Every finding on record at Diamond Ridge Healthcare Center

Based on interview, and record review, the facility failed to ensure Resident 2's family member (FM) 1 was provided proper training in the use of broda wheelchair (a broda wheelchair is a specialized, highly adjustable positioning wheelchair). This failure resulted in Resident 2 falling from the broda wheelchair and hitting her face on the floor while being wheeled by FM 1. During an interview on 1/13/26 at 10:14 a.m., with Resident 2, the resident stated that on 12/16/25, while being wheeled by FM 1, she fell from her wheelchair and hit her face in the floor. Further stated her fall could have been prevented if the facility trained FM 1 on how to safely and properly wheel Resident 2 with the broda wheelchair. During a review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) dated 1/16/26, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet and compression fracture of vertebra (meaning the resident's backbones had cracks). During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 10/10/25 under Section C, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 13, indicating Resident 2 was cognitively intact or has normal thinking and memory. During a review of Resident 2's Situation, Background, Assessment, and Recommendation notes (SBAR, is a structured communication framework that can help teams share information about the condition of a resident) dated 12/16/25, indicated, Resident 2 had a witnessed fall on 12/16/25 at 3:30 p.m. at the facility while the resident was being wheeled by FM 1. The SBAR indicated that Resident 2 stated she fell real hard with head first and hurt all over. During an interview 1/16/26 at 2:21 p.m., with FM 1, FM 1 stated the facility did not teach her on how to properly use and wheel the broda wheelchair. During a review of Resident 2's post fall Interdisciplinary Team Care Conference (IDT, a group of individuals representing different departments of the facility) meeting notes dated 12/21/25 indicated a recommendation to educate FM 1 on wheelchair safety. No departmental notes were found on educating FM 1 on wheelchair safety before the resident fell on [DATE]. During an interview and concurrent review on 1/16/26 at 12:03p.m., Resident 2's care plan and progress notes were reviewed with Physical Therapist (PT) 1. PT 1 confirmed that Resident 2 had been using a broda wheelchair in the facility and also stated that she could not find any documentation that FM 1 was trained on the use of the broda wheelchair. PT 1 acknowledged it could have helped FM 1's safety awareness if FM 1 was trained on the proper use of the wheelchair. PT 1 further stated she could not find a care plan addressing the resident's safety while using the broda wheelchair. During an interview and concurrent review on 1/16 at 2:13 p.m., Resident 2 's care plans were reviewed with the Minimum Data Set Coordinator (MDSC), MDSC confirmed there was no care plan on the safe use of the broda wheelchair. During an interview on 1/16/26 at 3:30 p.m., with the Director of Nursing (DON), the DON stated that facility did not have a policy and procedure on use of broda wheelchair.

Based on observation, interview, and record review, the facility failed to treat Resident 1 with respect and dignity when Certified Nursing Assistant (CNA) 1 did not wash Resident 1's buttocks when CNA 1 gave Resident 1 a shower. This failure resulted in Resident 1 feeling upset and angry. During an interview on 1/13/26 at 11:07 a.m., with Resident 1, the resident stated CNA 1 did not wash her buttocks when CNA 1 gave her a shower on 12/27/25 at 10 a.m. Resident 1 stated she asked CNA 1 to wash her buttocks because the resident could not reach it. Resident 1 stated CNA told her that CNA 1 did not want to hurt her back if CNA 1 bent too much to wash Resident 1's buttocks. Resident 1 stated she felt upset and angry. During a review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) dated 1/16/26, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/7/25 under Section C, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 15, indicating Resident 1 was cognitively intact. The MDS Section GG titled, Functional Abilities and Goals indicated, Resident 1 needed substantial/maximal assistance in showering meaning the helper lifts or holds trunk and limbs of the resident and provides more than half the effort when giving a shower to the resident. During an interview on 1/13/26 at 12:09 p.m., with CNA 1, CNA 1 confirmed she did not wash Resident 1's buttocks when she gave the shower on 12/27/25 because she was worried that she was going to hurt her back if she bent and washed the resident's buttocks. Further stated that it did not cross her mind to call for assistance from another CNA. Stated, she gave the shower to the resident in the morning of 12/27/25 at around 10:00 a.m. and was only able to clean Resident 1's buttocks in the afternoon around 1:30 p.m. because the resident was upset about the incident after the resident's shower. During an interview on 1/16/26 at 215 p.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 should not have refused to wash the resident's buttocks and should have asked for help from another CNA to fulfill the task. During an interview on 1/16/26 at 3:00 p.m., with the Director of Nursing (DON), the DON stated that CNA 1 should have cleaned Resident 1's buttocks to preserve the resident's dignity and to prevent the risk of skin breakdown. A review of the facility's policy and procedure (P&P) titled, Resident Rights, Revised on 12/19/22, the P&P indicated, .11. The facility will ensure that all direct care and indirect care staff members. are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on interview and record review, the facility failed to ensure the physician and responsible party (RP) were promptly notified for one of three sampled residents (Resident 1) when Resident 1 had respiratory distress (difficulty breathing). This failure had the potential for Resident 1 to develop further exacerbated medical complications and/or need for emergency medical treatment at the acute hospital. During a review of Resident 1's admission Record, dated 12/29/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included asthma (asthma is a long-term lung disease that makes it difficult to breathe. The tubes that carry air in and out of the lungs become swollen, narrow, and produce extra mucus, similar to trying to breathe through a very thin or clogged straw). During a review of the clinical record for Resident 1, the progress notes documented by Licensed Vocational Nurse (LVN) 1 dated 5/14/25 at 4:27 p.m., indicated, .Respiratory: Difficulty breathing noted. Nurse noted increasing respiratory distress. Shortness of breath noted . (respiratory distress is when the body struggles to get enough oxygen and is working much harder to breathe, making the resident feel very short of breath and scared). During an interview with the Licensed Vocational Nurse (LVN) 1 on 12/29/25 at 4:20 p.m., LVN 1 stated she did not call Resident 1's physician and RP when the resident had respiratory distress. During a concurrent interview and record review with the Director of Nursing (DON) on 12/29/25, at 3:55 p.m., DON could not find the documentation that the physician and Resident 1's RP were informed of the resident's episode of respiratory distress. DON further stated that the facility had to notify the physician and the RP when the resident had a change in condition to ensure that Resident 1 received the proper treatment needed. Also stated the RP had to be informed of the resident's change in condition. During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, Reviewed and Revised on 12/19/2022, the P&P indicated, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status. This may include a. life threatening conditions .

Based on observation, interview, and record review the facility failed to store and prepare foods in a sanitary manner that prevented foodborne illness for the facility when: 1. Eleven unlabeled and undated sandwiches were stored in the refrigerator, 2. Multiple food items were stored in the dry storage room beyond use by date, and 3. Two outdated sandwiches and eight grapes with mold was stored on Resident 54's bedside table. These failures had the potential for residents to be exposed to food borne illness. Findings: 1. During a concurrent observation and interview on [DATE] at 7:30 a.m. with the Dietary Supervisor (DS) in the kitchen, eleven unlabeled and undated sandwiches and a paper with written ,d+[DATE] and UBD [use by date] ,d+[DATE] was inside a rectangular plastic container stored in the refrigerator. The DS stated the sandwiches was prepared on [DATE] and should have been thrown away after use by date. During an interview on [DATE] at 10:25 a.m. with the Registered Dietitian (RD), the RD stated sandwiches should be labeled with a date of when it was prepared and should be thrown once it was past their use by date. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated [DATE], indicated, Any expired or outdated food products should be discarded . All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. 2. During a concurrent observation and interview on [DATE] at 8:03 a.m. with the DS inside the dry storage room, three bags of 5 pound pancake mix with [DATE] used by date label, one 48 ounce bag of dried cranberries with [DATE] best before date printed at the back of the packaging, and seven hamburger buns with [DATE] received date and [DATE] used by date written on the plastic packaging were in the dry storage room. The DS took the three bags of pancake mix, one bag of dried cranberries and burger buns out of the dry storage. The DS stated would discard the food items. During a review of the facility's P&P titled, Food Storage, dated [DATE], indicated, Any expired or outdated food products should be discarded. During a review of the facility's Dry Storage Quick Reference Guide, dated [DATE], indicated, Unopened Bread (hamburger) recommended storage was four to five days. 3. During an observation on [DATE] at 9:09 a.m. in Resident 54's room, two sandwiches with [DATE] and [DATE] date and label and a plastic cup of eight grapes with white fuzzy material and dark spots resembling mold was on Resident 54's bedside table. During a concurrent observation and interview on [DATE] at 8:32 a.m. with Certified Nursing Assistant (CNA) 3, two sandwiches with [DATE] and [DATE] date and label and a plastic cup of grapes with white fuzzy material and dark spots resembling mold was on Resident 54's bedside table. CNA 3 stated Resident 54 could get food poisoning symptoms such as stomachache, vomiting or diarrhea if Resident 54 accidentally ate the old sandwich and moldy grapes. During an interview on [DATE] on 8:43 a.m. with the Director of Nursing (DON), the DON stated the CNA are responsible to remove old food items from the resident's table and Resident 54 could be at risk for food borne illness if accidentally ingested old food items. During a review of Resident 54's Minimum Data Set (MDS, an assessment tool used to guide care) dated [DATE], the MDS indicated Resident 54 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 12 out of 15, which indicated intact cognition. The MDS indicted Resident 54 required partial/moderate assistance with eating. During a review of the facility's P&P titled, Food Storage, dated [DATE], the P&P indicated, Food items should be stored . in accordance with good sanitary practice . Any expired or outdated food products should be discarded.