiatrist would come see her.On September 18, 2025, at 3:07 p.m., the Director of Nursing (DON) was interviewed. The DON stated that the GDR of Depakote for Resident 7 was recommended by the IDT as they were trying to wean her off the medication. The DON stated that she did not mention the change in Depakote to Resident 7. The DON stated the IDT would discuss a plan for GDR of certain medications and they would implement the plan and interventions if the resident agreed. The DON stated that Resident 7 should have been involved in her plan of care and notified of the change. The DON stated. The DON stated that she was not aware that Resident 7 had been asking about the psychiatrist. The DON acknowledged that Resident 7 should have been involved in her care plan, and her rights were violated due to not being notified of the changes made.A review of facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, revised November 2018, indicated, .Each resident and/or resident representative will actively remain engaged in his or her care planning process through the resident's rights to participate in the development of, and be informed in advance of changes in the plan of care .

Based on interview and record review, the facility failed to ensure, for two of five residents (Resident 5 and 10) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when:1. Resident 10 was administered Aripiprazole (medication to treat mental illness) without potential adverse effect monitoring documented during use of risperidone; and2. Resident 5 was given quetiapine (medication to treat mental illness) without following the manufacturer's monitoring guidelines.These failures could have led to unnecessary medications for Residents 5 and 10, increasing the risk of medication interactions, adverse reactions, and side effects such as dyslipidemia (an abnormal balance of lipids or fats in the bloodstream), sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.Findings:1. On September 17, 2025, Resident 10's record was reviewed. A review of Resident 10's admission Record, indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including schizoaffective disorder (mental health condition characterized by psychotic symptoms like hallucinations/delusions and mood episodes like mania or depression).A review of Resident 10's medical record indicated the resident had been receiving Aripiprazole in various doses since July 2023. Resident 10's current Order Summary Report, included a physician's order, date ordered September 11, 2025, which indicated, Aripiprazole 2 mg (milligram, unit of measurement), give one tablet by mouth in the morning for Schizophrenia (mental illness) m/b (manifested by) visual hallucination AEB (as evidenced by) seeing people not there.A review of Resident 10's Care Plan Report, dated June 15, 2025, indicated, At risk for adverse side effects of psychotropic medications Aripiprazole r/t (related to dx (diagnosis) of Schizophrenia with interventions that included, Administer Psychotropic medication as ordered by physician. Monitor for side effects and effectiveness Q (every)- shift.Monitor/document/report PRN (as needed) any adverse reactions of Psychotropic medications.A review of Resident 10's medical record on September 17, 2025, indicated there was no physician's order to monitor side effects related to use of aripiprazole.A review of Resident 10's Medication Administration Record (MAR), dated June 16, 2025 through September 16, 2025, indicated Resident 10 was administered aripiprazole as ordered. There was no documented evidence in Resident 10's medical record that the side effects were monitored and documented by nursing staff during the use of aripiprazole between June 16, 2025, to September 16, 2025.On September 17, 2025, at 12:05 p.m., during an interview and record review, the Director of Nursing (DON) confirmed that nursing staff did not monitor or document side effects during the administration of aripiprazole. The DON acknowledged this should have been done according to the facility's psychotropic and antipsychotic monitoring process. The DON stated monitoring is crucial to ensure residents do not experience negative effects on daily living or discomfort. The DON emphasized the importance of evaluating residents for movement disorders or other side effects to determine if medication adjustments are needed. A review of the Prescribing Information (PI, manufacturer's instructions) for aripiprazole tablet, dated May 2023, retrieved from DailyMed (a public website maintained by the U.S. Food and Drug Administration), indicated, Adverse Reactions.Stroke. Neuroleptic Malignant Syndrome (NMS, rare life-threatening reaction that causes high fever, severe muscle stiffness, confusion). Tardive Dyskinesia (TD, uncontrolled movements of the face and body).Falls.Seizures. Cognitive and Motor Impairment.nausea, vomiting, constipation, headache, dizziness, akathisia (restlessness), anxiety, insomnia (difficulty sleeping). 2. On September 17, 2025, a review of Resident 5's admission Record, indicated Resident 5 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), dementia (memory loss), Parkinsonism (a brain condition that cause slowed movements, rigidity, and tremors), and depression. A review of Resident 5's medical record indicated the resident had been receiving quetiapine in various doses since June 2023. Resident 5's current Order Summary Report, indicated the following physician's orders:- Quetiapine 200 mg, give one tablet by mouth at bedtime for Schizoaffective d/o (disorder) AEB (as evidenced by) angry outbursts, date ordered July 14, 2025; and- Monitor for side effects of antipsychotic medication due to use of Seroquel (brand name for quetiapine) every shift, dated May 13, 2025.A review of Resident 5's MARs, dated May 13, 2025, through September 16, 2025, indicated Resident 5 was administered quetiapine as ordered. On September 17, 2025, at 12:59 p.m., during a concurrent interview and record review, the DON confirmed Resident 5 had been on quetiapine since June 2023. The DON could not find documentation for lipid monitoring as per manufacturer's instructions and emphasized its importance to avoid complications.A review of the PI for quetiapine tablet, dated January 2025, retrieved from DailyMed, indicated, Warnings and Precautions.Dyslipidemia: Undesirable alterations have been observed.Appropriate clinical monitoring.including fasting blood lipid testing at the beginning of, and periodically, during treatment.A review of the facility's policy and procedure titled, Behavior/Psychoactive Medication Management, revised date April 24, 2025, indicated, .Monitoring and Reporting for Side Effects.The resident will be observed and/or monitored for side effects, and adverse consequences.All complications and side effects should be reported to the Healthcare practitioner.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a clinical assessment tool) was accurately coded, for one of three residents reviewed for nutrition (Resident 41).This failure resulted in an inaccurate MDS assessment to be submitted to CMS (Centers for Medicare and Medicaid Services).Findings: On September 18, 2025, Resident 41's record was reviewed. Resident 41 was admitted to the facility on [DATE], with diagnoses which included senile degeneration of the brain (progressive decline in cognitive function that interferes with daily life), Alzheimer's dementia (memory loss), and palliative care (comfort care).A review of Resident 41's Weights and Vitals Summary, indicated the following weights:-155 lbs. (pounds - unit of measurement); June 2, 2025; and-139 lbs.; July 2, 2025; weight loss of 12.58% in a month (significant weight loss is 5% or more).A review of Resident 41's MDS, dated [DATE], Section K for nutrition assessment, indicated no weight loss in the last month.On September 18, 2025, at 5:23 p.m., the Director of Nursing (DON) stated that the previous MDS coordinator incorrectly coded a weight loss. The DON stated the weight loss exceeded 5% in 30 days and should have been coded in the MDS. The DON expects accurate completion of MDS assessments. The DON stated that the facility followed the RAI Manual guidelines for MDS assessments, without a specific policy on their accuracy.A review of the facility's policy and procedure titled, Evaluation of Weight and Nutritional Status, dated January 30, 2025, indicated, Definitions.Weight Loss.Unplanned weight loss in a resident. Significant weight loss (5%& (and)/or 5lb in one month, 7.5% in three months, or 10% in six months), as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss and does not trigger review of the Nutritional Status CAA (care area assessment).A review of the RAI manual, dated October 2024, indicated, .Weight loss can result in debility and adversely affect health, safety, and quality of life.Coding instructions.Code 2, yes, not on physician -prescribed weight-loss regimen: if the resident has experienced weight loss of 5% or more in the past 30 days.and the weight loss was not planned and prescribed by a physician.

Based on interview and record review the facility failed to ensure a copy of the Advance Directive (AD - written instruction for the provision of care and services when unable to make decisions for oneself) was readily available in the chart, for one of 13 residents reviewed for Advance Directives (Resident 4). This failure had the potential for Resident 4's wishes for health care services not to be honored.Findings: On September 17, 2025, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included rhabdomyolysis (a serious medical condition that occurs when muscle tissue breaks down, releasing harmful substances into the bloodstream).A review of Resident 4's Minimum Data Set (MDS- a clinical assessment tool), dated July 2, 2025, indicated Resident 4 had a Brief Interview for Mental Status score of 11 (mild cognitive impairment).A review of Resident 4's Social Services Assessment, dated June 26, 2025, indicated Resident 4 had an AD but was not on file, and a copy was requested from the resident/resident representative.Further review of Resident 4's record indicated there was no copy of Resident 4's AD in the electronic or paper record.On September 18, 2025, at 4:16 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated that Resident 4's record did not have a copy of the AD, which the Social Service Director (SSD) had not yet obtained. The DON confirmed that a copy should be in Resident 4's record and the SSD's AD binder.A review of the facility's policy and procedure titled, Advance Directive, dated July 25, 2024, indicated, .An Advance Directive is defined as a resident's written preference regarding treatment options.During the Social Services Assessment process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive.If the resident has an Advance Directive, the Facility shall request a copy of the document from the family or resident's representative.If a copy is provided by the resident or resident representative, it will be placed in the medical record.

Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for two of five sampled residents (Resident 5 and 10) when: 1. Resident 10 was administered aripiprazole (an antipsychotic medication for mental illness) without potential adverse effect monitoring documented during use of aripiprazole; and 2. Resident 5 was given quetiapine (an antipsychotic medication for mental illness, depression, and schizophrenia) without following the manufacturer's monitoring guidelines. These failures had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for Resident 5 and 10.Findings:1. On September 17, 2025, Resident 10's record was reviewed. A review of Resident 10's admission Record, indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including schizoaffective disorder (mental health condition characterized by psychotic symptoms like hallucinations/delusions and mood episodes like mania or depression).A review of Resident 10's medical record indicated the resident had been receiving Aripiprazole in various doses since July 2023. Resident 10's current Order Summary Report, included a physician's order, date ordered September 11, 2025, which indicated, Aripiprazole 2 mg (milligram, unit of measurement), give one tablet by mouth in the morning for Schizophrenia (mental illness) m/b (manifested by) visual hallucination AEB (as evidenced by) seeing people not there.A review of Resident 10's Care Plan Report, indicated a focus area initiated on June 15, 2025 for At risk for adverse side effects of psychotropic medications Aripiprazole r/t (related to dx (diagnosis) of Schizophrenia with interventions that included, Administer Psychotropic medication as ordered by physician. Monitor for side effects and effectiveness Q (every)- shift.Monitor/document/report PRN (as needed) any adverse reactions of Psychotropic medications.A review of Resident 10's medical record on September 17, 2025, indicated there was no physician's order to monitor side effects related to use of aripiprazole.A review of Resident 10's Medication Administration Record (MAR), dated June 16, 2025, through September 16, 2025, indicated Resident 10 was administered aripiprazole as ordered. There was no documented evidence in Resident 10's medical record that the side effects were monitored and documented by nursing staff during the use of aripiprazole between June 16, 2025, to September 16, 2025.On September 17, 2025, at 12:05 p.m., during an interview and record review, the Director of Nursing (DON) confirmed that nursing staff did not monitor or document side effects during the administration of aripiprazole. The DON acknowledged this should have been done according to the facility's psychotropic and antipsychotic monitoring process. The DON stated monitoring is crucial to ensure residents do not experience negative effects on daily living or discomfort. The DON emphasized the importance of evaluating residents for movement disorders or other side effects to determine if medication adjustments are needed. A review of the CP's monthly MRRs for Resident 10, dated June 24, 2025, July 19, 2025, and August 8, 2025, indicated there were no recommendations from the CP related to side effect monitoring during aripiprazole use. On September 17, 2025, at 3:35 p.m., during an interview and record review with the DON, it was confirmed that there were no recommendations from the CP for monitoring side effects of aripiprazole on June 24, July 19, and August 8, 2025. The DON stated that such recommendations should have been provided for Resident 10.A review of the Prescribing Information (PI, manufacturer's instructions) for aripiprazole tablet, dated May 2023, retrieved from DailyMed (a public website maintained by the U.S. Food and Drug Administration), indicated, Adverse Reactions.Stroke.Neuroleptic Malignant Syndrome (NMS, rare life-threatening reaction that causes high fever, severe muscle stiffness, confusion).Tardive Dyskinesia (TD, uncontrolled movements of the face and body).Falls.Seizures.Cognitive and Motor Impairment.nausea, vomiting, constipation, headache, dizziness, akathisia (restlessness), anxiety, insomnia (difficulty sleeping). 2. On September 17, 2025, a review of Resident 5's admission Record, indicated Resident 5 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), dementia (memory loss), Parkinsonism (a brain condition that cause slowed movements, rigidity, and tremors), and depression. A review of Resident 5's medical record indicated the resident had been receiving quetiapine in various doses since June 2023. Resident 5's current Order Summary Report, indicated the following physician's orders:- Quetiapine 200 mg, give one tablet by mouth at bedtime for Schizoaffective d/o (disorder) AEB (as evidenced by) angry outbursts, date ordered July 14, 2025; and- Monitor for side effects of antipsychotic medication due to use of Seroquel (brand name for quetiapine) every shift, dated May 13, 2025.A review of Resident 5's MARs, dated May 13, 2025, through September 16, 2025, indicated Resident 5 was administered quetiapine as ordered. On September 17, 2025, at 12:59 p.m., during a concurrent interview and record review, the DON confirmed Resident 5 had been on quetiapine since June 2023. The DON could not find documentation for lipid monitoring as per manufacturer's instructions and emphasized its importance to avoid complications.A review of the CP's monthly MRRs for Resident 5 dated May 21, 2025, June 24, 2025, July 19, 2025, and August 8, 2025, indicated there were no recommendations from the CP related to manufacturer's specified monitoring of lipids during quetiapine use. On September 17, 2025 at 3:05 p.m., during a concurrent interview and record review of Resident 5's MRR with the DON, the DON confirmed there were no recommendations from the CP related to manufacturer's specified monitoring of lipids during quetiapine use and stated there should have been recommendations from the CP, from May to August 2025.A review of the PI for quetiapine tablet, dated January 2025, retrieved from DailyMed, indicated, Warnings and Precautions.Dyslipidemia: Undesirable alterations have been observed.Appropriate clinical monitoring .including fasting blood lipid testing at the beginning of, and periodically, during treatment.A review of the facility's policy and procedure titled, Medication Regimen Review, dated October 2012, indicated, The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following.Laboratory results.Resident is monitored for adverse consequences.Side effects, adverse reactions.are evaluated.Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's [active record] and reported to the Director of Nursing, and/or prescriber as appropriate.A review of the facility's policy and procedure titled, Behavior/Psychoactive Medication Management, revised date April 24, 2025, indicated, Monitoring and Reporting for Side Effects.The resident will be observed and/or monitored for side effects, and adverse consequences.All complications and side effects should be reported to the Healthcare practitioner.