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 28, 21, 63 and 84) received necessary care to maintain good grooming and personal hygiene when: 1. Resident 28 had long facial hair and long fingernails with black matter underneath, 2. Resident 21 had long fingernails with black matter underneath, 3. Resident 63 had long, thick facial hair, and 4. Resident 84 had long facial hair. This failure resulted in Residents 28, 21, 63 and 84 at risk for skin irritation and infection. Findings: 1. During a record review of Resident 28's Admission Record dated on 8/13/24, the record indicated Resident 28 had diagnoses of dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and legal blindness. During a record review of Resident 28's Minimum Data Set (Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment dated [DATE], the MDS assessment indicated Resident 28 needed staff's maximum assist (Helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort.) in maintaining personal hygiene and grooming. The MDS assessment indicated Resident 28's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 3 out of 15 which indicated severely impaired mental status. During a record review of Resident 28's Care Plan for Activities of Daily Living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) with revision date on 12/16/21, the care plan indicated Resident 28 had ADL self-care performance deficit related to diagnosis of dementia and blindness. During an observation on 8/12/24 at 8:45 a.m. in Resident 28's room, Resident 28 had long facial hair and long fingernails on both hands with black matter underneath. During a concurrent observation and interview on 8/13/24 at 9:01 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated CNAs were responsible for maintaining the residents' personal hygiene and grooming. CNA 1 stated Resident 28 was partially blind and totally dependent with staff. CNA 1 further stated Resident 28's facial hair was long, and nails were long and dirty. CNA 1 stated residents with long and dirty fingernails were at risk for infection. CNA 1 stated residents with long facial hair could have made them feel not good about their looks. During a concurrent observation and interview on 8/13/24, at 11:05 a.m. with Licensed Vocational Nurse 3 (LVN), LVN 3 spoke to Resident 28 in Spanish. LVN 3 stated Resident 28 wanted his facial hair shaved and his fingernails cleaned and clipped. LVN 3 stated Resident 28 did not refuse when she offered the personal grooming. 2. During a record review of Resident 21's Admission Record dated 8/13/24, the record indicated Resident 21 had diagnoses of cerebrovascular disease (also called a stroke, occurs when blood flow to a part of the brain stops) and dementia. During a record review of Resident 21's MDS assessment dated [DATE], the MDS assessment indicated Resident 21 was totally dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff in maintaining personal hygiene. The MDS assessment indicated Resident 21 had severe impairment for cognitive skills in daily decision making. During a record review of Resident 21's Care Plan for Activities of Daily Living dated 10/6/20, the record indicated Resident 21 had ADL self-care performance deficit related to impaired balance, limited mobility, and diagnosis of dementia and stroke. The record further indicated Resident 21 had goals of will be clean, dry, odor-free and well-groomed daily. During an observation on 8/12/24 at 8:52 a.m. in Resident 21's room, Resident 21 had long fingernails with black matter underneath on both hands. During a concurrent observation and interview on 8/13/24 at 9:37 a.m. with CNA 1, in the shower room, CNA 1 stated Resident 21 was unable to verbalize needs. CNA 1 stated Resident 21's left fingernails were shorter than the right fingernails, but both were dirty with black matter underneath. CNA 1 stated Resident 21 was at risk for infection since Resident 21 mostly ate with her hands. 3. During a record review of Resident 63's Admission Record dated 8/13/24, the record indicated Resident 63 had diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. They may also have mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue.). During a record review of Resident 63's MDS assessment dated [DATE], the MDS assessment indicated Resident 63 needed maximum assist to maintain personal hygiene and grooming. The MDS assessment indicated Resident 63's BIMS score was 14 out of 15 which indicated intact mental status. During a record review of Resident 63's Care Plan for ADLs dated on 2/2/24, the record indicated Resident 63 had ADL self-care performance deficit related to diagnosis of Parkinson's disease. During a concurrent observation and interview on 8/12/24 at 09:00 a.m. with Resident 63 in Resident 63's room, Resident 63 had long and thick facial hair that was touching his neck and chest. Resident 63 stated he preferred his facial hair trimmed but the facility had not offered it to him. During a concurrent observation and interview on 8/13/24 at 9:05 a.m. with CNA 1, in Resident 63's room, CNA 1 stated Resident 63 needed maximum assistance from staff. CNA 1 stated Resident 63 had long and thick facial hair and needed a facial grooming. CNA 1 asked Resident 63 if he wanted his facial hair trimmed to which Resident 63 replied, Yes. 4. During a record review of Resident 84's Admission Record dated 8/13/24, the record indicated Resident 84 had diagnosis of dementia. During a record review of Resident 84's MDS assessment dated [DATE], the MDS assessment indicated Resident 84 needed staff's supervision, verbal cues and/or touching assistance to maintain personal hygiene and grooming. The MDS assessment indicated Resident 84's BIMS score was 3 out of 15 which indicated severely impaired mental status. During a record review of Resident 84's Care Plan for Activities of Daily Living, with revision date on 5/11/23, the record indicated Resident 84 had ADL self-care performance deficit related to diagnosis of dementia. During a concurrent observation and interview on 8/12/24 at 11:18 a.m. in Resident 84's room, Resident 84, a female resident, had long facial hair on her chin. Resident 84 stated she had her facial hair on her chin for a long time and the facility had not offered her to be shaved. Resident 84 was observed pulling the hair on her chin and stated she preferred it to be shaved. During an observation on 8/13/24 at 4:33 p.m. in the hallway, with Activity Director (AD) and CNA 2, Resident 84 stated to AD and CNA 2 that she wanted her facial hair on her chin to be shaved. During an interview on 8/14/24 at 4:13 p.m. with CNA 2, CNA 2 stated she did not notice Resident 84 had long facial hair on the chin. CNA 2 stated the risk of not providing facial hair grooming to female residents could make them feel uncomfortable. During an interview on 8/14/24 at 11:38 a.m. with the Director of Nursing (DON), the DON stated CNAs had the responsibility in providing residents with personal grooming. The DON stated having long and dirty fingernails were unsanitary that could have caused infection to the residents. The DON further stated the CNAs should have offered the residents for facial hair trimming or shaving especially with female residents. The DON stated food may get stuck in a resident's facial hair and may cause skin irritation. During a record review of the facility's policy and procedure (P&P), titled, Nail Care, dated 12/19/22, the record indicated, Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. and Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. During a record review of the facility's P&P, titled, Activities of Daily Living (ADLs), dated 12/19/22, the record indicated, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 4 did not wear face shield inside COVID-19 isolation room, 2. CNA 5 did not perform hand hygiene before entering Resident 166's room, 3. a glucometer (a device used to check blood sugar level) was stored inside the medication cart had traces of dark red stains around it, 4. a tray full of multiple single-use lancet supplies (a small sharp device that pricks the skin to draw a blood sample for testing blood sugar levels), a bottle of blood sugar test strips, alcohol pads and a glucometer device was placed on top of Resident 35's bed was not disinfected by Licensed Vocational Nurse (LVN) 4 after use, 5. LVN 5 dropped the bottle cap for Resident 363's Famotidine (an over-the-counter medicine that is used to prevent and treat acid indigestion and sour stomach) on the floor, picked it up and placed it back without disinfecting it, 6. one opened and unlabeled toothbrush and two used tubes of toothpaste were observed on top of the sink of the shared bathroom of Residents 10, 13, 59 and 95, 7. Resident 90's wheelchair, an off-loading cushion (type of chair cushion to relieve pressure on bony areas) and an abduction wedge (knee separator block) were found stored in the shared bathroom of Residents 16, 33, 55, 77, 85 and 90, 8. one used single-use razor was stored inside Resident 54, 68, 81, and 113's shared bathroom, 9. two unlabeled reusable wash basin was stored inside Resident 14, 15, 19, and 48's shared bathroom, and 10. LVN 2 did not perform hand hygiene when wound care treatment was performed for Resident 167. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During a review of Resident 213's Admission Record (AR), dated 8/13/24, the AR showed Resident 213 had diagnosis COVID-19 (Corona Virus Disease- highly contagious respiratory disease). During a review of Resident 213's Order Summary report, dated, 8/7/24, the order summary indicated, Admit to room isolation and services provided in room. In contact, droplet, airborne precaution. During a concurrent observation and interview on 8/13/24 at 8:50 a.m. with CNA 4, CNA 4 was seen inside Resident 213's room not wearing face shield. CNA 4 stated, she was supposed to wear face shield inside Resident 213's room because Resident 213 had COVID infection. CNA 4 also said, face shield was for the safety of other residents, staff, and self. During a concurrent interview and record review on 8/13/24 at 9:35 a.m. with the Infection Preventionist (IP), IP stated, CNA 4 should have worn face shield inside Resident 213's room because Resident 213 was on droplet/airborne precaution due to COVID-19 infection. During a concurrent interview and record review on 8/13/24 at 11:23 a.m., with the IP, Resident 213's Infection, Isolation, and Precaution Details document dated 8/13/24 revealed Resident 213 had COVID-19 infection. The document indicated contact, airborne, and droplet precaution were required. The document further indicated personal protective equipment (PPE is equipment used to prevent or minimize exposure to hazards) requirements included Eye protection (Face Shield or Goggles) . The document indicated Resident 213 will be out of isolation on 8/14/24. During a review of the facility's policy and procedures (P&P) titled, Corona Virus Prevention and Response, dated, 12/19/22, indicated under Policy: This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. The P&P also indicated, under Policy Explanation and Compliance Guidelines: .15. Health Care Providers (HCP) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. During a review of the facility's P&P titled, Personal Protective Equipment, dated 12/19/22, indicated, The facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff . Face protection: .Wear goggles or face shield as added face/eye protection. Personal eyeglasses are not substitute for goggles. During a review of facility's undated sign titled Droplet & Airborne Precaution, the sign indicated, Before entering zone: [NAME] face shield & N-95 respirator [a type of face mask]. 2. During a review of Resident 166's AR, dated 8/14/24, the AR indicated Resident 166 had diagnosis of immunodeficiency (weak immune system, allowing infections and other health problems to occur more easily). During an observation on 8/13/24, at 3:33 p.m., with CNA 5, CNA 5 picked up ice cube from wet floor with her right hand. CNA 5 entered Resident 166's room without performing hand hygiene. CNA 5 drew Resident 166's curtain close with the same hand (right) she used to pick up ice cube from wet floor. During an interview on 8/13/24, at 3:35 p.m., with CNA 5, CNA 5 acknowledged her hand became soiled from picking up dirty ice cube from the floor. CNA 5 stated, she did not perform hand hygiene before going into Resident 166's room because she was holding a cup with her other hand. CNA 5 further added, the expectation was to sanitize hands before going in and coming out of resident's room to prevent the spread of infection in the facility. During an interview on 8/14/24, at 10:30 a.m., with the IP, IP stated, the expectation from the staff was to gel in and gel out (term used to perform hand hygiene before and after entering and exiting a room) using Alcohol Based Hand Rub (ABHR), whenever staff go into the resident room. IP further added, if hand was visibly soiled staff should wash hands with soap and water for 20 seconds to prevent spread of infection to other residents. During a review of facility's P&P, titled Hand Hygiene, dated, 12/19/22, the P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. According to the Center for Disease Control (CDC) - Long Term Care Facilities guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 3/28/24, the guidance indicated, Health Care Providers (HCP) who enter the room of a resident with signs or symptoms of unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use NIOSH-approved(R) particulate respirator with N95(R) (% filters or higher, gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face. This PPE can be adjusted once the cause of the infection is identified. 