Based on interview and record review, the facility failed to ensure the personal funds of a deceased resident was provided to the resident's legal representative with the required timeframe, for one of three residents reviewed (Resident 1). In addition, the facility failed to provide the final financial statement and invoices of the breakdown of personal funds after multiple requests from Resident 1's legal representative.This deficient practice had the potential for loss and misuse of Resident 1's personal funds.Findings:On [DATE], at 10:30 a.m., an unannounced visit was conducted to investigate a complaint. On [DATE], Resident 1's record was reviewed. Resident 1 was admitted on [DATE], and expired on [DATE], with diagnoses which included dementia (memory loss). Resident 1's legal representative was her family member (FM)A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated Resident 1 was severely impaired in cognition. On [DATE], at 11 a.m., during an interview with Resident 1 legal representative (LR), she indicated Resident 1 expired on [DATE]. Resident 1's LR stated she called the facility and spoke with the previous Business Office Manager (BOM) on [DATE], and was informed Resident 1 had over $2000 on the resident's account. Resident 1's LR stated the following after Resident expired on [DATE]:-Called the facility on [DATE], to follow up regarding Resident 1's remaining money with no call back from facility;-Called the facility on [DATE], talked to previous BOM and informed Resident 1's LR that the supervisor had to release the funds;-Called the facility on [DATE], and was told the funds would be released and check would follow, but the previous BOM was not able to tell the LR the amount due to be disbursed;-Spoke with the previous Administrator (ADM) on [DATE], and was told the a check would be issued to the LR representing closed account of Resident 1, but the ADM was not able to tell the amount;-LR received a check amounting to $1,024 on [DATE] (two months after Resident 1 expired), but the facility was not able to provide her an itemized account for the refund;-LR received an invoice from the facility requesting payment from the LR in the amount of $1,311, with no breakdown of the amount due to be paid; and-LR received a check in the amount of $5,458.23, on [DATE], without itemized breakdown of the amount.On [DATE], at 11:30 a.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated the Business Office Manager (BOM) were involved in ensuring the resident's personal funds were to be accounted for when a resident gets discharged from the facility. The DON stated resident legal representative follow up calls should be returned within 24 to 48 hours. The DON further stated if a resident or legal representative request for itemized invoice from the facility, the request should have been sent immediately upon request.On [DATE], at 11:58 a.m., an interview with the Social Services Director (SSD) was conducted. The SSD stated Resident 1 had a trust fund money coming to the facility to cover share of cost or anything else the resident might need. The SSD stated the process was for the BOM to process the remaining money left by a resident upon discharge or upon death, then the corporate staff would process it thereafter. The SSD stated if the resident legal representative requested final financial statements and invoices, it should be sent on request per policy.On [DATE], at 12:10 p.m., an interview and record review with the Business Office Manager (BOM) was conducted. the BOM stated she had just started in the facility about two months. The BOM stated she reviewed Resident 1's record and conferred with the corporate supervisor and indicated the first check Resident 1's legal representative received on [DATE], was a refund, and the second check was from the trust account. The BOM stated any refund or money due to the resident who expired should be sent to the legal representative within 30 days from the death of the resident. The BOM stated any call should be returned to the resident or legal representative immediately and the request for itemized invoice should have been sent immediately upon request.A review of the facility's policy and procedure titled,BO-OP-14A-Refunds-Private, dated [DATE], indicated, .refunds will be processed within 30 days or within state guidelines.A review of the facility's policy and procedure titled, Resident Funds - Transactions, dated [DATE], indicated, .Objectives.provide for an individual and confidential accounting of funds received and disbursed on the resident's behalf.upon notification of a resident's death.business office reviews the resident's records and determines the resident trust account balance.the business office makes a final accounting.administering the resident's estate within 30 days of the death of the resident.A review of the facility's policy and procedure titled, Resident Funds-General, dated [DATE], indicated, .provide for the an individual and confidential accounting of funds received and disbursed on the resident's behalf.provide the resident with.statement .upon request. Statements are printed from the Residential Trust software system.

Based on observation, interview, and record review, the facility failed to ensure an alternative option was offered when a bed bath was refused, for one of five residents reviewed (Resident 1). This failure had the potential for the resident to not receive proper hygiene, feel unclean, and may result to skin irritation and/or skin breakdown. Finding: On April 17, 2025, at 8:50 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care. On April 17, 2025, at 9:10 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was in his room, alert and conversant. Resident 1 stated he gets a shower every Monday and Thursday and due to a recent plumbing issue in the shower room, regular showers were not provided to the residents as scheduled. Resident 1 stated he was offered a bed bath as an alternative to a complete shower. Resident 1 stated he tried the bed bath at first and then he refused the second time it was offered. Resident 1 further stated he was afraid the soap will not be rinsed off well from his body in the bed bath provided. Resident 1 stated if the soap will not be rinsed off well from his body, this could trigger his eczema (a chronic inflammatory skin condition that causes dry, itchy, often inflamed patches of skin). Resident 1 stated he was not given any other alternative options when he refused the bed bath offered. Resident the facility staff should have options or alternatives other than bed bath. On April 17, 2025, a record review was conducted on Resident 1. Resident 1 was admitted to the facility on [DATE]. The History and Physical dated May 19, 2024, indicated Resident 1 had the capacity to make own medical decision. The April Order Summary Report indicated Resident 1 had a current physician ' s order to apply Triamcinolone Acetonide Cream 0.1% (type of topical cream used to relieve redness, itching, swelling, or other discomfort caused by skin condition) to be applied to both lower extremities every day shift for dryness and scabs, date ordered March 25, 2025. The facility document titled, POC Response History, dated April 5 to 12, 2025, indicated Resident 1 refused a bed/towel bath on April 12, 2025, at 2:59 p.m. There was no documented evidence an alternative option was offered to Resident 1 when he refused the bed bath. The facility document titled, Documentation Survey Report, dated April 1 to 30, 2025, indicated Resident 1 refused a shower on April 12, 2025, at 2:59 p.m. There was no other documented evidence an alternative option was offered to Resident 1 when he refused the shower. On April 17, 2025, at 9:45 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated if a resident refused a bed bath, she was not aware of the next thing to do. CNA 1 stated she has no idea and she will just notify the licensed nurses. CNA 1 stated she was not aware of any alternative option if a resident refused a bed bath. CNA 1 stated if a resident will not receive a bed bath or a shower, the resident will smell bad and could have a body odor. CNA 1 further stated the resident would be dirty and not feel fresh. On April 17, 2025, at 9:49 a.m., an interview was conducted with CNA 2. CNA 2 stated they used the same soap and shampoo in the shower or bed baths provided to the residents unless the resident had a skin condition, then they should use a special soap. CNA 2 stated if a resident had a skin condition, a bed bath was not applicable for them if the soap could not be rinsed off the body properly. CNA 2 stated this could cause skin itching and irritation. CNA 2 stated Resident 1 refused a bed bath on April 12, 2025, and she was not sure if other alternative options were offered to the resident. CNA 1 stated she did not have an idea or did not know what to do when a resident refused a bed bath. On April 17, 2025, at 12:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated during the time the facility had plumbing issues in the shower room, she expected the staff to offer bed baths to all residents. The DON stated if a resident refused a bath for some reason, then another option should have been offered. The DON stated if a resident refused a bed bath, the staff should re-offer other alternatives such as calling the family to accommodate the resident for a shower. If the family agreed, the facility can facilitate or coordinate the transportation so the resident could go home for a shower and them come back to the facility. The DON further stated if a resident refused a bed bath and was not given an option to shower, then they will stink will not receive proper good hygiene, and they will become dirty and unhygienic. The DON stated Resident 1 refused bed bath on April 12, 2025, as documented by the CNA. The DON stated the staff did not ask Resident 1 why he refused. The DON stated Resident 1 should have been given an option or offered a shower. The DON stated the staff should have notified the family and offered to accommodate shower at home and would come back to the facility. The facility ' s policy and procedure titled, Resident Rights-Quality of Life, dated March 2017, was reviewed. The policy indicated, .Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being .Resident are groomed as they wish, including- bathing, dressing .

Based on interview and record review, the facility failed to ensure an appropriate orthostatic (standing upright) blood pressure (BP - measurement of the force of blood pushing against the blood walls) monitoring were conducted, for one of three residents reviewed (Resident 6). This failure had the potential for Resident 6 to experience complications related to orthostatic blood pressure. Findings: On March 6, 2025, at 8:50 a.m., an unannounced visit was conducted at the facility to investigate a quality care issue. On March 6, 2025, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s disease (memory loss) and osteoporosis (bone disease). A review of Resident 6 ' s Minimum Data Set (MDS - a tool for assessment), dated January 18, 2025, indicated Resident 6 had a moderately impaired and poor decisions regarding tasks of daily life. A review of Resident 6 ' s care plan goal, dated February 3, 2025, indicated Resident 6 will be free of falls and an intervention which included monitor orthostatic blood pressure every Thursday due to use of Escitalopram (brand of medicine) per pharmacist recommendation. A review of Resident 6's CNA (Certified Nursing Assistant) Task, indicated Resident 6 could stand and able to walk at least 10 feet inside the room. A review of Resident 6 ' s Order Summary, dated February 5, 2025, indicated Residents 6 ' s was monitored for orthostatic blood pressure for lying and sitting every Thursday of the week. A review of Resident 6 ' s Medication Administration Record (MAR), for the month of February 2025, indicated the following orthostatic blood pressure for laying blood pressure (LBP) and sitting blood pressure (SIT): - February 13, 2025, Thursday, LBP 130/60, SIT 128/60, no standing BP was recorded; - February 20, 2025, Thursday, LBP 128/66, SIT 124/64, no standing BP was recorded, and; - February 27, 2025, Thursday, LBP 130/66, SIT 128/64, no standing BP was recorded. There was no evidence of standing blood pressure was taken from Resident 6 for orthostatic blood pressure monitoring. On March 6, 2025, at 12:10 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 6 had history of multiple falls and was monitored for orthostatic blood pressure to evaluate if Resident 6 would have a sudden drop of blood pressure and would cause a possible repeated fall. LVN 1 stated Resident 6 was ambulatory with supervision and minimal assist in activity of daily living (ADL) and had a tendency to stand up and walk abruptly. LVN 1 stated Resident 6 had an order to obtain blood pressure while laying on bed position and sitting position. LVN 1 further stated the licensed nurses did not obtain standing blood pressure for Resident 6. LVN 1 stated the licensed nurses should have taken Resident 6's BP from laying to standing as the resident was ambulatory. On March 6, 2025, at 12:25 p.m., an interview was conducted with LVN 2. LVN 2 stated Resident 6 had an unwitnessed fall at night shift on March 5, 2025, and was sent out to the hospital for further management. LVN 2 stated the common cause of Resident 6 ' s fall last night was probably loss of balance due to sudden drop of blood pressure when she was laying on bed then abrupt standing to walk. LVN 2 stated the facility identified that resident was on orthostatic blood pressure monitoring, but nurses was taking BP in sitting blood pressure instead of standing blood pressure. LVN 2 further stated standing blood pressure should have been taken instead of sitting position. On March 6, 2025, at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected the nurses to follow policy and procedure in obtaining orthostatic blood pressure. The DON stated it would be more accurate if nurses would take standing blood pressure instead of sitting position to monitor the orthostatic blood pressure for ambulatory residents at risk for repeated fall. The DON further stated, I admit it, facility failed to identify the appropriate position to obtain orthostatic blood pressure. A review of the facility ' s policy and procedure titled, Orthostatic Hypotension, dated January 1, 2012, indicated, .To ensure that if a resident is experiencing orthostatic hypotension, there is development of an individualized care plan to address any issues related to orthostatic hypotension .Orthostatic vital signs will be taken and recorded when ordered by the position, and when a sudden drop in blood pressure is suspected as the cause of residents falls .feelings of dizziness and similar occurrences .Orthostatic hypotension is a .drop in .blood pressure within three minutes of standing up .The procedure for taking orthostatic blood pressure is as follows .In lying down position, use the appropriate size of blood pressure cuff of the residents arm .Have the resident stand up, taking precautions to ensure he/she does not fall .If the resident is unable to stand, this reading may be taken while he/she is sitting .

Based on interview and record review, the facility failed to assess the interventions for revisions to address multiple incidents of falls for two of three sampled residents (Residents 7 and 8). This failure had the potential to result in unmet needs and a potential for falls with possible injury. Findings: On December 26, 2024, at 9:13 a.m., an unannounced visit was conducted at the facility to investigate nursing services and accidents issue. A review of Resident 7's admission record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7 was admitted with diagnoses which included cellulitis (bacterial skin infection) of left lower limb, hypertension (force of blood against the artery walls is too high), anxiety disorder (a mental health disorder of worry, or fear that are strong enough to interfere with one's daily activities), difficultly walking and dementia (a group of conditions with impairment of at least two brain functions, such as memory loss and judgement). A review of Resident 7's Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool), dated December 28, 2024, indicated the following: - Resident 7 had a Brief interview for Mental Status (BIMS -a tool used to screen and identify cognitive condition of residents) score of 8 (moderate cognitive impairment); and - Resident 7 was maximum assistance to dependent with ADL's (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating). A review of Resident 7's Progress Notes titled Fall Risk Evaluation, dated November 21, 2024, indicated a score of 12 (a score of 10 or greater, considered at high risk for potential falls). A review of the care plan, developed on November 21, 2024, indicated, The resident is at high risk for falls r/t (related to) left bka (below knee amputation), decreased mobility pad .Goal .will be free of falls through the review date .Interventions/Tasks .Anticipate and meet the resident's needs .The resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs prompt response to all requests for assistance .Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Follow facility protocol .PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Further review of Resident 7's medical records indicated resident had multiple falls dated November 23, 2024, December 7, 2024, and December 17, 2024. A review of the care plans after the actual falls on December 7 and 17, 2024, did not indicate new interventions were added to the care plan. A review of Resident 7's Interdisciplinary Team (IDT-staff from different health care disciplines discuss to help people receive the care they need) Notes, dated December 9, 2024, for fall on December 7, 2024, indicated, to attend activities as needed, which was not included in the care plan post fall. A review of Resident 8's admission record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (a rapid heart rate that can cause poor blood flow), repeated falls, hydrocephalous (a build up of fluid in the cavities within the brain), hypertension ((force of blood against the artery walls is too high), diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease (long standing disease of kidneys leading to renal failure), and chronic obstructive pulmonary disease (a group pf lung diseases that block airflow and make it difficult to breathe). A review of Resident 8's Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool), dated November 20, 2024, indicated the following: - Reside 8 had a Brief interview for Mental Status (BIMS -a tool used to screen and identify cognitive condition of residents) score of 9 (moderate cognitive impairment); and - Resident 8 required moderate to maximum assistance to dependent with ADL's (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating). A review of Resident 8's Progress Notes titled Fall Risk Evaluation, dated November 11, 2024, indicated a score of 17 (a score of 10 or greater, considered at high risk for potential falls). A review of the care plan, developed on November 11, 2024, indicated, The resident is at high risk for falls r/t (related to) Gait/balance problems, increased weakness, hx (history) of multiple falls at home and fall with left hip fracture .Goal .Will be free of falls through the review date .Interventions .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .encourage the resident to participate in activities that promote exercise, physical activity fir strengthening and improved mobility .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) .PT (physical therapy) evaluate and trat as ordered or PRN .The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position; personal items within reach .The resident needs to be evaluated and supplied appropriate adaptive equipment or LPN (licensed practical nurse) devices as needed. Further review of Resident 8's medical records indicated resident had multiple falls December 7, 2024, December 16, 2024, and December 18, 2024. A review of the care plan after the actual fall on December 7, 2024, indicated no new interventions were added to the care plan after the fall. A review of Resident 8's Interdisciplinary Team (IDT-staff from different health care disciplines discuss to help people receive the care they need) Notes, dated December 24, 2024, for fall on December 18, 2024, recommended every one-hour check, which was not included in the care plan post fall. On December 26, 2024, at 2:05 p.m., during a concurrent interview and record review the Registered Nurse (RN) stated for Resident 7 the initial fall risk score was 12. The RN stated there were no new interventions added to the care plan after the falls on December 7 and December 17, 2024. The RN stated an IDT meeting was held on December 9, 2024, for the fall that occurred on December 7, 2024, and it was recommended for resident to attend activities as needed but that was not added to the care plan post fall. The RN further stated interventions should have been updated and discussed to evaluate the need for 1:1 monitoring or to send resident to activities to prevent further falls. The RN stated for Resident 8 there was no change in intervention from the initial care plan after the fall on December 7, 2024. The RN stated an IDT meeting was held on December 24, 2024, for fall on December 18, 2024, and was recommended for every one-hour check, which was not added to the care plan post fall. The RN stated it was important to update interventions to see if that could help a resident and prevent recurring falls. A review of facility's policy and procedure titled, Fall Management Program with a revision date of March 13, 2021, indicated, .if a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score .The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per Care Area Assessment (CAA) guidelines. The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission .upon significant change of condition, post fall and as needed. The licensed nurse will evaluate the Resident's response to the interventions on the Weekly Summary and update the Resident's care plan as necessary .Once the Post-FALL Huddle is completed the licensed nurse will immediately update the care plan with recommendations .The Resident's care plans will be updated with the IDT recommendations.

Based on observation, interview, and record review, for one of five residents reviewed (Resident A), the facility failed to ensure effective pain management was provided when the pain medications were not administered as ordered by the physician after spine surgery. This failure resulted in Resident A to experience severe pain which affected her quality of life and psychosocial well-being. Resident A was eventually transferred to acute hospital for pain management. Findings: On August 16, 2024, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, at 9:15 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was admitted to the facility on [DATE], after 3 p.m. The DON stated Resident A had a spinal compression surgery (a procedure that treats compressed nerves in the spine), and was taking pain medications. The DON stated Resident A started asking for her pain medications by 5 p.m. on the day she was admitted . The DON stated she spoke with Resident A and the resident requested to go to another facility. The DON stated Resident A wanted her pain medications, and the facility did not have the pain medications in the facility as the doctor had to approve the medications before the pharmacy would send them to the facility. The DON stated they offered to Resident A if she wanted to go back to the hospital. On August 16, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with Resident A, inside the resident's room. Resident A was observed lying in bed on her right side facing the wall. Resident A stated she was not doing okay and wanted out of the facility. Resident A stated she was in pain, and the nurses were not giving her the medication she needed. Resident A stated by the morning of August 15, 2024, she was upset and wanted to leave the facility. Resident A stated she waited for hours to get a pain pill when she asked for it, around 4 a.m. the following day after her admission. Resident A was observed crying, and her voice was raised as she spoke. Resident A stated that she wanted to feel better and her legs were having spasms (sudden involuntary muscular contractions) which was causing so much pain. Resident A was observed to wincing as she grabbed her leg and continued to cry. On August 16, 2024, Resident A ' s medical record was reviewed. Resident A's Admission Record, indicated Resident A was admitted on [DATE], with diagnoses which included orthopedic (branch of medicine deals with bones) aftercare, opioid (medication to reduce moderate to severe pain) dependence, spondylosis (abnormal wear on the neck), and spinal stenosis (narrowing of the spinal area causing pressure on the spinal cord, where spinal nerves leave the spinal column) cervical (neck), lumbar (back), lumbosacral (lower back and pelvic) regions. A review of Resident A's History and Physical, dated August 16, 2024, indicated, .associated symptoms include lumbar decompression (reduce pressure) fracture (broken bone) here for management of pain and physical therapy .plan continue her usual pain meds .problem list .opioid (medication to treat pain) dependence with uncomplicated intoxication .Impression .Lumbar compression fracture (occurs when one or more bones in the spine weaken and crumple) .Pain Management . A review of Resident A's care plan, dated August 14, 2024, indicated, .The resident has pain r/t (related to) OA (osteoarthritis-tissue at the end of bones wears down), recurrent stenosis L (lumbar)5 (five) - S (sacral)1 (one), spondylolisthesis (bones in the back slip and pinch nerves causing severe pain), radiculopathy (a condition that occurs when nerve roots in the spine are damaged or injured), lumbar region (spine) .Interventions. Administer analgesia (pain medicine) as per orders. Give 1/2 hour before treatments or care .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .(sign/symptoms) of non-verbal pain .vocalization (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open .tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, ridged, rocking .) .Monitor/record/report to nurse resident complaints of pain or requests for pain treatment .Observe and report .withdrawal or resistance to care . A review of Resident A's care plan, dated August 15, 2024, indicated, .The resident is on pain medication therapy r/t (related to) disease process of RADICULOPATHY, LUMBAR REGION, CHRONIC (long time) PAIN, SPINAL STENOSIS (the spaces inside the bones of the spine get too small), SPONDYLOSIS (age-related degenerative conditions that affect the spine) .Goal .The resident will be free of any discomfort .Interventions .Administer ANALGESIC (pain medicine) medications as ordered by physician . A review of Resident A's Order Summary Report, included the following physician's order related to pain, dated August 14, 2024: - Assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale; 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = excruciating pain .; - Baclofen (medication to treat spasms) Oral Tablet 10 MG (milligram - unit of measurement) Give 1 (one) tablet by mouth three times a day for Muscle spasm .; - Diclofenac Sodium (used to treat pain and inflammation) External Gel 1 % .Apply to right Hip topically (onto skin) three time a day for Pain .; - Diclofenac Sodium External Gel 1 % .Apply to right thigh topically three time a day for Pain .; - Diclofenac Sodium Tablet Delayed Release 75 MG Give 1 (one) tablet by mouth one time a day for pain .; - fentaNYL Transdermal Patch (narcotic pain medication) 72 Hour 50 MCG/HR (microgram [unit of measurement]/HR [hour]) Apply 1 (one) patch transdermally (apply on the skin) in the morning every 3 (three) day(s) for pain management .; - Gabapentin (pain medication) Oral Capsule 300 MG .Give 3 (three) capsule by mouth three times a day for Neuropathy (nerve pain) .; - Lidoderm External Patch (used to relieve the pain) .Apply to lower back topically every 12 hours as needed .; - Methadone HCl (narcotic pain medication) Oral Tablet 10 MG .Give 1 (one) tablet by mouth two times a day for pain .; and - Percocet (narcotic pain medication) Oral Tablet 10-325 MG .Give 1 (one) tablet by mouth every 4 (four) hours as needed for Breakthrough pain . A review of Resident A' s Medication Administration Record (MAR), dated August 2024, indicated the following: - Fentanyl transdermal patch was ordered to start August 15, 2024, at 9:00 a.m., was not applied, medication unavailable; - Methadone 10 mg tablet was not administered to Resident on August 15, 2024, at 9 a.m. and 5 p.m., and August 16, 2024, at 9 a.m. (3 doses) medication unavailable; - Baclofen tablet 10mg was not administered on August 14, 2024, at 10 p.m., and August 15, 2024, at 10 p.m. (two doses); - Diclofenac Sodium gel 1% to be applied to right hip and thigh was not administered to Resident A on August 14, 2024, at 10 p.m., August 15, 2024, at 6 a.m., 2 p.m., 10 p.m., and August 16, 2024, at 6 a.m. (five doses); - Gabapentin capsule 300 mg (3 capsules) was not administered to Resident A on August 14, 2024, at 10 p.m., and August 15, 2024, at 10 p.m. (two doses); - Lidoderm external patch 5% was not applied as needed to Resident A from August 14 to 16, 2024; - Percocet 10/325 mg was administered to Resident A on August 15, 2024, at 4:10 a.m., at 9:34 a.m., on August 16, 2024, at 12:51 a.m., and 11:47 a.m., with pain scale of 6 to 8 out of 10 pain. A review of Resident A's Progress Notes, indicated the following: - August 14, 2024, at 4:01 p.m., .Clinical Admission .Pain issue .New Location: Cervical region (the neck region of the spine). Pain score: 10 (severe pain). Spasm. Frequency: constant .chronic pain related to compression of cervical spine . Further review of Resident A's MAR, for the month of August 2024, indicated Resident A received Percocet for pain on August 15, 2024 at 4:10 a.m. (12 hours after initial pain assessment on admission). - August 15, 2024, at 9:05 p.m., indicated, .Diclofenac Sodium External Gel .awaiting delivery to facility . - August 15, 2024, at 9:05 p.m., indicated, .Baclofen .awaiting delivery to facility . - August 15, 2024, at 9:06 p.m., indicated, .Gabapentin .awaiting delivery to facility . - August 16, 2024, at 9:54 a.m., indicated, Methadone .awaiting pharmacy delivery . - August 16, 2024, at 10:17a.m., indicated, .called pharmacy to follow up on resident narcotics (medications) with narcotic department stating they spoke with (name of physician) on 08/14/2024 (August 14, 2024) .Per pharmacy (name of physician) stated she would clarify order with facility then call pharmacy back. Pharmacy stated that they have not received a return call from (name of physician). The case manager requested to reach back out to (name of physician) . - August 16, 2024, at 10:30 a.m.: indicated, .fentanyl Transdermal Patch .pending pharmacy delivery . - August 16, 2024, at 10:34 a.m., indicated, .Late entry for 8/14/24 (August 14, 2024 at 1915 (7:15 p.m.) .Resident upset her medications were not available upon arrival to facility, expressed wanting to leave facility AMA (Against Medical Advice). This nurse informed resident her medications would be delivered by our contracted pharmacy, after MD (physician) authorized .Medication details were not discussed with resident . - August 16, 2024, at 12:45 p.m., indicated, .Resident is stating that her pain is 10/10 throughout her entire body .given pain medication per order at 1147 (11:47 a.m.) with results ineffective .n/o (new order) received to send to ER for further evaluation . - August 16, 2024, at 12:49 p.m., indicated, .MD notified of resident complain of back pain, Md did a video call with resident to see if we can offer an extra Percocet but resident stated she wants her pain to be managed. Md notified resident that her Methadone and fentanyl was authorized and will be waiting for delivery .The resident opted to go back to hospital for pain management . - August 16, 2024, at 1:28 p.m., indicated .Pt sent out to ER per MD for c/o (complain of) excruciating 10/10 unmanageable pain . On August 16, 2024, at 10:45 a.m., a concurrent interview and review of Resident A's record was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 reviewed Resident A's MAR and stated some of Resident A's medications were delivered. However, LVN 1 stated Resident A's Fentanyl patch and Methadone, had not been received from the pharmacy yet after the medications were ordered on August 14, 2024. LVN 1 stated Resident A's Percocet was taken out of the E-kit (emergency medication kit). Resident A did not receive any pain medications this morning and had not received any Lidocaine 5% patches for her back pain. LVN 1 stated the doctor was supposed to authorize the medications still needing to be delivered from the pharmacy. On August 16, 2024, at 12:10 p.m., an interview was conducted with the DON. The DON stated Resident A's medications (Methadone, Fentanyl patch, and Percocet) had not been received from the pharmacy. The DON stated the pharmacy needed authorization from the doctor, the doctor needed to verify the medications, and call the pharmacy to authorize them. The DON stated she has not heard from the pharmacy or the doctor since August 14, 2024. The DON stated once medications were faxed to the pharmacy it generally takes four to six hours to receive them in the facility, and if faxed after 4:00 p.m., the medications are to be received the next morning. The DON stated we called the pharmacy this morning, August 16, 2024, at 10:17 a.m., to find out where the medications are and the pharmacy told them the medications are supposed to be delivered this afternoon (two days after admission). The DON stated the nursing staff would assess the resident's pain every shift, and when passing medications, the nursing staff would document the pain level assessment in the MAR, the nursing staff should have asked Resident A during morning medication pass if she was having any pain. The DON stated Resident A was here for pain management and rehabilitation therapy, and it was not acceptable for Resident A who had been in the facility for almost 48 hours and has not received her medications and may be experiencing some withdrawal symptoms. The DON stated we offered to send Resident A back to the hospital on August 14, 2024, and Resident A stated she would wait until the morning to receive her pain medicines, and on August 15, 2024, we did not offer to send Resident A back to the hospital, her pain was being controlled. On August 16, 2024, at 12:34 p.m., an interview was conducted with Resident A together with the DON. The Ombudsman was observed to be at beside with Resident A. Resident A stated she received some Percocet, but her pain was off the chart since admission, on August 14, 2024. Resident A stated she had been in excruciating pain, she just wanted her medications. Resident A began crying and stated she was hurting and wanted to end her life. Resident A stated she did not want to feel this way anymore. On August 16, 2024, at 1:20 p.m., Resident A was observed to be sent out to the hospital for pain management. A review of the facility's policy and procedure titled Pain Management, dated November 2016, indicated, .To ensure the assessment and management of the resident's pain to the extent possible when such services are required .staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible .Pain Assessment Flow Sheet .will be initiate for residents who require pain management .Licensed Nurse will administer pain medication as ordered and document .Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift .the pain has not been relieved with current medication, the Licensed Nurse will notify the attending physician .audit and assess the success of the pain management program .