50474 3. During a concurrent observation and interview on 8/13/24, at 11:10 a.m. LVN 3, a glucometer stored inside the medication cart # 2B had dark red stains on the insertion port, on the side, and back of the device. LVN 3 stated the glucometer device looked dirty. LVN 3 stated the stain was from dried blood. LVN 3 stated not cleaning and disinfecting the glucometer device could spread infection in the facility. During an interview on 8/13/24, at 1:11 p.m. with the Director of Nursing (DON), the DON stated having a glucometer with blood stain was unacceptable practice. The DON stated the licensed nurses were responsible for cleaning and disinfecting the glucometer thoroughly to prevent the spread of infection. During an interview on 8/13/14, at 3:34 p.m. with the IP, IP stated the licensed nurses should have cleaned and disinfected the glucometer using the facility's approved disinfectant wipes from top to bottom and all the sides. IP stated the glucometer should have been free from stains and dirt. IP stated the risk of not properly cleaning and sanitizing the glucometer device may cause spread of blood infection among the residents and staff. During a record review of the facility's P&P, titled, Glucometer Disinfection, the P&P indicated, Cleaning is the removal of visible soil from objects and surfaces . and Disinfection is a process that eliminates many or all pathogenic microorganisms . P&P further indicated Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 4. During a concurrent observation and interview on 8/13/24, at 3:42 p.m. with LVN 4, in Resident 35's room, LVN 4 placed a tray that had multiple single-use lancets, a bottle of blood sugar test strips, glucometer, and alcohol pads on top of Resident 35's bed. After LVN 4 administered Resident 35's medication, LVN 4 returned to the medication cart and did not disinfect the tray. LVN 4 then proceeded with medication administration to other residents leaving the tray of supplies exposed on top of the cart. LVN 4 stated she brought the tray full of single-use lancets because she thought she needed to use the extra tray that was placed underneath. LVN 4 stated the risk of bringing the whole tray of single-use lancets supply to different resident rooms and not disinfecting the tray after placing it on a resident's bed could spread infection in the facility. During an interview on 8/14/24, at 10:33 a.m. with IP, IP stated when licensed nurses performed blood sugar checks, they should have only brought enough supplies in the resident's room. IP stated one to two single-use lancets in each blood sugar check should be enough. IP stated bringing a tray full of single-use lancets inside a resident's room and placing it on the bed may cause contamination of the lancets and could spread infection to residents. 5. During an observation and interview on 8/13/24, at 4:45 p.m. with LVN 5, outside Resident 364's room, LVN 5 was observed preparing Resident 364's scheduled medications. LVN 5 dropped the bottle cap for Famotidine on the floor. LVN 5 then picked up the bottle cap and placed it back to cover the Famotidine bottle without disinfecting the bottle cap. LVN 5 stated she should have cleaned and disinfected the bottle cap before putting it back to cover the medicine. LVN 5 stated not disinfecting the bottle cap could be risk for infection to other residents who was also taking the same medication. During an interview on 8/14/24, at 10:35 a.m. with IP, the IP stated when licensed nurses dropped something on the floor they were expected to disinfect or throw away the item. IP stated the risk of not disinfecting the medicine bottle cap could potentially contaminate the rest of the medicines in the bottle and could cause infection to residents who were taking the same medication. During a record review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Equipment, the P&P indicated reusable resident-care equipment will be cleaned and disinfected to break the chain of infection. The P&P further indicated single-used items were designed to be used once, for only one person and should be discarded after each use and multiple-resident use equipment shall be cleaned and disinfected after each use. 46487 6. During an interview with CNA and 1 initial tour observation of the facility on 8/12/24 at 7:35 a.m., one opened and unlabeled toothbrush exposed to air, and two used tubes of toothpaste were observed on top of the sink of the shared bathroom of Residents 10, 13, 59 and 95. When asked, CNA 1 stated she did not know whom the said items belonged to. CNA 1 also stated, the items should not be on top of the sink due to the risk of spread of infection. During a concurrent observation and interview on 8/12/24, at 7:36 a.m., with LVN 1, in the shared bathroom of Residents 10, 13, 59, and 95, LVN 1 stated the toothbrush, and tubes of toothpaste should not be stored on top of the bathroom sink because of the risk of spread of infection. 7. During an interview with LVN 1 and initial tour observation of the facility on 8/12/24 at 7:40 a.m., Resident 90's wheelchair, an off-loading cushion and an abduction wedge were found stored in the shared bathroom of Residents 16, 33, 55, 77, 85 and 90. When asked, LVN 1 stated the wheelchair belonged to Resident 90, but she did not know whom the off-loading cushion and the abduction wedge knee separator belonged to. LVN 1 also stated the said items should not be stored in the bathroom for infection control. During a review of Resident 90's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/25/24, the MDS indicated Resident 90 used a wheelchair and was dependent on the help of the staff for wheelchair mobility. During an interview on 8/13/24 at 9:26 a.m., with IP, IP stated a resident's toothbrush should be placed in a clean plastic bag and should be labeled and stored with the resident's clean belongings for infection control. IP stated the wheelchair, off-loading cushion, and the abduction wedge knee separator should not be stored in the bathroom due to the risk of spread of infection. During an interview on 08/13/24 at 1:58 p.m., with DON, DON stated, the residents' toothbrush, toothpastes, wheelchair, off-loading cushion, and the abduction wedge knee separator should not be stored in the bathroom due to the risk of spread of infection. DON further stated Resident 90's wheelchair should have been stored at the resident's bedside. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2022, the P&P indicated, .All staff shall demonstrate competence in relevant infection control practices. Direct care staff shall demonstrate competence in resident care procedures established by our facility . 49498 8. During an observation on 8/12/24 at 8:56 a.m. in Resident 54, 68, 81, and 113's shared bathroom, one blue razor with two strands of black and white hair was on top of the paper towel dispenser. During a subsequent observation and interview on 8/12/24 at 2:12 p.m. with CNA 6 in Resident 54, 68, 81, and 113's shared bathroom, one blue razor with two strands of black and white hair was observed on top of the paper towel dispenser. CNA 6 took the razor, walked into the shower room and threw the razor in the sharps disposal container. CNA 6 stated the razor should have been discarded in the sharps container after use. During an interview on 8/14/24 at 9:05 a.m. with the IP, the IP stated razors should be used one time and disposed in the sharps container after resident use to prevent cross contamination. The IP stated sharps containers are located inside the shower room. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Equipment, dated 12/19/2022, indicated, Resident-care equipment can be a source of indirect transmission of pathogens [a bacterium, virus, or other microorganism that can cause disease.] . 'Single-use items' are items that are designed to be used once, for only one person; These items are to be discarded after use. 9. During an observation on 8/12/24 at 10:36 a.m. in Resident 14, 15, 19, and 48's shared bathroom, two unlabeled wash basins were on top of the paper towel dispenser. During a subsequent observation and interview on 8/12/24 at 2:36 p.m. with CNA 7 in Resident 14, 15, 19, and 48's shared bathroom, two unlabeled wash basin were on top of the paper towel dispenser. CNA 7 stated wash basins should be stored inside the resident's bedside cabinet. During a concurrent observation and interview on 8/12/24 at 3:40 p.m. with Resident 19, Resident 19 stated the staff took the basin with his stuff in the shower room. Resident 19 stated did not know to whom the basin in the bathroom belonged. During an interview on 8/12/24 at 3:44 p.m. with CNA 6, CNA 6 stated wash basin should be marked with resident's name and room number to prevent the spread of infection, loss and getting mixed up. During an interview on 8/14/24 at 9:05 a.m. with the IP, the IP stated wash basin can be reused but must be labeled and wiped with sanitizing wipes after use. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Equipment, dated 12/19/2022, the P&P indicated, 'Reusable single-resident items' are items that may be used multiple times, but for one resident only. 36593 10. During a review of Resident 167's Order Summary Report, dated 8/8/24, the order summary report indicated physician prescribed Resident 167 to receive wound treatment for stage 3 pressure injury (full thickness tissue loss, subcutaneous (under the skin) fat may be visible, but bone, tendon, or muscle is not exposed. Slough (yellow or white material in wound bed) may be present but does not obscure the depth of tissue loss) on sacra-coccyx (tail-bone), cleanse with wound cleaner, pat dry with gauze, apply medi honey (medical grade honey used for promote wound healing), oil emulsion (oil to help support wound environment), top with calcium alginate (substance used to treat wounds), and cover with foam dressing every day. During a review of Resident 167's actual impairment to skin integrity care plan, dated 8/9/24, indicated Resident 167 had stage 3 wound on his tailbone and intervention included follow facility policies/protocols for the prevention/treatment of skin breakdown. During a wound dressing change observation on 8/14/24 at 9:58 a.m., with LVN 2, in Resident 167's room, Resident 167 was positioned lying in bed on his left side, with the tailbone wound exposed for wound treatment. Resident 167 requested to use the urinal, LVN 2 with same gloved hands used to cleanse Resident 167's wounds assisted Resident 167 with urinal and provided penile care. LVN 2 then removed his gloves, put on a new pair of gloves without performing hand hygiene or hand washing, continued wound treatment to Resident 167's tail bone. During an interview on 8/14/24 at 11:02 a.m., with LVN 2, LVN 2 stated he did not perform hand hygiene or hand washing after he offered Resident 167 urinal, penile care, removed gloves and before continued wound treatment to Resident 167 tail-bone area. During an interview on 8/14/24 at 12:02 p.m., with IP, IP stated licensed nurses were expected to use hand sanitizer or wash hands with soap and water after penile care, removing gloves and before continuing wound care treatment. During a review of the facility's P&P titled, Clean Dressing Change, revised 12/19/22, the P&P indicated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Wash hands and put on clean gloves. Remove gloves, pulling inside out over the dressing. Wash hands and put on clean gloves.