Based on observation, interview, and record review, the facility failed to ensure, for one of five residents sampled (Resident A) had equipment to use was being maintained in a safe and operable condition when the left brakes of the wheelchair was not working. This failure had the potential to cause injury to Resident A when she was using a wheelchair. Findings: On August 16, 2024, at 8:30 a.m., an announced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, at 10:30 a.m., an observation and concurrent interview was conducted with Resident A. Resident A was lying in bed on her right side facing the wall. Resident A stated she was not doing okay and wants out of the facility. Resident A stated when she wants to get up and go to the bathroom, she presses her call light, but the staff do not show up, and she had to try to take herself to the bathroom. Resident A stated the wheelchair was broken, and it was difficult for her to transfer herself to the wheelchair to go to the bathroom. Resident A stated the brake on her wheelchair was broken. The left brake of the wheelchair was observed would not lock when attempted to apply both hand brakes to the wheelchair. On August 16, 2024, at 11:05 a.m., an interview was conducted with the Physical Therapist (PT). The PT stated there were several wheelchairs in the facility residents may use if a resident does not have a personal wheelchair. The PT stated the facility would provide wheelchairs for the residents to use, usually one per room when appropriate. The PT stated all wheelchairs were expected to be cleaned, without rips or tears in them, arms of the wheelchairs should also not contain holes or tears, maintenance should be ensuring all wheelchairs are in a safe and working order. The PT stated if the brakes were not working on a wheelchair, the wheelchair should not be used, it should be tagged and a maintenance request put in to have the wheelchair fixed. On August 16, 2024, at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated normally we make sure equipment was within working order before a resident is assigned to a room upon admission. The DON stated we did not know when Resident A was coming to the facility, and if Resident A had a wheelchair with a brake not working, Resident A could have told us. The DON stated all equipment should be in working order prior to a resident being admitted to a room. On August 16, 2024, Resident A's medical record was reviewed. Resident A was admitted on [DATE], with diagnoses which included orthopedic (branch of medicine deals with bones) aftercare, opioid (controlled class of pain medication) dependence, spondylosis (abnormal wear on the neck), and spinal stenosis (narrowing of the spinal area causing pressure on the spinal cord, where spinal nerves leave the spinal column) cervical (neck), lumbar (back), lumbosacral (lower back and pelvic) regions. On August 20, 2024, at 4:45 p.m., an interview was conducted with the DON. The DON stated any equipment found to not be working properly or broken in the facility, should not be use, it should be put aside, a request placed in the maintenance log, explaining what is wrong with the equipment, and the item should be taken outside, and fixed. A review of the facility's policy and procedure titled Maintenance Service, dated January 1, 2012, indicated, .The maintenance department maintains all areas of the building, grounds, and equipment .equipment in a safe and operable manner at all times .in compliance with current federal, state, and local laws, regulations, and guidelines .establishing priorities in providing repair service .maintaining a schedule of maintenance service .a copy of the maintenance schedule .

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of a resident, for one of five residents reviewed (Resident A), when medications (pain medications and Nictoine patch [medication for smoking cessation]) were not acquired by the facility timely. This failure resulted in a delay in the care and treatment of Resident A's overall health condition. In addition, this failure had the potential for other residents to have a delay in the care and treatment. Findings: On Augsut 16, 2024, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate an allegation of quality of care. On August 16, 2024, at 9:15 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident A was admitted to the facility on [DATE], after 3 p.m., after a spine surgery. The DON stated Resident A was prescribed pain medications such as Fentanly (narcotic pain medication), Methadone (narcotic pain medication), and Percocet (narcotic pain medication), and Nicotine patch. The DON stated at around 5 p.m. on August 14, 2024, Resident A was asking for her pain medications. The DON stated she explained to Resident A that the facility did not have the prescribed medications. On August 16, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with Resident A. Resident A was observed lying in bed on her right side facing the wall. Resident A stated she was not doing okay and wanted out of the facility. Resident A stated she was in pain, and the nurses were not giving her the medication she needed. Resident A stated by the morning of August 15, 2024, she was upset and wanted to leave the facility. Resident A stated she waited for hours to get a pain pill when she asked for it, around 4 a.m. the following day after her admission (August 14, 2024). Resident A was observed crying, and her voice was raised as she spoke. Resident A stated that she wanted to feel better and her legs were having spasms (sudden involuntary muscular contractions) which was causing so much pain. Resident A was observed wincing as she grabbed her leg and continued to cry. On August 16, 2024, Resident A's record was reviewed. Resident A's Admission Record, indicated Resident A was admitted on [DATE], with diagnoses which included orthopedic (branch of medicine deals with bones) aftercare, opioid (medication to reduce moderate to severe pain) dependence, spondylosis (abnormal wear on the neck), and spinal stenosis (narrowing of the spinal area causing pressure on the spinal cord, where spinal nerves leave the spinal column) cervical (neck), lumbar (back), lumbosacral (lower back and pelvic) regions. A review of Resident A's Order Summary Report, included the following physician ' s order, dated August 14, 2024: - Baclofen (medication to treat spasms) Oral Tablet 10 MG (milligram - unit of measurement) Give 1 (one) tablet by mouth three times a day for Muscle spasm .; - Diclofenac Sodium (used to treat pain and inflammation) External Gel 1 % .Apply to right Hip topically (on skin) three time a day for Pain .; -- Diclofenac Sodium External Gel 1 % .Apply to right thigh topically three time a day for Pain .; - Diclofenac Sodium Tablet Delayed Release 75 MG Give 1 (one) tablet by mouth one time a day for pain .; - fentanyl Transdermal Patch (narcotic pain medication) 72 Hour 50 MCG/HR (microgram [unit of measurement]/HR [hour]) Apply 1 (one) patch transdermally (apply on the skin) in the morning every 3 (three) day(s) for pain management .; - Gabapentin (pain medication) Oral Capsule 300 MG .Give 3 (three) capsule by mouth three times a day for Neuropathy (nerve pain) .; - Lidoderm External Patch (used to relieve the pain) .Apply to lower back topically every 12 hours as needed .; - Methadone HCI (hydrochloride-salt used to stabilize a medication) (narcotic pain medication) Oral Tablet 10 MG .Give 1 (one) tablet by mouth two times a day for pain .; and - Percocet (narcotic pain medication) Oral Tablet 10-325 MG .Give 1 (one) tablet by mouth every 4 (four) hours as needed for Breakthrough pain . - Nicotine Transdermal (on the skin) Patch (medication for smoking cessation) 24 hour 7 MG/24HR (Nicotine) Apply 1 (one) patch transdermally in the morning for Smoking Cessation . A review of Resident A's Medication Administration Record (MAR), for the month of August 2024, indicated the following medications were not administered timely as ordered by the physician: - Gabapentin 300 mg (three capsules); August 14 and 15, 2024 at 10 p.m. (two doses); - Diclofenac sodium External Gel 1% (to be applied to right hip and right thigh); August 14, 2024, at 10 p.m.; August 15, 2024, at 6 a.m., 2 p.m., and 10 p.m. (four doses); - Baclofen 10 mg; August 14 and 15, 2024 at 10 p.m. (two doses); - Methadone 10 mg; August 15, 2024, at 9 a.m. and 5 p.m.; August 16, 2024, at 9 a.m. (three doses); - Nicotine 7 mg/hr patch; August 15 and 16, 2024 (two doses); and - Fentanyl Transdermal Patch (to be applied every three days); August 15, 2024. A review of Resident A ' s Progress Notes, indicated the following: - August 14, 2024, at 6:19 p.m., indicated, .Methadone .Awaiting pharmacy delivery . - August 15, 2024, at 5:47 a.m., indicated, .Diclofenac Sodium External Gel .Pending pharmacy arrival . - August 15, 2024, at 10:09 a.m., indicated, .pending from pharmacy awaiting MD (physician) signature . - August 15, 2024, at 1:41 p.m., indicated, .Diclofenac Sodium External Gel .pending pharmacy delivery . - August 15, 2024, at 9:05 p.m., indicated, .Diclofenac Sodium External Gel .awaiting delivery to facility . - August 15, 2024, at 9:05 p.m., indicated, .Baclofen .awaiting delivery to facility . - August 15, 2024, at 9:06 p.m., indicated, .Gabapentin .awaiting delivery to facility . - August 15, 2024, at 9:07 p.m., indicated, .Methadone .awaiting delivery to facility . - August 16, 2024, at 9:28 a.m., indicated, .Nicotine Transdermal patch .awaiting pharmacy delivery . - August 16, 2024, at 9:54 a.m., indicated, .Methadone .awaiting pharmacy delivery . - August 16, 2024, at 10:17a.m., indicated, .called pharmacy to follow up on resident narcotics (medications) with narcotic department stating they spoke with (name of physician) on 08/14/2024 (August 14, 2024) .Per pharmacy (name of physician) stated she would clarify order with facility then call pharmacy back. Pharmacy stated that they have not received a return call from (name of physician). The case manager requested to reach back out to (name of physician) . - August 16, 2024, at 10:30 a.m.: indicated, .fentanyl Transdermal Patch .pending pharmacy delivery . On August 16, 2024, at 10:45 a.m., a concurrent interview and review of Resident A's record was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 reviewed Resident A's MAR and stated some of Resident A's medications were delivered. LVN 1 stated, Resident A's Fentanyl patch, Methadone,and Nicotine patch had not been received from the pharmacy yet, the medications were ordered on August 14, 2024. LVN 1 stated Resident A did not receive any pain medications this morning and had not received any Lidocaine 5% patches for her back pain. LVN 1 stated the doctor was supposed to authorize the medications still needing to be delivered from the pharmacy. On August 16, 2024, at 12:10 p.m., an interview was conducted with the DON. The DON stated Resident A's medications (Methadone, Fentanyl patch, and Percocet) had not been received from the pharmacy. The DON stated the pharmacy needed authorization from the doctor, the doctor needed to verify the medications, and call the pharmacy to authorize them. The DON stated she has not heard from the pharmacy or the doctor since August 14, 2024. The DON stated once medications were faxed to the pharmacy it generally takes four to six hours to receive them in the facility, and if faxed after 4:00 p.m., the medications are received the next morning. The DON stated we called the pharmacy this morning, August 16, 2024, at 10:17 a.m., to find out where the medications are, the medications are supposed to be delivered this afternoon (two days after admission). The DON stated Resident A was here for pain management and rehabilitation therapy, and it was not acceptable for Resident A who had been in the facility for almost 48 hours and has not received her medications and may be experiencing some withdrawal symptoms. On August 16, 2024, at 4 p.m., a follow up interview and review of the pharmacy delivery receipt was conducted with the DON. The DON stated the pharmacy receipt, dated August 15, 2024, indicated some of Resident A's medications were received, which included Baclofen, Diclofenac tablet, Gabapentin, and Lidociane patch. A review of the facility's policy and procedure titled, Medication Ordering and Receiving from Pharmacy, dated October 2012, indicated, .A pharmacy provides a method of confirmation of receipt of medications by the driver for each delivery that leaves the dispensing pharmacy .

Based on interview and record review, the facility failed to ensure residents' mail or packages were not opened without prior consent from the resident, for two of five residents sampled (Residents B and C). This failure resulted in Resident B and C's rights not being respected. Findings: On August 16, 2024, at 8:30 a.m., an announced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, Resident B's medical record was reviewed. Resident B was admitted to the facility on [DATE], with diagnoses which included heart failure and prostate (a male reproductive gland) cancer. A review of Resident B's Minimum Data Set (MDS - an assessment tool), dated April 24, 2024, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact). On August 20, 2024, at 11:30 a.m., during an interview with Resident B, Resident B stated he did not like when the staff opened his packages, he thought it was a violation of his rights, and he did not give them permission to do so. On August 20, 2024, at 12:00 p.m., during an interview with Resident C. Resident C stated he did not like when the staff opened his packages, including his health plan letters, and supply catalog. Resident C stated he would get the package after it has been opened and the staff have removed items he ordered. Resident C stated he did not remember giving the facility permission to open up any of his mail or packages. On August 20, 2024, Resident C s medical record was reviewed. Resident C was admitted to the facility on [DATE], with diagnoses which included bimalleolar fracture (broken ankle) and left tibial fracture (broken lower leg bone). Resident C's Minimum Data Set, July 8, 2024, indicated Resident C had a BIMS score of 14 (cognitively intact). On August 20, 2024, at 2:10 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the protocol for resident's mail or packages include, all mail and packages being received at the nurse's station, taken to the business office first, then the mail and packages would go to Social Services, and items were to be divided between the case manager and the activities department. The DSD stated the mail and packages were then to be delivered to the residents and staff would open all packages in front of the resident, to do inventory with them. A review of the facility's policy and procedure titled Resident Rights-Mail, dated January 1, 2012, indicated, .Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail unopened .Mail is delivered to the resident unopened. Facility staff will not open mail for the resident unless the resident requests them to do so . A review of the facility's undated document titled Resident Rights, indicated, .Personal privacy .including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility .

Based on interview and record review the facility failed to ensure sufficient licensed nurses with the appropriate competencies and skill sets necessary to care for one (Resident A) of six sampled residents' needs, as identified through resident assessments, and described in the plan of care. This failure has the potential to affect the provision of care for Resident A and other residents at the facility. Findings: On September 11, 2024, at 12:30 p.m., an announced visit to the facility was conducted to investigate a complaint for quality of care. On September 16, 2024, at 11 a.m., Resident A ' s Admission Record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke-loss of blood flow to a part of the brain), epilepsy (a disorder in which nerve cells in the brain are disturbed, causing seizures), and aphasia (a disorder that makes it difficult to speak). A review of Resident A ' s Order Summary Report indicated: - July 15, 2024, Observe for discolored urine, black tarry stools, sudden severe headache, n/v (nausea, vomiting), diarrhea, muscle joint pain, lethargy (lack of energy), bruising, sudden changes in mental status and/or VS (vital signs-reflect body functions-heart rate, blood pressure, temperature, breathing rate), SOB (shortness of breath), nosebleed every shift, for use of Apixaban (Eliquis- blood thinner), if symptoms exist, document Y for yes or N for no. If yes, document findings in a progress note or a change of condition. -August 7, 2024, Monitor left side of face discoloration and edema (buildup of fluid in the body ' s tissue) everyday shift for s/p (status post-after) fall injury. -Observe for discolored urine, black tarry stools, sudden severe headache, n/v, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, and/or VS (vital signs), SOB (shortness of breath), nosebleed every shift for use of Apixaban. A review of Resident A ' s document titled,SBAR (Situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among a patient) Communication Form,indicated the following: -dated August 6, 2024, . Resident was found on the floor by staff on left side of the body noted, no other injuries noted .Recommendations of Primary Clinicians (doctor) .monitor continue neuro (neurological) checks X ray of area . -dated August 7,2024, .Altered level of consciousness .8/6/24 (August 6, 2024) pt had fall .Skin evaluation .no changes observed .patient noted to have edema to left side of face and purple discoloration to left, no response to verbal stimuli, pt opened eyes with sternal rub .vitals are abnormal temperature 102, respiratory rate 24, Pulse rate 142, blood pressure 167/100 . A review of Resident A ' s document titled Weights and Vitals Exceptions indicated: -On August 6, 2024, at 3:20 p.m., BP 140/99, Pulse 122 (regular-Rhythm of heart rate) -On August 7, 2024, at 5:21 a.m., BP 176/114, Pulse 141 (irregular-new onset) -On August 7, 2024, at 9:06 a.m., BP 167/100, Pulse 142 (irregular-new onset) -On August 7, 2024, at 11:29 a.m., BP 160/90, Pulse rate 105 (regular) A review of Resident A ' s Care Plans indicated: - .Resident is on anticoagulant (blood thinner) therapy Apixaban r/t (related to) stroke . dated March 13, 2024, .Interventions .monitor/document/report PRN (as needed) adverse reactions (undesired harmful effect resulting from a medication) of Anticoagulant therapy .bruising .sudden change in mental status, significant or sudden change in v/s (vital signs), review medication list for adverse reactions. Avoid use of aspirin or NSAIDS (non-steroidal anti-inflammatory drugs-used to relieve pain, reduce swelling) . - .had an actual fall with injury r/t (related to) poor balance, seizure, Type 2 (two) DM (Diabetes Mellitus-characterized by high sugar levels in the blood), HX (history) of stroke ., dated August 6, 2024, .Interventions .monitor x (times) 72 hours for coc (change of condition), Neuro-checks x (times) as schedule, notify MD of any changes . - .COC (change of condition) .Patient with ALOC (altered level of consciousness), abnormal vitals . dated August 7, 2024, .Interventions . monitor left side of face discoloration and edema, notify MD/RP (resident representative) . A review of Resident A ' s Neurological Flow Sheet, indicated the following: -On August 6, 2024, was reviewed, neuro check at 3:00 p.m. indicated BP increased to 140/99, and pulse rate 122, at 7:00 p.m. pulse rate 110, and at 11:00 p.m. pulse rate 108. -On August 7, 2024, at 3:00 a.m. BP elevated 170/90, pulse rate 110, at 7:00 a.m. BP 169/100, pulse rate 136. Further review of Resident A ' s record did not indicate any documentation that the elevated blood pressure and elevated pulse rate was addressed on August 6, 2024 (at 3 p.m., at 7 p.m.; and 11 p.m.) and on August 7, 2024 (at 3 a.m. and 7 p.m.). On September 16, 2024, at 2:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she came in at 6:45 a.m., on August 6, 2024, and Resident A was already in her bed, with a bruise on her check. CNA 1 stated if the heart rate is 50 bpm or less or 100 bpm or more, it is important to tell the charge nurse. CNA-1 stated if a pulse rate is 120 bpm or more, she would tell the charge nurse immediately, fill out a stop and watch form, and give it to the licensed nurse, and the licensed nurse would fill out a COC. On September 16, 2024, at 3:15 p.m., an interview was conducted with CNA 3. CNA 3 stated Resident A ' s heart rate was 122 bpm, and her Blood Pressure was 140/99 at the beginning of the shift, around 3:00 p.m., onAugust 6, 2024. CNA 3 stated it was reported to the licensed nurse. CNA-3 stated when she takes a resident ' s vital signs, and if they are abnormal, she may need to adjust the blood pressure cuff or reposition the resident and try again, if the vital signs are still abnormal, would let the licensed nurse know and write it on a Stop & Watch form. CNA-3 stated if a resident had a heart rate of 142 bpm, and it was an irregular rhythm, she would check the radial (wrist) or apical (bottom tip of the heart-area over the left chest wall below the nipple line, need a stethoscope to hear the heartbeat) pulse to confirm, and go straight to the licensed nurse and tell them immediately. On September 16, 2024, at 4:05 p.m., an interview was conducted with CNA 4. CNA 4 stated she was the CNA working the night shift and she stated the CNAs normally take vital signs at the beginning of their shift, working nights, she would try to get vital signs on her patients between 11:00 pm and 12:00 a.m. to not disturb them. CNA 4 stated she does not remember when she took Resident A ' s vital signs, Resident A ' s heart rate was 142 bpm and blood pressure was 176/111, she should have told the charge nurse right away and she did not. CNA-4 stated she manually put the vital signs into the electronic medical record at 5:00 a.m. but forgot to let the charge nurse know, if she had told the charge nurse about Resident A ' s vital signs being out of range and irregular, the charge nurse would have called the Director of Nursing (DON), and Resident A ' s blood pressure and pulse would have been re-checked, she failed to tell the nurse. CNA 4 stated she thought Resident A ' s heart rate and blood pressure were high because of her falling, Resident A looked beat up, Resident A ' s face was swollen, CNA-4 was surprised Resident A had not been sent to the emergency room . On September 16, 2024, at 5:25 p.m. an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he was the charge nurse on the evening shift August 6, 2024, after Resident A fell . LVN 1 stated CNA 3 had told him, Resident A ' s heart rate was 122 bpm, and the blood pressure was 140/99, he asked Resident A if she was in pain. LVN 1 stated he does not remember giving Resident A any additional medication to help with her heart rate or blood pressure and does not remember if Resident A ' s heart rate and blood pressure were lower as the shift progressed. On September 17, 2024, at 12 p.m., an interview was conducted with LVN 2. LVN 2 stated she was the charge nurse who took care of Resident A on the night shift, of August 6th through August 7, 2024. LVN 2 stated she did not know about Resident A ' s high heart rate or blood pressure until after Resident A went to the hospital. LVN 2 stated she was monitoring Resident A ' s vital signs and neurological checks every four hours. LVN 2 stated she did not know Resident A had an irregular heart rate of 142, or high blood pressure of 176/114. She stated if she had known, she would have assessed Resident A, asked the other licensed nurse in the facility to also assess Resident A and recheck the vital signs, then she would have checked Resident A ' s code status, and let the Director of Nursing (DON) know she was calling 911, and call the doctor and Resident A ' s family. On September 17, 2024, at 4:45 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the CNAs and the licensed nurses have been in-serviced on needing to be aware of abnormal vital signs, and when to complete a change of condition form. The DSD stated the licensed nurses should have called the DON or the physician when Resident A ' s vital signs were abnormal. A review of Resident A ' s record indicated the resident was transferred to the hospital on August 7, 2024, at approximately 9:30 a.m. A review of Resident A ' s hospital records indicated the resident had a sinus tachycardia (fast heart rate) with PVC (pre-ventricular contractions-extra heart beats that begin in the lower portion of the heart-disrupts a regular rhythm), Incomplete Right Bundle Branch Block (a partial interruption in the flow of electrical impulses in the heart to beat regularly). A review of a document used for training titled Anticoagulant (blood thinner-a medication used to prevent the blood from clotting) and Antiplatelet (medication used to prevent blood clots from forming) Use: Indications and Monitoring, no date, indicated .intense monitoring for unspecified or uncomplicated ' bruising ' is not recommended or required .UNUSUAL bruising (i.e. bruises that develop without known cause or grow in size) should be regularly monitored and reported .to the physicians a change of condition (COC) . A review of the facility ' s policy and procedure titled, Fall Management Program, dated March 13, 2021, indicated .provide residents a safe environment that minimizes complications associated with falls .following every resident fall, the licensed nurse will perform a post-fall evaluation .for an unwitnessed fall .with suspected or known head injury, the licensed nurse will complete neurological checks for 72 hours following the fall incident .the Attending physician will be informed if there is a deviation (abnormal) from the Resident ' s baseline (normal) status for further instructions . A review of the facility ' s policy and procedure titled, Change of Condition Notification, dated April 1, 2015, indicated .ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition in a timely manner .The facility will promptly inform the resident, consult with the resident ' s attending physician .when the resident endures a significant change in their condition caused by, but not limited to .an accident .a significant change in the resident ' s physical, mental status . ' Change of Condition ' related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denote (indicate) a new problem .and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan .It is the responsibility of the person who observes the change to report the change to the licensed nurse .the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review .Licensed Nurse will notify the resident ' s Attending Physician . when there is an .accident involving the resident which results in injury .deterioration in health .clinical complications .Emergency Situations .