Based on interview and record review, the facility failed to timely develop and provide a baseline care plan for three of 32 sampled residents (Resident 108, 109, and 363) when the baseline care plans were not developed within 48 hours of Resident 108, 109 and 363's admission and the baseline care plan written summaries were not provided to the Resident 108, 109, 363 and the representatives. This failure had the potential to reduce the continuity of care and communication between Resident 108, 109, 363, the representatives, and the facility staff. Findings: During a review of Resident 108's Admission Record(AR), the AR indicated, Resident 108 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move on one side of the body). During a review of Resident 108's Baseline Care Plan dated 7/23/24, the Baseline Care Plan indicated Resident 108's baseline care plan was not developed within 48 hours of admission and Resident 108 and their representatives were not provided a summary of the baseline care plan. During an interview on 8/13/24 at 9:45 a.m., with Registered Nurse/Supervisor (RN 1), RN 1 stated it was not a practice for the facility to provide residents and family with a written summary of the baseline care plan. RN 1 stated she initiated residents' baseline care plan. RN 1 stated she was one of the staff that completed this task. During a concurrent interview and record review on 8/15/24 at 8:04 a.m., with the Licensed Vocational Nurse/ Case Manager (CM), Resident 108's Baseline Care Plan and Summary dated 7/23/24 was reviewed. The baseline care plan indicated Resident 108 and their representative were not provided a summary of base line care plan. CM stated she was responsible for scheduling and coordinating residents' care plan conferences. CM stated it was not facility's practice to provide residents and their representatives with written summary of base care plan after completion of care conferences. CM stated Resident 108 and representatives have not been provided a summary of baseline care plan. During a review of Resident 109's AR, dated 8/15/24, the AR indicated, Resident 109 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move on one side of the body). During a review of the Resident 109's Baseline Care Plan and Summary dated 8/9/24 indicated baseline care plan was not developed within 48 hours of admission and Resident 109 and representative were not provided with a written summary of baseline care plan. During a concurrent interview and record review on 8/15/24 at 8:04 a.m., with the CM, Resident 109's Baseline Care Plan dated 7/23/24 and Interdisciplinary Care Conference (IDT) dated 7/19/24 were reviewed. CM stated it was not facility's practice to provide residents and their representatives with written summary of base care plan after completion of care conferences. CM stated Resident 109 and representatives have not been provided a summary of baseline care plan. During an interview on 8/13/24 at 9:55 a.m., with Assistant Director of Nursing (ADON), ADON stated facility had identified timely completion of baseline care plan and provision of written summary to residents and representatives as an issue and had addressed it on Quality Assurance Performance Improvement (QAPI, Quality Improvement is about giving the people closest to issues affecting care quality the time, permission, skills, and resources they need to solve them). During an interview on 8/14/24, at 10:35 a.m., with Director of Nursing (DON), DON stated facility was aware that residents' baseline care plans were not developed within 48 hours and written summaries of residents' base line care plans were not provided to residents and family representatives. 40968 50474 During a review of Resident 363's AR, dated 8/14/24, the AR indicated Resident 363 had a diagnosis of right femur fracture (broken upper leg bone). During a review of Resident 363's Baseline Care Plan and Summary dated 8/2/24 indicated Resident 363 was admitted on [DATE] and the Baseline Care Plan and Summary was electronically signed by the ADON on 8/2/24. During a concurrent interview and record review on 8/14/24, at 11:22 a.m. with the DON, Resident 363's Baseline Care Plan and Summary dated 8/14/24 was reviewed. The DON stated the Interdisciplinary Team members (IDT) did not develop a baseline care plan for Resident 363 within 48 hours from admission and no written summary was provided to Resident 363 and family representatives. During a record review of the facility's policy and procedure (P&P) titled, Baseline Care Plan dated 12/19/22, the P&P indicated the baseline care plan will be developed within 48 hours of a resident's admission. The P&P further indicated, A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the initial goals of the resident, a summary of resident's medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 364) received Cromolyn Sodium Ophthalmic Solution (a prescription eye drop medication used to treat allergic eye conditions) according to physician's order. This failure resulted in Resident 364 not receiving appropriate treatment to control eye allergy symptoms and experiencing very itchy eyes. Findings: During a record review of Resident 364's Minimum Data Set (Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) dated 7/8/24, the MDS assessment indicated Resident 364's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 8 out of 15 which indicated mildly impaired mental status. During an observation on 8/13/24 at 4:38 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 only administered oral medications to Resident 364 during the medication pass observation. During a record review of Resident 364's Medication Administration Record (MAR), dated 8/1/24 through 8/31/24, the record indicated Resident 364 had a routine Cromolyn Ophthalmic Solution to be administered at 9:00 a.m. and 5:00 p.m. daily. During an interview on 8/14/24 at 3:07 p.m. with LVN 5, LVN 5 stated she did not give the Cromolyn Ophthalmic Solution eye drops to Resident 364 because it had been out of order for quite some time. LVN 5 further stated she did not call the MD to inform about the missing eye drops and to ask for advice. During a concurrent record review and interview on 8/14/24 at 3:42 p.m. with the Director of Nursing (DON), Resident 364's MAR, dated 8/13/24 was reviewed. The DON stated Resident 364's Cromolyn Ophthalmic Solution had a status of reordered since 8/5/24. The DON further stated the status meant the eye medication had not been delivered by the pharmacy. During an interview on 8/15/24, at 8:35 a.m. with Resident 364, Resident 364 stated she had been taking the prescription Cromolyn Ophthalmic Solution eye drops for two years. Resident 364 stated she noticed the nurses had not been giving it to her. Resident 364 stated without the eye medication, it made her eyes feel very itchy. During a phone interview on 8/15/24, at 9:07 a.m. with the facility's Consultant Pharmacist (CP), CP stated Cromolyn Sodium Ophthalmic Solution was a prescription eye drops used to treat eye allergies. CP stated Cromolyn Sodium Ophthalmic Solution was a stronger eye medication that would have prevented inflammation around Resident 364's eyes due to allergies. CP stated licensed nurses should have followed up with the pharmacy and should have contacted the MD for alternatives if the eye medication was unavailable. CP stated without the eye medication, Resident 364 was at risk for worsening of eye allergy symptoms such as redness and itchiness. During an interview on 8/15/24, at 11:48 a.m. with Nurse Consultant (NC), NC stated there were no documentations from licensed nurses the pharmacy had been followed up or if MD was notified about the missing Cromolyn Sodium Ophthalmic Solution. During a record review of the facility's policy and procedure (P&P), titled, Provider Pharmacy Requirements, dated April 2008, the record indicated the .pharmaceutical service is available to provide residents with prescription and nonprescription medications . The record further indicated, The provider pharmacy agrees to perform the following pharmaceutical services . 2) Accurately dispensing prescriptions based on authorized prescriber's orders . 6) Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week. During a record review of the facility's P&P titled, Medication Orders, dated April 2008, the record indicated, The prescriber is contacted for direction when the medication will not be available.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 110, when: 1. Resident 5's inhalation medication with limited shelf life after opening was not dated for beyond used date in medication cart #2b, and 2. Resident 59's intravaginal (insertion through the vagina or birth canal) medication was stored together with the oral medications in medication cart #2a. These failures had the potential to contribute to unsafe use of medications and potential for medication error. Findings: 1. During a concurrent interview and observation on 8/13/24, at 11:10 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's opened and undated Symbicort (an inhalation drug used to treat breathing problems) was stored in medication cart #2b. The manufacturer label on the box indicated Discard within three months after removing from foil pouch. LVN 3 stated there was no open date written on the box nor on the inhaler. LVN 3 stated when an inhalation medication was opened, it should have been dated per the facility's standard of practice. During an interview on 8/13/24, at 1:11 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should have dated the opened inhaler. The DON stated if there was no open date, the licensed nurses would not be able to identify the expiration date of the inhalation medication. 2. During a concurrent observation and interview on 8/13/24, at 12:04 p.m. with LVN 1, Resident 59's Estradiol 10 microgram tablet (a hormonal medication that reduces vaginal symptoms such as vaginal irritation, dryness, burning, or itching) had an instruction to administer one tablet intravaginally three times a week, was stored in medication cart #2a with other oral medications. LVN 1 stated the intravaginal medication should have been separated and not stored with oral medications. LVN 1 stated storing the intravaginal medication with oral medications was potential for infection due to its different administration routes. During an interview on 8/13/14, at 1:15 p.m., with the DON, the DON stated she expected the licensed nurses to store all medications with different routes in separate storages. The DON further stated storing the intravaginal medication with the oral medications was an unacceptable practice because it had a potential risk for spread of infection due to its different routes. During an interview on 8/15/24, at 9:07 a.m. with the facility's Consultant Pharmacist (CP), CP the inhalation medication Symbicort had a shelf life of eight weeks. CP stated licensed nurses should have dated the inhalation medication, to determine until when the medication can be used effectively. CP further stated the Estradiol intravaginal tablet should have not been stored with any other medications that had different routes especially with oral medications. CP stated the Estradiol intravaginal tablet stored with oral medications had a potential risk to be given orally that could have led to accidents and medication errors. During a record review of the facility's policy and procedure (P&P), titled, Labeling of Medications and Biologicals, dated 12/19/22, the record indicated All medications used in the facility will be labeled in accordance with current state and federal regulations to facilitate considerations of precautions and safe administration of medications. During a record review of the facility's P&P, titled, Medication Storage dated 12/19/22, the record indicated medications to be administered by mouth are stored separately from other formulations (i.e. eye drops, ear drops, injectables).

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 52) was free from unnecessary medication, when Resident 52 was prescribed and given Risperidone (medication to treat symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions)) and did not have schizophrenia. This failure resulted in Resident 52 being administered an unnecessary medication and had the potential for increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death). Findings: During a review of Resident 52's admission record, dated 8/13/24, indicated, Resident 52 had diagnoses of Unspecified Dementia (symptoms affecting thinking and social abilities interfering with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During a review of Resident 52's Minimum Data Set (MDS - an assessment tool used to guide care), dated 4/25/24, indicated Resident 52's vision was severely impaired. MDS showed, Resident 52 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 3 out of 15 which indicated severely impaired cognition. The MDS revealed, Resident 52 did not have indicators of psychosis (not in touch with reality) such as hallucination (false perceptions of sensory experiences) and/or delusions (fixed false belief). The MDS also showed, Resident 52 did not exhibit physical and behavioral symptoms (hitting or scratching self, pacing .) and did not exhibit verbal behavioral symptoms (threatening others, creaming at others, cursing at others). During an interview on 8/14/24 at 2:50 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated, Resident 52 required special attention because Resident 52 was blind. CNA 8 further added, Resident 52 was not physically abusive towards others. During an interview on 8/14/24 at 3:04 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, Resident 52 was blind, forgetful, and confused. LVN 6 added, Resident 52 screamed for help but when attended to, Resident 52 said I don't need you, I'm sorry. During an interview on 8/15/24 at 10:35 a.m. with the Director Of Nursing (DON), DON stated, Resident 52 was taking Risperidone due to manifestation of screaming. DON revealed, Resident 52 was non-violent and non-threatening. During a review of Resident 52's physician order dated, 8/6/24, indicated Resident 52 was prescribed Risperidone oral tablet, 0.5 mg give 1 tablet by mouth at bedtime for Schizophrenia manifested by screaming. During a review of Resident 52's Pharmacy Recommendation dated 6/20/24, indicated, Antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric adults; avoid use of risperidone if possible due to an increase in morbidity and mortality in geriatric patients with dementia receiving antipsychotics. Please consider discontinuing the medication. During a review of Resident 52's Preadmission Screening and Resident Review (PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.), dated 9/13/22, indicated Resident 52's Level II Mental Health Evaluation was not scheduled for the following reason: The individual had no serious mental illness (SMI). During a review of the facility's Policy and Procedures (P&P), titled Use of Psychotropic Medication, dated 12/19/22, indicated, Resident are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .4. The indications for use of any psychotropic drug will be documented in the medical record. a. Pre-admission screening and other preadmission data shall be utilized for determining indication for use of medications ordered upon admission to the facility. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician.