Based on observation, interview, and record review, the facility failed to ensure, for one of three residents reviewed (Resident A), was free from physical abuse when the Certified Nursing Assistant (CNA) grabbed both Resident A's arms and hands and continued with care while the resident was being combative during provision of care. This failure resulted in Resident A to have discolorations on both arms, hands, left side of the cheek, and neck area. In addition, Resident A was not able to tell the CNA to stop as she was afraid and felt threatened by CNA 1. Findings: On August 7, 2023, at 9:40 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On August 7, 2023, at 9:46 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Licensed Vocational Nurse (LVN) 1 noted Resident A with some discolorations on her upper extremities and left side of the face on July 23, 2023, at around 9 a.m. The DON stated LVN 1 indicated the discolorations were not there when she cared for her on July 22, 2023. The DON stated LVN 1 interviewed Resident A and the resident indicated a CNA who provided care for her from the previous night during NOC shift (11 a.m. to 7 a.m.) was rough with her. Resident A further stated the CNA hit her on the face and grabbed both her wrist together while she was turned to her side in the bed. The DON stated the alleged CNA (CNA 1) was interviewed and stated that when she came to change the resident's brief, Resident A was yelling, screaming, scratching her, and was being uncooperative with care. The DON stated CNA 1 continued to provide care for Resident A despite the resident resisting care. On August 7, 2023, at 10:47 a.m., Resident A was observed awake, alert, and sitting down in her wheelchair in the hallway. Resident A was observed to have multiple scattered red, pink, and purple discolorations on her right forearm approximately measuring 10 cm (centimeters- unit of measurement) by 10 cm, and dark red discolorations measuring 2 cm by 2 cm on her left posterior (back) hand. In a concurrent interview with Resident A, she stated she had discolorations on her left side of the face after the incident but it went away. Resident A stated a CNA from the night shift was rough with her. She stated she needed her brief to be changed, but CNA 1 took a long time to get to her. She stated when CNA 1 came into her room to change her brief, CNA 1 told her to shut up and grabbed both of her hands (while both hands crossed together close to her chest) and jabbed it to her chest several times. Resident A further stated she did not tell the CNA to stop because she was afraid and felt threatened by her. On August 7, 2023, Resident A's clinical record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included calorie malnutrition (imbalance of nutrients in the body), muscle weakness, anxiety, and dementia (cognitive impairment). A review of Resident A's Order Summary Report, dated August 11, 2023, indicated Resident A was on aspirin (medication used to prevent blood clot) to be given once a day for cerebrovascular accident (CVA - stroke) prophylaxis (prevention), with order date of February 27, 2023. A review of Resident A's Minimum Data Set (MDS- an assessment tool), dated July 10, 2023, indicated Resident A required two-person physical assist with toileting. A review of Resident A's Weekly Skin/Wound Assessment, dated July 22, 2023, indicated Resident A's skin was intact with no identified skin impairment and skin was fragile. A review of Resident A's Progress Notes, dated July 23, 2023, indicated, .Resident has bluish discoloration or bruises to the right forearm and bluish-purple discoloration to the left hand. There was also pinkish blue skin discoloration about the size of a penny to the left side of the face, one by the chin and other area by end of the mandible (chin bone) . On August 7, 2023, at 12 p.m., an interview was conducted with Administrator (ADM). The ADM stated Resident A was screaming and yelling at CNA 1 while CNA 1 was changing the resident's brief during the NOC shift of July 22, 2023. The ADM stated CNA 1 continued with the provision of care despite Resident A being uncooperative. He stated CNA 1 should have asked for assistance from another staff to help with brief change and/or have waited to do the brief change later when Resident A was calm. The ADM further stated, CNA 1 had poor judgement and probably just wanted to get her work done. The ADM further stated if CNA 1 would have asked for help, the incident or discolorations could have been avoided. The ADM stated CNA 1 did not follow protocol when providing care for Resident A who was exhibiting resistive behavior on July 22, 2023. On August 11, 2023, at 1:40 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. She stated she observed Resident A with multiple discolorations on her body in which she stated the multiple discolorations were not present before when she cared for the resident the previous day on July 22, 2023. She stated Resident A had discolorations which covered her entire hand, bluish discoloration on her right forearm from the wrist to the elbow, and bluish discolorations approximately size of a penny on her left side of the face near the chin bone. She stated Resident A's skin was very fragile and the resident was on a blood thinner medication which would make the resident at risk for bruising. She stated the staff should need to be very gentle with Resident A during care. LVN 1 stated it was possible for Resident A to have the multiple discolorations if someone held her too tight. On August 14, 2023, at 11:08 a.m., a follow up interview was conducted with the DON. The DON stated when she interviewed CNA 1 on July 24, 2023, CNA 1 stated Resident A was screaming and scratching her while she was changing her diaper and had to hold Resident A's arms to prevent the resident from scratching her . The DON further stated Resident A was on aspirin (medication used to thin the blood to prevent blood clots) which could make her bruise easily and the staff should need to be very gentle with her when providing care. She stated CNA 1 did not follow protocol and should have asked for assistance when Resident A was being uncooperative during diaper change. The facility's policy and procedure titled Dementia Care, dated October 2017, was reviewed. The policy indicated, .To optimize the quality of life for individuals living with a diagnosis of dementia at the facility .it is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards of meeting health, psychological, and behavioral needs of residents living with dementia .The facility will provide a supportive environment that promotes comfort and recognizes individual needs and preferences by focusing on consistent staffing, empowering nurse aides, promoting team involvement, and building relationships .Individualized approaches to care are utilized to address BSBP (Behavioral or Psychological Symptoms of Dementia), such that behaviors can be understood and behavioral expressions of distress can be reduced .The IDT (Interdisciplinary Team - a group of healthcare professionals) will develop plans of care and interventions in an attempt to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the resident's needs/preferences .The resident's plan of care will be communicated across shifts and among caregivers . The facility's policy and procedure titled Behavior Management, dated January 16, 2020, was reviewed. The policy indicated, .To ensure the facility provides the necessary behavioral healthcare and services to residents in accordance with their comprehensive assessment and person-centered plan of care .The facility will ensure that when resident displays a mental disorder, psychosocial adjustment difficulties (e.g. crying yelling, hitting, etc.) .they will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial wellbeing .In an effort to manage the behavioral problem(s) the IDT will .Work with the resident to develop strategies to address the root cause of the problem when possible and appropriate .Work to build a positive, trusting relationship with the resident .Avoid arguing or debating with the resident .Communication strategies .touch the resident in a comforting manner if appropriate .determine the cause of frustration and address concern .

Based on observation, interview, and record review, the facility failed to provide two person-assist during incontinent care (cleaning the resident while in bed after periods of urination or bowel elimination) in accordance with the plan of care, for one of four residents reviewed (Resident 1). This failure resulted in Resident 1's fall from the bed and was sent out to the acute care hospital for further management. Resident 1 sustained a fracture (broken bone) to the right arm and required to have surgical repair of the fracture. Findings: On April 10, 2023, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. On April 10, 2023, at 9:55 a.m., an interview was conducted with the Director of Nursing (DON). She stated Resident 1 fell from the bed on March 26, 2023, at 3:46 a.m. She stated Certified Nursing Assistant (CNA) 1 was providing incontinent care to Resident 1 and CNA 1 turned the resident away from her towards Resident 1's left side and Resident 1 rolled over and fell off the bed. She stated Resident 1 complained of pain on the right shoulder, was referred to the physician, and the physician ordered for x-ray (radiologic procedure - digital picture of the body) of the right shoulder. She stated Resident 1 refused the x-ray and was transferred to the acute hospital for further evaluation on March 27, 2023. The DON stated Resident 1 returned to the facility on [DATE], with diagnosis of right humerus fracture (broken right arm). She stated the acute hospital placed an arm splint on Resident 1's right arm and recommended to have orthopedic (specializes on bone disorders) consult. She stated Resident 1 had an orthopedic appointment on March 31, 2023, and was recommended to schedule for surgery to the right arm fracture. The DON stated Resident 1 was dead weight (heavy), dependent on staff for all activities of daily living (ADL's), and required two-to-three-person assistance when turning and repositioning to prevent falls and injury. On April 10, 2023, at 10:17 a.m., an observation with concurrent interview with Resident 1 was conducted. Resident 1 was observed to be alert and awake, and had a right arm splint. When Resident 1 was asked about the fall incident, Resident 1 was not able to provide further detail. On April 10, 2023, Resident 1's records were reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included right hemiplegia (paralysis of one side of the body). A review of Resident 1's History and Physical Examination, dated March 7, 2023, indicated Resident 1 did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated March 10, 2023, indicated Resident 1 needed extensive to total assistance with bed mobility and toilet use and with functional limitations to one side of the upper and lower extremities (limbs). A review of Resident 1's care plan, indicated the following: - .The resident is at risk for falls .Interventions .Anticipate and meet The (sic) resident's needs ., dated March 4, 2022; - .The resident has a decreased ability to perform self-care related to Decreased ROM (range of motion), Impaired activity intolerance, Impaired balance/safety, Weakness .Interventions .2-person assistance with Adls (ADL - activities of daily living) ., dated March 5, 2022. A review of Resident 1's Weights and Vitals Summary, dated March 1, 2023, indicated Resident 1 weighed 235 pounds (lbs - unit of measurement). A review of the Resident 1's Fall Risk Evaluation, dated March 6, 2023, indicated, .Chair bound - requires .assist with elimination .predisposing disease .1-2 present . A review of Resident 1's Progress Notes, indicated the following: - March 26, 2023, at 4 a.m.; .Patient was being changed when she lost her balance and fell to floor. Assessed, pain noted to right shoulder and hand . - March 27, 2023, at 2:57 p.m.; .Transfer to Hospital Summary .pt (patient) to be transferred to (name of hospital) .for further eval (evaluation) r/t (related to) pain to RUE (right upper extremity [an end part of a limb in the body, for example hand or foot]) . A review of Resident 1's acute hospital records titled Emergency/Urgent Care, dated March 27, 2023, at 10:11 p.m., indicated Resident 1 sustained a fracture of the right arm and treated with immobilization (application of splint). The document included instruction to follow up with orthopedic surgery within three to five days. A review of Resident 1's Progress Notes, dated March 27, 2023, at 11:35 p.m., indicated, .Arrived from (name of hospital) .Arrived in sling to R (right) arm, Dx (diagnosis) Fx (fracture) to R (right) humerus (upper arm). Referral to orthopedic surgeon (bone specialist) . A review of Resident 1's orthopedic appointment notes, dated March 31, 2023, indicated recommendation to schedule surgical repair of Resident 1's broken arm. On April 10, 2023, at 10:32 a.m., an interview was conducted with CNA 2. CNA 2 stated Resident 1 was dependent on staff for all ADL's including repositioning and required two-person assistance for safety and to prevent falls. On April 10, 2023, at 11 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 1 had a fall on March 26, 2023, and sustained a right arm fracture. LVN 1 further stated Resident 1 was dependent on staff for all ADL's and required two-person assistance to prevent falls when turning and providing care. On April 10, 2023, at 11:15 a.m., an interview was conducted with RNA 1. RNA 1 stated Resident 1 was dependent on staff for all ADL's and needs two to three persons to assist in turning. RNA 1 further stated it is not safe if only one CNA will assist Resident 1. On April 10, 2023, at 11:40 a.m., an interview was conducted with LVN 2. She stated Resident 1 was dependent on staff and required two-person assistance on all her ADLs for safety to prevent falls. On April 10, 2023, at 12:50 p.m., an interview was conducted with the Administrator (ADM) and the DON. The ADM stated he was aware of Resident 1's fall incident. The ADM and the DON further stated Resident 1 had right hemiplegia and CNA 1 should have turned Resident 1 towards her and CNA 1 should have called another nurse for assistance when turning and providing care to Resident 1 to prevent falls and injuries. On April 10, 2023, at 5:02 p.m., a telephone interview was conducted with CNA 1. CNA 1 stated Resident 1 had right side weakness and was dependent to staff on all ADL's including turning and repositioning. CNA 1 stated Resident 1 rolled over and fell on the floor after she turned Resident 1 away from her while providing care. CNA 1 stated she was aware Resident 1 required two-person assistance with ADL's and she did not ask for help as she had provided care to Resident 1 by herself many times with no incident. CNA 1 further stated she did not follow Resident 1's plan of care and she should have asked for help when providing care and turning Resident 1 to prevent the fall. On April 13, 2023, at 12 p.m., a telephone interview was conducted with the DON. The DON stated there was no policy regarding the use of two-person assistance during provision of care. The DON further stated the facility's general practice to prevent falls was to have a two-person assistance for heavy and or dependent residents. A review of the facility's skills evaluation checklist titled Turning and Repositioning a Resident, indicated, .When resident cannot assist .Two CNAs perform this procedure positioned on opposite sides of the bed . A review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, dated November 2018, indicated, .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being .the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . A review of the facility's policy and procedure titled Falls Management Program, dated March 13, 2021, indicated, .The Facility will implement a Fall management Program that supports providing an environment free from fall hazards .If a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score .The Interdisciplinary Team (IDT - a group of healthcare professionals) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s) .

Based on interview and record review, for one of three sampled residents reviewed for falls (Resident A), the facility failed to ensure the following: 1. Adequate supervision and close monitoring were provided when Resident A did not have a sitter at bedside consistently as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals); and 2. The effectiveness of the initial interventions were evaluated, and new interventions were developed to address the resident's falls on December 18, 21, and 29, 2022. These failures resulted to Resident A to have three falls on December 18, 21, and 29 of 2022, while at the facility. Resident A's third incident of fall on December 29, 2022, resulted in a left wrist fracture (broken bone). Findings: On January 5, 2023, at 10:15 a.m., an announced visit to the facility to investigate a quality care issue. On January 5, 2023, at 10:20 a.m., during an interview with the Administrator (ADM), he stated Resident A was found by a staff member on the floor at bedside on December 29, 2022, at around 2 p.m. He stated Resident A was noted with bruising swelling on her left wrist and complained of pain on December 30, 2023, at 10 a.m. The ADM stated an X-ray (imaging procedure that creates pictures of the inside of the body) was done at the facility on December 30, 2023, at around 4 p.m., and result was received on December 31, 2022, which indicated Resident A sustained a left wrist fracture. On January 5, 2023, during a review of Resident A's record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included fracture of right pubis (part of the hip bone), history of fall, muscle weakness, and abnormal gait and mobility (walking pattern). A review of Resident A's care plan, dated December 11, 2022, indicated, .Resident has had an actual fall with .Poor Balance .Unsteady gait .Interventions .Continue interventions on the at-risk plan . The care plan initiated on admission did not indicate specific interventions to prevent future falls for Resident A. Further review of Resident A's record did not indicate a care plan was developed to address at risk for further falls. A review of Resident A's History and Physical, dated December 12, 2022, indicated, XXX[AGE] year old female present to SNF (Skilled Nursing Facility) admission .Fall 2 (two) days prior resulting in fracture of multiple pubic rami (group of bones which makes part of pelvis [bone at the base of the spine]) .pain .of left hip noted and unable to ambulate (walk) .associated with weakness in both hips and legs . A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated December 18, 2022, indicated the following: - Required extensive assistance of two - person assist during transfer; and - Not steady and only able to stabilize with staff assistance when moving from sitting to standing position, and when transferring between bed and wheelchair. A review of Resident A's Progress Notes, dated December 18, 2022, at 8:35 p.m., indicated, .Resident attempted to get out of her bed to reach her wheelchair. She fell to the floor and ended in a prone position. She got a hematoma (blood clot) on the back of her head . A review of Resident A's care plan, initiated on December 19, 2022, indicated, .The Resident has had an actual fall with injury .Goal .The resident will resume usual activities without further incident through the review date .Continue interventions on the at-risk plan . Further review of the care plan initiated on December 19, 2022, did not include specific interventions to prevent further falls and minimize injuries for Resident A. A review of Resident A's Progress Notes - Interdisciplinary Team (IDT) Minutes, dated December 20, 2022, at 2:07 p.m., indicated Resident A had a fall trying to get out of bed. The document indicated interventions to prevent further falls included frequent checks of Resident A. A review of the facility document titled, Interdisciplinary Team, dated December 20, 2022, indicated for the staff to conduct frequent checks and requested for a sitter for Resident A to address her fall incident. A review of Resident A's Progress Notes, indicated Resident A had a sitter at bedside on the following days: - December 19, 2022, at 9:58 p.m.; - December 20, 2022, at 4 a.m.; and - December 21, 2022, at 1:15 a.m.; A review of Resident A's Progress Notes, dated December 21, 2022, at 9 p.m., indicated, .Date/Time of Fall: 12/21/2022 (December 21, 2022) 9:00 PM (9 p.m.) Fall not witnessed. Fall occurred in the Resident's room .hematoma on the back of her head .Did fall result in an ER (emergency room ) visit/hospitalization : Yes .Additional Needs Note: Needs 1-1 (one on one) caregiver specially at night . A review of the progress note, dated December 21, 2022, at 9 p.m., did not indicate a sitter was at Resident A's bedside as recommended in the IDT notes on December 20, 2022. Further review of Resident A's record indicated there was no documented evidence an IDT meeting was conducted to address Resident A's repeated falls after December 21, 2022. A review of Resident A's Progress Notes, dated December 23, 2022, at 10:09 p.m. and December 24, 2022, at 12:43 a.m. indicated, .Sitter at bedside . A review of Resident A's Progress Notes, dated December 25, 2022, at 5:14 p.m., indicated Resident A tested positive for COVID-19 (corona virus - an infectious disease) and was placed on isolation precautions (measures to prevent spread of a disease). A review of Resident A ' s Progress Notes, dated December 29, 2022, at 2:30 p.m., indicated, .Date/Time of Fall: 12/29/2022 (December 29, 2022) 2:30 PM (2:30 p.m.) Fall was not witnessed. Fall occurred in the Resident's room .tired of being in bed, TV (television) not functioning .Fall Details Note: CNA (Certified Nursing Assistant) heard a loud noise coming from room .(sic) when entered pt (patient) found on the floor .pt has hematoma to back of head (sic) and arm bruising from previous fall . Further review of the progress note, documented on December 29, 2022, did not indicate Resident A had a sitter at bedside. A review of Resident A's Progress Notes, dated December 30, 2022, at 10 a.m., indicated Resident A complained of pain and was noted with bruising and swelling at the left wrist. The document indicated the physician ordered for x-ray to be done on Resident A's left wrist. A review of Resident A's Radiology Results Report, dated December 30, 2022, indicated, Examination: (LT- left) WRIST .Findings: Distal (away from the body) Radius (wrist) fracture . The document titled Interdisciplinary Team (IDT) Minutes, dated December 30, 2022, indicated the following: - Resident A fell on [DATE]; - Resident A had history of falls on December 18 and 22, 2022, while at facility; - Resident A was noted with swelling and bruising on left wrist; and - Resident A's sitter was discontinued due to the resident had COVID-19. A review of the IDT meeting notes, dated December 30, 2022, did not indicate specific interventions or preventative measures to prevent repeated falls for Resident A. In addition, there was no further evaluation of the cause why Resident trying to get out of bed after the second fall (December 18, 2022) and third fall (December 29, 2022). Further review of Resident A's record did not indicate the care plan was updated with new interventions to address repeated falls for Resident A, after the last fall incident on December 19, 2022. On February 7, 2023, at 1:05 p.m., an interview with CNA 1 was conducted. She stated she was assigned to Resident A when the resident fell in her room on December 29, 2022. She said she was sitting outside of Resident A's room, while the resident's door was closed due to COVID, when the resident had a fall incident on December 29, 2022. She stated she heard a loud noise, went in Resident A's room and found her on the floor near her bed. She stated Resident A was at risk for falls and the resident was being closely monitored because the resident had a tendency to get up on her own without asking for assistance. CNA 1 stated she could not be in the resident's room to watch her since she had four other residents under her care. CNA 1 was unable to answer when asked how she could monitor the resident if the door was closed. She stated Resident A used to have a sitter at bedside but did not know why the resident did not have a sitter on December 29, 2022 (date of fall incident). She stated Resident would benefit from having a sitter at all times. On February 8, 2023, at 4:29 p.m., an interview with Licensed Vocational Nurse (LVN) 1 was conducted. She stated Resident A was closely being monitored due to her history of falls at home and in the facility. She stated Resident A has tendency to get out of bed unassisted and or without asking for help. On February 16, 2023, at 12:50 p.m., during an interview with the ADM, he stated Resident A had three fall incidents on December 18, 21, and 29, 2022, since Resident A was admitted to the facility on [DATE]. He stated Resident A tried getting out of bed unassisted and had sustained injuries from the three fall incidents. He stated the last fall incident on December 29, 2022, resulted in Resident A sustaining a left wrist fracture. He stated Resident A was being closely monitored due to her history of falls at home and in the facility. He stated Resident A kept falling despite the frequent visual checks for Resident A. The ADM further stated the only interventions that kept Resident A from falling was having a sitter in her room. He stated Resident A had a sitter in her room but was inconsistent. He stated after the first fall on December 18, 2022, at 10 p.m., the sitter was initiated. He stated there was no sitter from 2 p.m. to 10 p.m. on December 20, 2022, and the sitter was resumed at 10 p.m. on December 20, 2022, until 8 a.m. on December 21, 2022. He stated Resident A fell on [DATE], at around 9 p.m., and there was no sitter at bedside. He stated the sitter was resumed on December 22, 2022, at 7 p.m. to December 25, 2022, at 2:20 p.m. He stated Resident a had a fall every time the sitter was not present at the resident's bedside. The ADM stated IDT meeting was conducted to address the repeated falls for Resident A. However, the ADM stated there was no further evaluation of what caused Resident A to frequently attempt of getting out of bed unassisted. He stated there was no new interventions developed to address Resident A's repeat falls. The ADM stated there should have been interventions to identify Resident's behavior for getting out of bed after the 2nd fall. He stated the care plan to address Resident A's fall should have been developed specifically to address the resident's behavior of getting out of bed. The ADM stated there should have been more aggressive interventions implemented to prevent the second and third fall incidents. He further stated they were responsible to keep the resident safe and free from any accidents at all cost while under the facility care. A review of the facility's policy and procedure titled, Fall Management Program, dated March 13, 2021, indicated, .To provide residents a safe environment that minimizes complication associated with falls .The facility will implement a Fall Prevention and Management Program that supports providing an environment free from hazards .The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause .The IDT will initiate, review, and update the Resident's fall risk status and care plan .upon significant change of condition identification, post fall .The IDT will investigate the fall including a review of the Resident's medical record, post-fall huddle and review of the Incident and Accident Report .The IDT will review the circumstances surrounding the fall then summarize their conclusions on an IDT note. In an effort to prevent more falls, the IDT will review and revised the care plan as necessary .A Resident who endures more than one fall in a day, week or month, will be considered at high risk for falls .Monthly, for those identified as high risk for falls, the IDT will meet to review the fall risk interventions for appropriateness and effectiveness until the frequency of their falls diminishes .The Residents' care plans will be updated with IDT's recommendations .

Based on observation, interview, and record review, the facility failed to ensure the facility policy and procedure for medication administration was implemented and the resident's blood pressure and heart rate were monitored before medication was administered as ordered by the physician for one resident (Resident 32). This facility failure increased the potential for exacerbation (worsening of medical symptoms) of the resident's blood pressure. Findings: Resident 32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] is a medication for the treatment of [REDACTED].drugs.com). A review of Resident 32's Medication Administration Record [REDACTED]. The facility's failure to obtain blood pressures for Resident 32, as ordered by the physician, increased the potential for an elevated blood pressure to go untreated. On March 13, 2017, at 7 p.m., an interview was conducted with the Director of Nurses (DON). The DON acknowledged the medication was not administered for Residents 39, 23, 36, 33, 32, and 44, as ordered by the physician. He further stated, The blood pressure should have been taken before the medications were administered . All the above findings were confirmed with the Director of Nursing (DON) on March 13, 2017. On March 14, 2017, the facility policy and procedure (P&P) titled, Specific Medication Administration Procedures dated February 23, 2015, was reviewed. The P&P indicated, .MONITORING BLOOD PRESSURE LOWERING MEDICATION, POLICY .To safe guard against harmful consequences for patients on blood pressure lowering medications, it is imperative for the facility to monitor and record blood pressure measurement .To ensure the patient safety and well being by minimizing any unnecessary risk for dizziness and possible falls due to sudden drop in blood pressure . On March 15, 2017, at 3 p.m., an interview was conducted with the facility Medical Director. The MD stated, It is a standard practice to take the blood pressure before giving the medication for resident with hypertensive medications. The Physicians make the decision for parameter of blood pressure .