Based on interview and record review, the facility failed to develop new interventions to address behavioral care and treatment for one of 32 sampled residents (Resident 264) with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) when Resident 264 exhibited physical and/or verbal aggression towards others 24 days of out 31 days in May 2024. This deficient practice had the potential for Resident 264 to harm herself and other residents in the facility. Findings: Review of Resident 264's Admission Record dated 8/13/24 indicated, Resident 264 was admitted with diagnosis of dementia with behavioral disturbance. Review of Resident 264's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/16/24, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 5 out of 15, indicated Resident 264 had severely impaired cognition. The MDS indicated Resident 264 had episodes of physical symptoms (hitting, kicking, pushing, scratching, grabbing .) and verbal symptoms (threatening, screaming, cursing .) directed toward others. Review of Resident 264's Physician's Orders (PO), dated 5/1/24, indicated Quetiapine Fumarate (antipsychotic medications are a class of drugs commonly used to treat serious mental disorders) 50 milligrams (mg., a form of measurement) two times a day for aggression to others. The PO had a start date of 4/25/24. Review of Resident 264's Medication Administration Record (MAR) dated May 2024, indicated Resident 264 was observed with behaviors of aggression toward others related to schizophrenia for 15 out of 31 mornings and 24 out of 31 evenings in May 2024. During an interview and concurrent review of Resident 264's behavior care plan with the Minimum Data Set Coordinator (MDSC) on 8/14/24 at 12:44 p.m., MDSC stated, all nursing staff were responsible in updating Resident 264's care plan. MDSC stated, Resident 264's behavior care plan was not revised when the resident exhibited multiple aggression towards others in May 2024 until 5/26/24. MDSC stated she could not find a documentation the Interdisciplinary Team (IDT, a group of individuals representing different departments of the facility) met to discuss Resident 264's dementia care since the resident was admitted to the facility. During an interview and concurrent review of Resident 264's behavior care plan with the Director of Nursing (DON), on 8/14/24 at 1:27 p.m., DON acknowledged, behavior care plan interventions/approaches for May 2024 was only revised on 5/26/24. DON stated to minimize Resident 264's aggressive behaviors, the care plan should have been reviewed and revised before 5/26/24. DON further stated was not able to find a documentation the IDT met to address Resident 264's dementia care. DON further stated, IDT should have met to discuss Resident 264's dementia care, to evaluate the root cause of the resident's aggression and, to discuss if the antipsychotic medication Quetiapine Fumarate was effective in controlling the Resident 264's aggression. During an interview and concurrent review of Resident 264's social services notes with the Social Services Director (SSD) on 8/14/24 at 1:40 p.m., SSD stated she did a psychosocial evaluation on Resident 264 but was unable to find documentation. Review of the facility's policy and procedure (P&P) titled, dementia care, revised December 2022, indicated, .The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary .

Based on interview and record review, the facility failed to ensure one of three closed resident records sampled (Resident 112) was not coded correctly on the Minimum Data Set (MDS-a standardized assessment tool used to direct health care needs) when Resident 112 was discharged home. This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS) regarding Resident 112's discharge status. Findings: During a review of Resident 112's admission record, dated 8/14/24, revealed Resident 112 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The admission record also revealed, Resident 112 was discharged on [DATE] and was discharged to: Home. During a review of Resident 112's MDS, dated [DATE], Section A2105 indicated 04 which meant Resident 112 was discharged to an Acute Care Hospital. During a review of Resident 112's order summary dated 6/17/24, indicated Patient discharging home per request on 6/21/24 with family . During a review of Resident 112's post discharge plan of care and summary dated 6/20/24, indicated under recap of resident's stay, indicated Resident 112 was discharging home with daughter. During a review of Resident 112's physician's discharge summary, dated 6/21/24, indicated Resident 112 was discharged to: Home. During a concurrent interview and record review on 8/14/24 at 3:23 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 112's discharge MDS record was reviewed. MDSC stated Resident 112 was discharged home and not to the acute care hospital. MDSC further added, Resident 112's discharge MDS was encoded incorrectly.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant 1 (CNA 1) raised her arm at Resident 1, as if she was to strike Resident 1. CNA 1 had previously exhibited aggressive verbal behavior towards Resident 4 and 5. This failure placed Resident 1 at risk for emotional and psychological distress. Findings: During a record review of Resident 1's Admission record dated 4/17/24, indicated Resident 1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.). During a record review of Resident's 1's Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) dated 3/1/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) was 0 out of 15, indicated severely impaired mental status. The MDS indicated Resident 1 required total care with Activities of Daily Living (ADL, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) and included full assistance with feeding. During an interview with Resident 1 on 4/16/24, at 9:53 a.m., Resident 1 was lying in bed, awake, able to talk, but confused with questions, stating she lived at the facility for one day. During a review of Resident 1's nursing progress note titled, Change of Condition (COC), dated 1/5/24, at 5:00 p.m., the COC indicated, [Resident 1]'s roommate [Resident 2] witnessed [CNA 1] hit [Resident 1] a few days ago, and told [Resident 1]'s roommate [Resident 2], not to tell anyone. The COC further indicated, Roommate [Resident 2] states that the curtains were wide-open, and [CNA 1] was feeding [Resident 1] then became combative and [CNA 1] struck [Resident 1] back. [CNA 1] then told roommate Shh, don't tell anyone. During a record review of Resident 2's MDS assessment, dated 12/2/23, the MDS indicated Resident 2's BIMS score was 15 out of 15, indicating intact mental status. During a phone interview with the witness, Resident 2, on 4/22/24, at 3:00 p.m., Resident 2 stated she saw CNA 1 enter Resident 1's room and went to Resident 1. Resident 2 stated CNA 1 raised her arm and hand to Resident 1, as if to strike. Resident 2 stated CNA 1 then looked at her and said, You didn't see what happened. Resident 2 further stated it was a horrible experience, that left a mark on her. During a phone interview on 4/23/24, at 3:50 p.m. with the Director of Nursing (DON), the DON stated if a CNA raised his/her hand and arm towards a resident, she would not like it because this gesture looks like they are about to hit the resident. The DON also stated if the CNA said not to tell anyone, she would perceive this as a threat as if he/she is trying to cover up something. During a phone interview with CNA 2, on 4/18/24, at 8:25 a.m., CNA 2 stated, on 1/5/24, while assisting Resident 2 to the bathroom, Resident 2 told her that she witnessed CNA 1 hit her roommate. CNA 2 stated Resident 2 did not want CNA 1 as the nursing assistant caring for her. CNA 2 stated Resident 2 told her that she was afraid to tell anyone about what happened, as she was afraid of retaliation. CNA 2 further stated there have been instances where CNA 1 was rough with other residents. During an interview on 4/17/24, at 10:08 a.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 has a history of being verbally and physically abusive to residents. DSD stated provided CNA 1 individual, one-on-one training, prior to the incident occurring on 1/5/24. During a concurrent interview and record review on 4/17/24, at 11:25 a.m., with Administrator (ADM), facility's undated document titled, Concern/Grievance Reporting Form, indicated, CNA 1 had verbally aggressive behavior toward Resident 4 and Resident 5 on 4/16/23 and 8/21/23, respectively. During a concurrent observation and interview on 4/17/24, at 11:45 a.m., Resident 4 was lying in the bed. Resident 4 stated CNA 1 was rough while providing ADL care to her and one time. Resident 4 stated she had bruises on her arms after the incident, pointing at both arms. Resident 4 stated it made her angry and she wondered what she did to make CNA 1 treat her this way. Resident 4 stated she told CNA 1 You are hurting me but she felt disregarded. During a concurrent observation and interview on 4/17/24, at 11:53 a.m., Resident 5 was sitting upright at the edge of her bed, facing the door to her room. Resident 5 stated that there was an incident with CNA 1 where she yelled at Resident 5 when Resident 5 asked to hand her the phone charger. Resident 5 stated that incident made her feel disrespected . During record review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/22, the P&P indicated, The facility will implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift .

Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 was unable to sleep despite the use of sleep medication. This failure potentially contributed to increase in episodes of negative behavior and falls and had the potential to result in delayed modification of treatment regimen. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal blood sugar levels), non-traumatic chronic subdural hemorrhage (brain injury), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and epilepsy (a disorder of the brain characterized by repeated seizures). During an observation on 11/1/23 at 11:43 a.m., Resident 1 was in a wheelchair in front of the nurses' station with a blanket covering his shoulder and upper torso. Resident 1 appeared tired and engaged in a conversation with Certified Nursing Assistant (CNA) 1 in a monotone voice. During an interview on 11/1/23 at 12:10 p.m. with CNA 1, CNA 1 stated Resident 1 had a behavior of screaming and yelling at the staff, got irritated very quickly when he did not get what he wanted. CNA 1 stated Resident 1's agitation was usually triggered by pain and when delirious from lack of sleep. During a review of Resident 1's Order Summary Report, dated 11/2/23, the Order Summary Report indicated an order dated 4/14/23 for Resident 1 to receive Temazepam (a strong sedative) oral capsule 15 milligrams (mg) one capsule by mouth at bedtime for insomnia manifested by inability to sleep. The report also indicated an order dated 9/27/23 for melatonin (a hormone that regulates sleep-wake cycle) five mg two oral tablets by mouth in the evening to regulate circadian rhythm. During a review of Resident 1's Medication Administration Record (MAR) for September 2023, the MAR indicated Resident 1 slept seven hours over a 72-hour period from 9/5/23 to 9/7/23 and 13 hours over a 120-hour period from 9/13/23 to 9/17/23. The MAR indicated Resident 1 only slept for two hours over a 48-hour period (two days) from 9/29/23 to 9/30/23. During a review of Resident 1's MAR for October 2023, the MAR indicated Resident 1 slept for four hours over a 72-hour period from 10/5/23 to 10/7/23. The MAR indicated Resident 1 had one hour of sleep over an 88-hour period from 10/12/23 to 10/18/23, with zero hours of sleep from 10/12/23 to 10/14/23 (more than two days) and only sleeping an hour on 10/15/23 during the day shift, and zero hours for the evening and night shift. The MAR also indicated, on 10/24/23, Resident 1 only slept for two hours during the morning shift from 7:00 am to 3:00 p.m. and did not sleep from 3:00 p.m. until 11 p.m. the following day on 10/25/23. During review of Resident 1's SBAR (Situation, Background, Appearance, Review, a structured communication framework that help health care teams share information among themselves), Resident 1's SBAR indicated the following: -On 10/4/23 at 2:05 a.m., Resident 1 was found sitting on the floor in the room. -On 10/21/23 at 7:55 p.m., Resident fell during a struggle with a staff while in the hallway. -On 10/27/23 at 11:00 p.m., Resident fell on the floor while walking on the hallway unassisted. Resident 1 attempted to hit the staff twice for trying to help. -On 10/29/23 at 11:30 p.m., Resident 1 slipped on the floor while up in the wheelchair in front of the nurses' station. -On 10/24/23 at 5:40 p.m., Resident was violent towards the staff and refused to sit in the wheelchair. Resident 1 lost balance and fell when Resident 1 attempted to hit a CNA. During a concurrent interview and record review on 11/1/23 at 1:37 p.m. with Director of Nursing (DON), Resident 1's MAR for October 2023 and clinical records were reviewed. DON stated Resident 1's lack of sleep could have affected his behavior. DON stated when Resident 1 was not able to sleep for 48 hours, the physician should have been notified so that appropriate re-evaluation could be done. DON stated the clinical record did not indicate that Resident 1's physician was notified of Resident 1's inability to sleep. During a telephone interview on 11/3/23 at 3:57 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 received Temazepam and melatonin every evening and number of hours of sleep was monitored each shift to evaluate the efficacy of these medications. RN 1 stated she entered the number of hours for the evening shift in the MAR but was not able to see the screens for the other two shifts. RN 1 also stated Resident 1 rarely slept during the evening shift but did not know that Resident 1 did not sleep during the day and nights shifts too. During a telephone interview on 11/3/23 at 11:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 did not sleep most nights. LVN 1 stated when Resident 1 was up all night, he was usually very hard to re-direct, went in and out of bed, walked in the hallway, screamed, yelled, and became very aggressive towards the staff. LVN 1 stated when Resident 1 did not sleep the entire night shift, LVN 1 would enter zero (0) on the sleep monitoring page in the MAR. LVN 1 also stated not notifying the physician of Resident 1's inability to sleep during the night shift.

Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was administered olanzapine (treats psychosis, a mental illness), lexapro (anti-depressant, treats depression) and trazodone (anti-depressant) with adequate monitoring of adverse effects from the medications. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, paranoid schizophrenia and bipolar disorder, diabetes mellitus, and end stage kidney disease. During a review of Resident 2's Order Summary Report as of 9/6/23, the Order Summary Report indicated orders for Resident 2 to receive the following medications: lexapro 5 milligrams (mg) one tablet daily, olanzapine 5 mg one tablet in the morning and olanzapine 15 mg one tablet at bedtime. During a review of Resident 2's Medication Administration Record (MAR) for September 2023, the MAR indicated Resident 2 received olanzapine 5 mg daily from 9/8/23 to 9/30/23, 15 mg at bedtime from 9/7/23 to 9/24/23, and 10 mg at bedtime from 9/27/23 to 9/30/23. The MAR for September 2023 indicated Resident 2 was given lexapro 5 mg daily from 9/7/23 to 9/23/30, 5 mg at bedtime on 9/24/23, and at 9 am daily from 9/25/23 to 9/30/23. The MAR for September also indicated Resident 2 was administered trazodone 50 mg at bedtime from 9/28/23 to 9/30/23. The MAR did not indicate there was documented monitoring for adverse reactions from all three medications. During a review of Resident 2's Order Summary Report as of 10/1/23, the Order Summary report indicated a new order dated 9/28/23 to administer trazodone 50 mg one tablet at bedtime for sleeplessness, in addition to lexapro 5 mg and olanzapine 5 mg in the morning and 15 mg at bedtime. During a concurrent interview and review of Resident 2's MAR for October 2023 on 10/17/23 at 10:27 a.m. with Registered Nurse Supervisor (RNS), Resident 2's MAR for October 2023 and care plans were reviewed. The MAR indicated lexapro and olanzapine were administered from 10/1/23 to 10/17/23, trazodone was administered from 10/1/23 to 10/16/23. RNS stated the MAR indicated Resident 2 was not monitored for presence of absence of adverse effects from all three medications. RNS also stated there was no care plan to address the use of antipsychotic olanzapine. Resident 2's care plan indicated olanzapine was monitored as an antidepressant and not as antipsychotic. Resident 2's anti-depressant care plan initiated 9/18/23 indicated the following adverse reactions related to anti-depressant medications/therapy; dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension (high blood pressure), nausea and vomiting, lethargy (sleepiness or deep unresponsiveness and lack of activity), drooling, dizziness, diarrhea, anxiety, insomnia (persistent problem of falling and staying asleep), somnolence (strong desire to fall asleep), and many of these effects can increase the risk for falls. According to Dailymed, a nationally recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration, lexapro and trazodone have a black-box warning to alert caregivers to closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Dailymed also indicated the following adverse reactions related to olanzapine that include postural hypotension (when blood pressure drops when you go from lying down to sitting up, or from sitting to standing), constipation, weight gain, dizziness, personality disorder, akathisia (restlessness and inability to sit still), asthenia (physical weakness or lack of energy), dry mouth, nausea, somnolence, and tremor. During a telephone interview on 10/18/23 at 3:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was on antipsychotic and anti-depressant medications. LVN 1 stated Resident 2 was very restless, got in and out of bed constantly and had on and off confusion. LVN 1 stated the MAR would prompt the licensed nurse to enter information regarding the medication. LVN 1 stated there was no prompt in the MAR to watch out for adverse reactions for both anti-depressants and antipsychotic, and without it, LVN 1 stated, she would not know what adverse reactions to watch out for. LVN 1 also stated she was not aware of the facility's policy and procedure for the use of anti-depressant and antipsychotic medications. During a telephone interview on 10/23/23 at 2:52 p.m. with Family Member (FM) 1, FM 1 stated Resident 2 was always very drowsy during visits and could not finish a conversation without looking very confused and sleepy. During a review of the facility's policy and procedure (P&P) titled Use of Psychotropic Medications last revised 12/19/22, the facility P&P indicated the facility's policy was the staff to monitor and document the resident's response to the medication, including progress towards goals and presence/absence of adverse consequences in the resident's medical record.

Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at risk for aspiration, was provided honey thick liquids (thicker than nectar thick, less pourable from a cup or a bowl) as ordered by the physician when nectar thick consistency liquid (easily pourable than honey thick, like thicker cream soups) was served. This failure had the potential to result in aspiration (when food or liquid enters the airway and goes into the lungs). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in August 2015 with diagnoses that included chronic pain syndrome, glaucoma (eye condition when pressure increases inside the eyes, damaging the optic nerve), hyperlipidemia (increased blood cholesterol levels), hypertension (high blood pressure) and hypothyroidism (underactive thyroid gland, thyroid does not produce enough thyroid hormones). During a review of Resident 1's SBAR (Situation, Background, Appearance, Review, a structured communication framework that help health care teams share information among themselves) and Communication Form and Progress Notes dated 9/30/23, the SBAR indicated, on 9/30/23, Resident 1 was noted with a blood pressure of 86/40(normal range: 95-145 over 70-90), oxygen saturation of 66 percent (%), lips looked pale, skin was cold and clammy and body temperature was 95.1 Fahrenheit (F, normal temp range 97-99 F). Resident 1 was sent to the hospital via 911. During a review of Resident 1's Hospitalist Discharge Summary dated 10/3/23, the Hospitalist Discharge Summary indicated Resident 1 was discharged from the hospital with diagnoses that included metabolic encephalopathy (brain problems caused by chemical imbalance from medical issues like infection, diabetes, etc.), dementia (loss of memory and capacity to understand and make decisions), acute respiratory failure hypoxic (not enough oxygen in the body), possible aspiration, septic shock (life-threatening condition caused by a widespread infection), urinary tract infection, and hypernatremia (blood sodium levels are too high) from lack of free water intake. Under Follow-Up & Discharge Instructions dated 10/3/23 from the hospital, The Follow-up & Discharge Instructions indicated Resident 1 was to have moderately thick (honey) liquids. During a review of Resident 1's Swallow Evaluation dated 10/2/23, the Swallow Evaluation indicated Resident 1 was at high risk for aspiration and was evaluated for difficulty swallowing. The evaluation also indicated Resident 1's recommended diet was honey thick consistency liquid. During a review of Resident 1's Order Summary Report dated 10/4/23, the Order Summary report indicated aspiration risk precaution and honey thick liquids for Resident 1. During a review of Resident 1's Progress Notes dated 10/7/23, the Progress Notes indicated Resident 1 was nonverbal, .Fluids offered and encouraged. On nectar thick liquid. During an interview on 10/10/23 at 12:18 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she helped Resident 1 with breakfast. CNA 1 stated Resident 1 drank 120 milliliters (ml) of honey-thick milk and two spoonfuls of honey-thick water. CNA 1 also stated Resident 1 was also given a bowl of cereal-like gritty food item that CNA 1 could not identify. CNA 1 stated she had to return it to the kitchen because CNA 1 felt like it was too runny, and Resident 1 coughed after being given a few spoonfuls of it. During a concurrent observation and joint interview on 10/10/23 at 12:55 p.m., with CNA 2 and Licensed Vocational Nurse (LVN) 2, Resident 1's lunch tray was on the over-the-bed table. CNA 2 and went in and out of the room, alternating to check if Resident 1 was ready to be assisted with meals. CNA 2 proceeded to grab a chair to sit on, drew the privacy curtain, and took the lids off the bowls on Resident 1's tray. There was one carton of 120 ml Mildly Thick Nectar Consistency shake and a 120 ml glass of amber colored thickened liquid marked U on the lid. CNA 2 stated she did not know what the U stands for. CNA 2 and LVN 2 both stated they did not know for sure if the amber colored liquid was honey thick consistency and would ask the kitchen to verify. CNA 2 left the room and proceeded to the kitchen, leaving the carton of Mildly Thick Nectar Consistency shake on Resident 2's lunch tray. During an interview on 10/10/23 at 1:09 p.m. with Dietary Aide (DA) 1, DA 1 stated the amber colored liquid was nectar thick consistency juice. DA 1 stated he will give another glass of honey thick juice in exchange and stated the U was n but written upside down, which stood for nectar thick consistency. During a follow-up interview on 10/10/23 at 1:15 p.m. with LVN 2, LVN 2 stated she did not have a chance to check Resident 1's lunch tray as LVN 2 was in another resident's room when Resident 1's lunch tray was taken to Resident 1's room. LVN 2 stated Resident 1's breakfast tray was not checked in the morning before being taken to Resident 2's bedside. During a concurrent interview and review of Resident 1's clinical record on 10/10/23 at 2:21 p.m. with Director of Nursing (DON), DON stated both the CNAs and licensed nurses were supposed to check all trays for accuracy. DON stated not being sure if CNAs knew the difference between honey thick and nectar thick consistency. DON also stated Resident 1's clinical record did not indicate documentation of a care plan to address Resident 1's risk for aspiration.