Based on observations, interviews, and record reviews, the facility failed to ensure resident food was stored, prepared, and served in a sanitary manner when: 1. Multiple roaches were observed under the dish washer sink. The roaches were observed coming in and out from a hole approximately 1/8 inch encircling the outer surface of the drainage pipe for the dish washer. The wall was compromised with two holes located on left side of the drainage pipe, which exposed the inner surface of the outside wall; The cove base also had an approximately 1/8 inch gap which was unpatched on several areas of the upper and lower edges of the cove base; and 2. The dietary aide did not check the water temperature before washing the dishes per the facility policy and procedure on proper use of dish washing machine. These failures increased the potential to result in food borne illness in a medically vulnerable resident population of 61, causing nausea, vomiting, diarrhea, and dehydration. Due to unsanitary conditions and multiple roaches observed, which had the potential to result in food borne illness, the Administrator was verbally notified of an Immediate Jeopardy situation on March 14, 2017, at 1:10 p.m. The Immediate Jeopardy was abated on March 23, 2017, at 11:22 a.m., after the facility provided an acceptable and immediate action plan implementing measures to ensure residents' safety by providing a clean and sanitized kitchen that was free from roaches. Findings: On March 14, 2017, at 11 a.m., during kitchen observation, multiple roaches (approximately 15- 20) were observed coming in and out of an 1/8 inch unpatched gap, open to the outside of the facility, surrounding the outer surface of the drain pipe. The wall to the left of the drain pipe was observed to have two holes open to the inner surface of the outer wall of the facility: one measuring approximately ½ inch by three inches; and another hole measuring one by four inches. Also noted was an unpatched 1/8-inch gap on the upper and lower edge of the cove base. A concurrent interview with the Dietary Aide (DA) 2 was conducted. DA 2 observed and verified the roaches. On March 14, 2017, at 11:10 a.m., the Dietary Supervisor (DS) was interviewed. The DS stated that the facility just had a pest control treatment in the kitchen the previous month. The DS further stated any staff who discovered pests should report the pests immediately to the maintenance department. The Centers for Disease Control and Prevention; Chapter 4; Disease Vectors and Pests, indicated, .Cockroaches . carry disease .has been demonstrated to carry Salmonella . Literature on food safety titled, Cockroaches and foodborne illnesses, dated January 2017, indicated, Cockroaches are known to spread the bacteria which cause foodborne illnesses and contribute to the contamination of food products. On March 14, 2017, at 11:15 a.m., the Maintenance Supervisor (MS) was interviewed. The MS verified and measured the holes on the wall to the left of the drain pipe and confirmed the opening was about 1/8 inch surrounding the pipe. On March 14, 2017, the facility document titled, Pest Control, dated January 1, 2012, was reviewed. The policy indicated, The facility maintains an ongoing pest control program .the Administrator arranges for a pest control company to visit and inspect the facility at least once a year .The company will submit a work plan .with recommendations on how to keep the facility pest-free . On March 14, 2017, at 11:50 a.m., the facility maintenance logbook was reviewed. There was no documented evidence of Pest Control Company visits found in the logbook. On March 14, 2017, at 12 p.m., two receipts of Pest Control Company visits were reviewed. The documents indicated the pest control agency visits were conducted on January 8, 2017, and February 15, 2017. There was no documentation of recommendations by the pest control company regarding the holes observed in the kitchen wall. Due to the pest infestation in the kitchen, the Administrator was verbally notified of an Immediate Jeopardy situation on March 14, 2017, at 1:10 p.m. On March 20, 2017, at 11 a.m. two live roaches, one approximately a half inch long, and another approximately 3/4 inch long, were observed in the same area under the sink. On March 23, 2017, at 11 a.m., a post-survey monitoring visit was conducted at the facility. There were no roaches observed in the kitchen during the visit. The Immediate Jeopardy was abated on March 23, 2017, at 11:22 a.m., after the facility provided an acceptable and immediate action plan implementing measures to ensure residents' safety by providing a clean and sanitized kitchen that was free from roaches. 2. On March 16, 2017, at 10:30 a.m., Dietary Aide (DA) 1 was observed while washing dishes. DA 1 did not check the water temperature before beginning the dish washing, as per facility policy and manufacturer's guidance. On March 16, 2017, at 10:40 a.m. the Dietary Supervisor (DS) was interviewed. DS stated the dietary staff doing the dish washing should check and record the water temperature in the morning and each time they do the dishwashing. On March 16, 2017, the undated facility policy and procedure titled, Dish Machine Operation and Cleaning, was reviewed. The policy indicated, Check water temperature gauges (wash must be within 120 °- 160°).

Based on interview and record review, the facility failed to: 1. Ensure urology consults were completed in a timely manner when ordered for one unsampled resident (Resident 23) who was experiencing recurrent urinary tract infections [MEDICAL CONDITION], dysuria (blood in the urine), and uralia (discomfort urinating); and, 2. Notify physician for a change in condition for Resident 61, who developed a persistent cough. This facility failure increased the potential for further physical decline for Residents 23 and 61, Additionally, it increased the potential for increased discomfort and emotional distress without interventions to resolve the issues for Residents 23 and 61. Findings: On March 14, 2017, beginning at 10 a.m., during the confidential group interview, Resident 23 complained he was not being seen by a specialist to his recurrent UTI's after more than two years. On March 15, 2017, at 11 a.m. a review of Resident 23's record was conducted. Resident 23, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The records further indicated Resident 23 had a history of [REDACTED]. Phycisian's orders indicated Resident 23 had an order for [REDACTED]. A further review of Resident 23's record indicated the resident had received multiple different oral and intravenous antibiotics for recurrent dysuria and UTIs from November 2016, through March 14, 2017. A physician order [REDACTED]. There was no documented urology consult follow-up in Resident 23's record. A physician order [REDACTED].consult. There was no documented urology consult follow-up in Resident 23's clinical record. An interview was conducted with Resident 23 on March 20, 2017, at 11:10 a.m., Resident 23 stated, I don't see my Doctor for four months, I saw my Doctor doing paper work in the nurses station but I did not see him personally. I have not seen by the urologist for a long time. I am tired having UTIs and problem urination for three years. An interview was conducted with the Director of Nurses (DON) on March 20, 2017, at 12 p.m. The DON stated, Due to medical coverage, we had an hard time getting a urology consult. An interview was conducted with the Social Service Designee (SSD) on March 20, 2017, at 12:20 p.m. The SSD stated, There was no urologist accepting Medi-Cal in the valley. An interview was conducted with the Social Service Designee (SSD) on March 20, 2017, at 4:10 p.m. The SSD stated the urologist was not completed on October 2016, and November 2016, because the physician's office was not accepting Medi-Cal insurance. The SSD stated the resident needed to go to the county hospital. The SSD was unable to state why the resident was not transferred to the county hospital for the urology consult. The SSD and DON were unable to state or described any efforts made to secure or obtained a urology consult for Resident 23 in the expanded area surrounding the valley. On March 20, 2017, a review of the undated policy and procedure (P&P), titled, Referrals to Outside Services, was conducted. The P&P indicated, .1. The Director of Social Services (DSS) coordinated the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the facility .The DSS is responsible for locating agencies and programs that meet the needs of residents .The DSS or his designee will coordinate with Nursing staff to ensure that the Attending physician's orders [REDACTED].The DSS maintains a list of service providers available for resident referral . 2. On March 13, 2017, Resident 61's record was reviewed. Resident 61 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On March 15, 2017, during an interview Certified Nurse Assistant (CNA) 7 by the door of Resident 61's room, Resident 61 was overheard coughing. CNA 7 stated Resident 61 started experiencing a slight cough the day before, and she seemed to coughing more today. On March 20, 2017, Resident 61 was again overheard coughing. On March 20, 2017, a facility document titled, Nurses Notes, dated March 15, 2017, thru March 20, 2017, at 4 a.m., was reviewed and a concurrent interview with Registered Nurse (RN) 2, was conducted. RN2 verified CNA 7 reported Resident 61's cough to Charge Nurse (CN), but there was no documented evidence the CN assessed the resident or called the physician about the cough. On March 20, 2017, the facility policy and procedure titled, Change of Condition Notification, dated January 1, 2012, was reviewed. The policy indicated, Change of Condition- related to the Attending Physician (AP) notification is defined . any sudden and marked adverse change in resident's condition which is manifested by signs and symptoms different than usual denote a new problem .require a medical assessment , coordination and consultation with AP.

Based on interview and record review the facility failed to protect the rights of Resident 1 from the misappropriation of the resident's property by the Minimum Data Set Coordinator (MDSC) when Resident 1's money was deliberately used without Resident 1's consent. This failed practice placed Resident 1 and other residents/Residents at risk for fiduciary abuse by MDSC. Findings: On December 5, 2014, the facility reported MDSC had been accused of stealing money from Resident 1. Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was alert but had confusion and memory loss. Resident 1 was [AGE] years old and had no family or friends. On December 11, 2015, at 5 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the facility had launched an investigation regarding the suspicious transactions at the bank concerning Resident 1. The DSD stated MDSC had given them two checks made out to MDSC (herself) and signed by Resident 1. Each check was for $10,000, and had not been cashed. MDSC also gave them receipts from Walmart and Kmart. DSD stated the Walmart receipts had items including a ladies watch and cosmetics that Resident 1 would not have used, as he had no family or friends. The DSD stated during the investigation they learned MDSC would pick up Resident 1 on Sundays, without telling anyone at the facility. She stated MDSC had helped Resident 1 set up his checking account and had access to his checks. The DSD stated after the investigation, MDSC was terminated on December 9, 2014. On December 11, 2015, a review of Patient A's medical record was conducted. The medical record had no physician order for [REDACTED]. On December 23, 2014, at 4:15 p.m., an interview was conducted with the administrator. The administrator stated the facility's social worker had received a call from Resident 1's current caregiver reporting several suspicious bank transactions occurring during the Resident 1's stay at the facility, September 21, 2014, to November 24, 2014. The facility employee involved with the transactions had been the facility's MDSC. The administrator stated he had his own investigators look at the two checks dated November 12, 2014, and November 13, 2014, made out to MDSC and signed by Resident 1. Each check was for the amount of $10,000. The administrator stated the investigators told him Resident 1's signature was probably forged. The administrator stated MDSC had not told her supervisor that she had received these checks. In addition, MDSC had a box of blank checks for Resident 1 in her possession. The administrator stated the bank had shown him transactions for Resident 1, which occurred, with MDSC in attendance. The amounts were: 1. On October 3, 2014, a withdrawal for $2000; 2. On October 8, 2014, a withdrawal of $1000; and, 3. On November 19, 2014, a withdrawal for $3000. These transactions were not made with the buddy system (two staff members present), per facility policy. MDSC had taken Resident 1 to the bank by herself. On December 23, 2014, at 4:25 p.m., an interview was conducted with the Director of Nurses (DON). The DON stated MDSC had met Resident 1 on admission and had always given Resident a special interest, more than was seen with other residents. On December 23, 2014, the employee file for MDSC was reviewed. MDSC had been hired July 1, 2010. MDSC had been disciplined in 2011, for attempting to discharge a resident to her own home. On December 9, 2014, MDSC was terminated for, managing Resident's funds without prior authorization or notifying a supervisor. On January 22, 2015, at 3:35 p.m., the caregiver (CG) at the board and care where Resident 1 then resided, was interviewed. CG stated when she took Resident 1 to the bank to introduce herself (to the bank staff) and change Resident 1's address with the bank. CG stated she was informed a woman had come in trying to close Resident 1's account and transfer the funds to her account. CG stated the bank executive told her they flagged Resident 1's account and notified Adult Protective Services. CG stated another check had cleared from Resident 1's account made out to Kmart-mart and was dated after Resident 1 had moved to the board and care home. CG stated she had not taken Resident 1 to Kmart-mart and he had no way to get there on his own. CG stated the Ombudsman had come to her home to interview Resident 1, but he could not remember the name of MDSC or any facts pertaining to his checking account. The facility's policy and procedure, dated February 2013, and titled, Reporting abuse, indicates, IX. 'Financial abuse' occurs when a person or entity does any of the following: A. Takes, secret, appropriates, obtains, or retains real or personal property of an elder or dependent adult for a wrongful use or with intent to defraud, or both; B. assists in taking, secreting, appropriating, obtaining, or retaining real or personal property of an elder or dependent adult by undue influence. The facility employee handbook, revised February 2012, indicated, You may not accept a gift or gratuity from .customer . The facility failed to protect Resident 1 from the misappropriation of the Resident 1's funds by MDSC when Resident 1's funds; totaling $ 6628.88, were deliberately used without the Resident 1's consent and $20,000 was attempted to be used without Resident 1's consent. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma with the potential to affect the safety of other residents.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1), remained free from accident hazards. This failure had the potential to cause increased pain, risk of infection, risk of blood clots, respiratory depression (decreased respirations-risk from pain relief medications), sepsis (generalized infection), coma, and death. Findings: On May 29, 2014, a review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. His Minimum Data Set (MDS, an assessment tool), indicated that he was totally dependent for transfers from wheel chair to bed. He required two people to assist him when he transferred from wheelchair to bed. The care plan for Resident 1, titled, Activities of Daily Living, dated, March 1, 2013, indicated a Hoyer lift should be used for all transfers. Review of Licensed Nursing Progress Notes indicated on May 19, 2014, Resident 1, complained of left wrist pain and the Charge Nurse (CN1) found Resident 1's left wrist to be slightly swollen and painful. The Medical Doctor (MD) was notified and an x-ray was ordered. The x-ray showed a left wrist fracture. There had not been a report of any fall or injury for Resident 1. Review of the Investigation Report by the Director of Nurses (DON) dated May 20, 2014, indicated the DON, was first notified of the injury on May 20, 2014.The DON interviewed staff working with Resident 1 in the days before May 19 when he complained of pain to his left wrist. None of the staff had noted any swelling of his left wrist and were not aware of any falls. CNA 1 was one of the staff who denied any knowledge of a fall when first interviewed. On May 20, 2014, the DON interviewed Resident 1. Resident 1 indicated, "a fat Mexican boy accidentally dropped him on the floor when he was transferring him." Resident 1 identified the Certified Nursing Assistant that dropped him as CNA 1. On May 20, 2014, the DON re-interviewed CNA 1. At this time, CNA 1 stated that on May 18, 2014, Resident 1 had a fall incident. CNA 1 stated he was attempting to transfer Resident 1 by himself. CNA 1 stated that he did not report the fall because he was afraid of being reprimanded, and he did not think Resident 1 had been injured. On May 29, 2014, at 4:20 p.m., an interview was conducted with Resident 1. Resident 1 stated CNA 1 always helped him back to bed by himself. Resident 1 stated that usually CNA 1 placed his wheelchair near the bed. However, this time he placed him by the window. CNA 1 lifted him up from the chair and then dropped him. Resident 1 stated CNA 1 picked him up from the floor and put him in bed without any help. When asked how his arm felt now, he stated, "Oh it hurts, it aches so." A review of the facility CNA Job Description indicated under the section, "Duties and Responsibilities - Administrative Functions, " ...Report all accidents and incidents you observe on the shift that they occur." The Corrective Action Memo, dated May 20, 2014, indicated, "On 5/18/14 you failed to report to Charge Nurse pt (patient) had a fall, which caused injury to pt." On May 27, 2014, the facility terminated CNA 1 for "not reporting incident to charge nurse