Based on observation, interview and record review, the facility failed to maintain the facility cooling system to provide eight of 12 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8) an environment with a safe and comfortable temperature. The failure to prevent excessive heat (temperatures in excess of 81 F, degrees Fahrenheit) in the facility resulted in physical discomfort for Residents 3, 4, 6, 7; Resident 5 was nauseous for three days; Resident 2 had difficulty sleeping; and Resident 1 was unable to receive restorative nursing care for two days. This failure had the potential for dependent, bed-bound Residents 1, 2, 3, 5 and 6 to suffer death or disability as a result of heat stroke (the body temperature rises rapidly, sweating mechanisms fail, and the body is unable to cool down) and/or heat exhaustion (the body overheats causing excessive sweating and rapid pulse). This failure resulted in an Immediate Jeopardy (IJ, a situation in which a facility's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility's Director of Nursing (DON) was notified of the IJ on 8/17/23, at 5:46 p.m. The facility submitted an acceptable Plan of Action to prevent excessive heat in the facility on 8/22/23, at 12:05 p.m., and based on observation, staff and resident interviews, and record reviews, the IJ was lifted during an onsite visit on 8/23/23 at 3:34 p.m. Findings: During a review of an email dated 8/24/23, at 11:32 a.m., written by the ombudsman (OBM), the email indicated the ombudsman had been visiting residents at the facility on 8/15/23, from 2:30 p.m. to 3:00 p.m. The email indicated the OBM noted the therapy room had several residents in the therapy room and the wall thermometer showed a temperature of 82 F. The email indicated the OBM observed thewall thermometer in the occupational therapy room showed a temperature of 92 F; there were no residents in the occupational therapy room at that time. During a review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility in 2017 with diagnoses of quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and left and right ankle contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints and decreased mobility and function). During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/28/23, the MDS indicated Resident 1 used a wheelchair for mobility, required extensive assistance from one person for bed mobility, and total assistance from two people for transfer between surfaces. The MDS indicated Resident 1 had a score of nine on the Brief Interview for Mental Status exam. (BIMS, a tool to determine a resident's cognitive ability to remember and recall information; a score of 8-12 indicates moderately impaired cognition.) During a concurrent interview and record review, on 8/21/23, at 12:40 p.m., with the DON, Resident 1's care plan titled, Restorative Nursing Program: Splint/Brace Assistance, dated 3/2/23, and Treatment Record dated 8/12/23 to 8/20/23, was reviewed. The DON stated Resident 1's care plan indicated for two hours per day, five days per week, Resident 1 should have splints applied to both ankles/feet and both hands/fingers. The DON stated the Treatment Record indicated Resident 1 had refused the ankle/foot and hand/finger splints on 8/16/23 and 8/17/23; the Treatment Record did not indicate the reason for the splint refusal. During a concurrent observation and interview on 8/17/23, at 3:20 p.m., with the OMB and Maintenance Supervisor (MS), in Resident 1's room, Resident 1 sat in a wheelchair next to his bed under the air conditioning (A/C) vent. MS stated Resident 1's room had functional air conditioning, and no portable A/C unit was necessary to maintain adequate cooling. MS stated the air vent directly above Resident 1 was for cool air entry from the A/C unit in the attic and used an infrared surface thermometer (device that uses infrared light to measure surface temperature) to obtain a temperature of 69 F at the surface of the vent outlet. During a concurrent observation and interview, on 8/17/23, at 3:25 p.m., in Resident 1's room, with Resident 1, and OBM and MS, Resident 1 was in a wheelchair in his room next to his bed with a bedside table in front of him. Resident 1's forehead and neck were glistening with sweat. Resident 1 stated he was a quadriplegic and was unable to reposition himself for comfort or for cooling. Resident 1 stated he was uncomfortable because there was no cool air in the room and the room was getting hot. Resident 1 stated he had contractures of his limbs and needed to wear splints on his hands and feet, but the past few days were so hot, and the portable A/C had been taken out of his room a few days ago, so he could not tolerate wearing the splints. A clinical digital thermometer (CDT) was placed on Resident 1's bedside table with the probe tip left in free air and allowed to equilibrate for 6 minutes: the CDT indicated the air temperature was 84.9 F. During a review of Resident 2's admission record, the record indicated an admitted [DATE] for aftercare following knee replacement surgery. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had a BIMS of 14 (an indication of intact cognitive status). The MDS indicated Resident 2 required a wheelchair and extensive assistance from one person for locomotion between rooms. The MDS indicated Resident 2 had received physical therapy five days out of the seven day look back period. During a concurrent observation and interview, on 8/17/23, at 4:12 p.m., with Resident 2, Resident 2 sat in a wheelchair in the rehabilitation therapy room. The wall thermostat (device which measures room temperature and adjusts the function of the A/C based on the temperature) indicated the rehabilitation therapy room temperature was 86 F. A second temperature reading taken with a CDT with the probe tip left in free air and allowed to equilibrate for 5 minutes indicated an air temperature of 86 F. The rehabilitation therapy room had two portable A/C units operating in the room. Resident 2 stated the temperature and comfort of the facility was a joke. Resident 2 stated he had been here a month and his room was always hot and uncomfortable. Resident 2 stated his room got so hot this week he had difficulty sleeping at night. Resident 2 stated when he complained to staff about the heat, he had received one [expletive] popsicle and a warm drink to help him cool down. Resident 2 became visibly upset and started pointing and shaking his finger. Resident 2 stated he was here for rehabilitation after knee surgery, but the rehabilitation therapy room was too hot for therapy. Resident 2 stated he had complained about the rehabilitation room temperature, but nothing was done to correct it. Resident 2 stated he did his physical therapy in the front hallway with other residents because the therapy room was so hot. Resident 2 stated the facility knew they needed to fix the A/C, but they refused and allowed residents to suffer. During an interview, on 8/17/23, at 4:05 p.m., with rehabilitation staff (RS), RS indicated the rehabilitation therapy room was too hot for residents to safely complete rehabilitation despite the portable A/C units and fans in the room. RS stated the rehabilitation equipment had been moved into the hallway for residents to complete their therapy. RS stated the rehabilitation room A/C was not functional. During a review of Resident 3's admission record, the record indicated Resident 3 was admitted to the facility in 2022 with a diagnosis of chronic (long-term) difficulty in breathing. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 required extensive assistance from one person to reposition herself in bed. The MDS indicated Resident 3 required a wheelchair and was totally dependent on one person for locomotion. The MDS indicated Resident 3 had a BIMS score of 13 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/17/23, at 3:53 p.m., with Resident 3, in her room, Resident 3 lay in bed with no covers on. Resident 3's bed was next to an open window; outside air was blowing through the window into the room. There was no portable A/C unit in the room. Resident 3 stated the room was hot right now but had been hotter the past few days. Resident 3 stated for the past few days she was melting from the heat because her room did not have A/C. Resident 3 stated staff gave her popsicles, but the relief was temporary and not enough to keep her comfortable and cool. The CDT was placed at the foot of Resident 3's bed in free air and allowed to equilibrate for 3 minutes and indicated a temperature of 88.2 F. A second temperature was taken with the CDT placed near the room entrance and indicated a temperature of 88 F. During a review of Resident 4's admission record, the record indicated Resident 4 was admitted to the facility with diagnoses of depression, high blood pressure, and difficulty breathing. During a concurrent observation and interview, on 8/17/23, at 3:03 p.m., with MS, in Resident 4's room, Resident 4 lay in bed with no covers on. MS stated Resident 4's room was not supplied with cool air from the working A/C units but would be supplied with a portable A/C unit if the room temperature was over 79 F. During a concurrent interview and observation, on 8/17/23, at 3:46 p.m., with Resident 4, in Resident 4's room, Resident 4 wore a hospital gown and lay in bed on top of the bed covers. Resident 4 stated it was uncomfortably hot in the room, and she was waiting for staff to bring her a popsicle. Resident 4 stated her room has been unbearably hot for the past few days. Resident 4 stated she would never keep her own home at this temperature. The CDT was placed on Resident 4's bedside table exposed to free air and allowed to equilibrate for 3 minutes. The CDT indicated the room was 86.2 F. The room did not have a portable A/C unit. During a review of Resident 5's admission record, the record indicated Resident 5 was originally admitted in 2015 with diagnoses of quadriplegia, hypothyroidism (a malfunctioning thyroid gland which can cause disruptions of heart rate, and body temperature) and familial dysautonomia (a genetic disease which can cause disruptions in the nervous system and effect body temperature control, blood pressure and digestion). The admission recorded further indicated she was her own responsible party. During a concurrent interview and observation, on 8/18/23, at 12:20 p.m., with Resident 5, Resident 5 sat in a wheelchair in her room next to a window with an air conditioning unit and fan pointed directly toward her. Resident 5 stated she had been in the facility for years and there had never been a summer when the temperatures were comfortable. Resident 5 stated the past week the hallway became so hot and uncomfortable she got nauseous when she went out to the hallway and had to take additional medication to keep from vomiting. Resident 5 stated she took [brand name ondansetron] (a medication for nausea) and [brand name dimenhydrinate] (a medication for nausea). Resident 5 stated she normally doesn't take [brand name dimenhydrinate] but she had to take it a few times this week because the heat was making her nauseous. Resident 5 stated she had brought up the temperature issues during Resident Council numerous times but the facility response was a band-aid fix for the air conditioning units that broke again within a month. During an observation on 8/17/23, at 5:15 p.m., a wall thermometer in Resident 5's room indicated a room temperature of 84 F. During a review of Resident 5's August medication administration record (MAR), the MAR indicated Resident 5 received dimenhydrinate for nausea on 8/17/23 at 10:37 a.m., 8/16/23 at 12:51 p.m., and on 8/13/23 at 10:12 a.m., and ondansetron for nausea twice a day on 8/12/23, 8/13/23, 8/14/23, 8/15/23 and on 8/17/23. The MAR indicated Resident 5 received ondansetron once on 8/16/23. During a record review of Resident Council Minutes, dated 5/5/23, The minutes indicated resident's rooms need to be checked for temperature regulation and rooms need fans as it gets hotter. During a record review of Resident Council Minutes, dated 6/2/23, the Minutes indicated a current discussion about temperature control in resident rooms and maintenance issues for resident room thermostats and in the Franchesca Room. The Minutes indicated the resident rooms' temperature control and thermostat maintenance issues were also entered under Old Business. During a review of Resident 6's admission record, the record indicated Resident 6 was originally admitted to the facility in 2015 with diagnoses of heart failure (a chronic condition in which the heart does not pump blood as well it should), chronic obstructive pulmonary disease (a long-term condition of breathing difficulty), and diabetes (uncontrolled blood sugar). The record further indicated Resident 6 was self-responsible and able to make health care decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a BIMS score of 15 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/18/23, at 1:00 p.m., with Resident 6, Resident 6 sat in a wheelchair in her room. Resident 6 stated she had lived here for five years, and her room A/C and heat have never worked right so every summer residents had to suffer through the heat. Resident 6 stated she had breathing problems and diabetes and being hot made those conditions worse. Resident 6 stated on 8/17/23 in the afternoon, she was in the activities room listening to music and felt so hot she thought she was having a heart attack and had to return to her room to recover. During an observation, on 8/17/23, at 4:50 p.m., a wall thermometer in the activities room indicated a temperature of 85 F. A review of Resident 7's admission record indicated Resident 7 was admitted to the facility with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and hypothyroidism. The admission record indicated Resident 7 was responsible for herself and had capacity to make health care decisions. A review of Resident 7's MDS, dated [DATE], indicated she required assistance from two people for bed mobility and one person's assistance for transfer to a wheelchair. The MDS indicated Resident 7 had a BIMS score of 12 (moderate cognitive impairment). The MDS indicated Resident 7's choice of clothing was very important. A record review of Resident 7's annual physical exam, dated 8/19/22, indicated Resident 7 had capacity to make health care decisions. During a concurrent interview and observation on 8/17/23, at 2:36 p.m., with Resident 7, Resident 7 lay in bed in her room, on top of the bed covers, next to the window. Resident 7 wore a hospital gown. There was a fan in the room circulating room air toward Resident 7. Resident 7 stated her room was always hot, so she was limited to wearing a hospital gown. Resident 7 stated she had complained to staff about the heat in her room, so a portable A/C unit had been brought to her room but had then been removed. Resident 7 stated her room felt like it was 80 F, and she was only comfortable at 70 F due to her difficulty in repositioning herself. During an observation on 8/17/23, at 3:33 p.m., the CDT was placed on Resident 7's bedside table and allowed to equilibrate for 5 minutes. The CDT indicated a temperature of 82.2 F. During a review of Resident 8's admission record, the record indicated Resident 8 was admitted in 2022 with a diagnosis of difficulty breathing, diabetes, and generalized muscle weakness. The record further indicated she was responsible for herself and had capacity to make health care decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated a BIMS score of 15. During a concurrent observation and interview on 8/18/23, at 12:35 p.m., with Resident 8, Resident 8 sat in a wheelchair in the hallway. Resident 8 stated the A/C in her room was working today but had not worked yesterday or in the past week. Resident 8 stated for the past week, her room got so hot she could not stay in her own room but went to her friend's room to stay cool. During a record review of the monthly weather data for the facility's city titled Accuweather Pittsburg, CA, dated 8/2023, the monthly weather data indicated the following high temperature readings: 8/13/23 - 100 F 8/14/23 - 99 F 8/15/23 - 104 F 8/16/23 - 98 F 8/17/23 - 103 F 8/18/23 - 93 F. During a concurrent observation and interview, 8/18/23, at 2:10 p.m., with MS, the facility's A/C units in the attic were inspected. MS stated the attic A/C units were to provide cool air to the resident rooms and other areas of the facility. MS stated the A/C units were dependent on a cooling tower outside the building in order to function correctly. MS stated multiple attic A/C units were partially disassembled or had the electrical wiring disconnected. MS stated he was unable to provide the reason for the disassembled A/C units. MS stated some A/C units could circulate air, but were unable to cool the air, so uncooled attic air would be circulated to resident rooms if staff or residents turned the units on. MS stated on hot days, the attic air could reach over 110 F. MS stated five A/C units in the attic were currently operating. MS stated the working A/C units pulled fresh air from the attic space, cooled the air, and blew the cool air to resident areas. During a review of the A/C company's repair summary titled Invoice, dated 5/31/23, the invoice indicated the A/C repair company noted the facility had four operable A/C units and 11 A/C units in need of repair. The Invoice summary further indicated the cooling tower was in dire need of service or replacement and showed signs of yearly neglect. During a review of an A/C repair update titled Water Source Heat Pump Research, dated 6/28/23, the document indicated most of the water source heat pumps (technical designation of the A/C units) were not functional or had limited functionality. The update indicated the cooling tower was not operating properly and was in poor condition. During a review of an A/C repair update email titled, Invoice 1072, dated 8/2/23, the document indicated A/C unit #1 was operating at roughly 30% efficiency. The email indicated a replacement compressor would restore 100% efficiency if the cooling tower could function adequately. During a review of an A/C repair update email titled, RE: Summary of 8/11/23 visit, dated 8/17/23, the email indicated the A/C repair company was unable to complete A/C repairs in the facility attic because of the extreme heat in the attic. The update further indicated a solarium A/C unit that was not working because it was completely disassembled and was missing all major components. The email indicated six A/C units covering resident rooms 101-115, 201-207, rehab gym, dining room and solarium were not working. The email further indicated the A/C unit for rooms 117-135 was operating at a reduced efficiency. During an interview on 8/17/23, at 2:50 p.m., with MS, MS stated the facility utilized portable A/C units in resident rooms to maintain a temperature below 81 F. MS stated not all rooms had portable A/C units because the facility was at or near the capacity of the electrical system. MS stated adding more portable A/C units would trip the circuit breakers (device which prevents electrical fire due to excess electric loads) and cause the power to go off. MS stated he had to prioritize which rooms could get those A/C units based on daily temperatures taken in the morning and the afternoon and whether the room could be cooled from the attic A/C units. During an interview on 8/17/23, at 2:42 p.m., with the DON, the DON stated the resident room A/C units were not functioning so portable A/C units were being used to cool resident rooms. During a concurrent observation and interview on 8/17/23, at 5:44 p.m., with the DON, the hallway next to the DON's office and rehabilitation room had no power: lights and fans in the hallway were observed to be non-functional. The DON stated she was on the phone with MS for instructions on how to reset the electrical breaker so power could be restored. During an observation on 8/17/23, at 5:58 p.m., the hallway next to Resident 12's room showed no working fans in the hallway; the portable A/C unit in Resident 12's room was not working while Resident 12 was in the room; lights and electronic equipment at the nurses' station and the adjacent hallway had no power. During an observation on 8/19/23, at 2:45 p.m., in the hallway next to Resident 12's room, the lights in the hallway turned off and a portable A/C unit in Resident 12's room quit working. A fan in the hallway continued to function. During an interview on 8/21/23, at 12:02 p.m., with MS, Administrator, and the regional management representative, the MS stated the two observed power outages on 8/17/23, at 5:44 p.m. and 8/19/23, at 2:45 p.m., were due to the circuit breakers turning off the power to those circuits due to excess electricity demands from the portable A/C units and patient care equipment. During a review of facility's policy and procedure (P&P) titled, Resident Environmental Quality, dated 12/19/22, the P&P indicated the facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The P&P further indicated, preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. The P&P further indicated resident rooms and activity areas should be of a comfortable temperature for the resident and resident behavior should be observed to determine appropriate temperature levels. A review of facility's P&P titled, Loss of Heating or Cooling, dated 12/19/22, indicated, It is the policy of this facility to take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71-81 F.

Based on observation, interview and record review, the facility failed to maintain a safely operating toilet for two of 12 sampled residents (Resident 9 and 10). This failure resulted in toilet water leaking on the bathroom floor, attracting insects and had the potential to become a slip hazard resulting in injury or death. Findings: During an observation and interview, on 8/17/23, at 2:30 p.m., with Resident 9, a toilet was observed in Resident 9's bathroom. The bathroom was shared between Resident 9 and Resident 10. A blanket was folded and placed beneath the toilet. The blanket was wet and upon lifting the blanket, insects were found underneath. Photos of the insects were taken by surveyor. Resident 9 stated the toilet had not been fixed since the last time surveyor was in the facility in June 2023. During a record review of surveyor notes, dated 6/6/23, at 3:14 p.m., the notes indicated Resident 9's toilet was leaking, and a blanket was placed beneath the toilet. The notes indicated Resident 9 stated the toilet was leaking for over 2 years and a blanket was used to contain the leaking toilet fluid. Resident 10 stated she had been changing the blanket. During an interview on 8/21/23, at 3:55 p.m., with Administrator (Admin), Admin recalled surveyor's previous visit in June 2023 and was informed of the leaky toilet in Resident 9 and 10's bathroom. Admin recalled inspection of the toilet was subsequently done, but a leak could not be located. Admin recalled the toilet was dry at the time of inspection. A review of facility's policy and procedure titled Resident Environmental Quality, dated 12/19/22, indicated the facility maintain all essential mechanical .equipment in safe operating condition.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide care and services to attain and maintain highest practicable physical and mental well-being when a medication to aid sleep was not clarified and administered as ordered by the physician. This failure had resulted in the lack of restful sleep leading to negative behaviors like yelling and screaming. Findings: Review of Resident 1's Admission Record indicated Resident 1 had been known to the facility since April 2022, with diagnoses that included depression (persistent feeling of severe sadness with symptoms that include not being able to sleep, feeling hopeless, irritable or anxious), psychosis (severe mental disorder causing abnormal thinking and perception) and dementia (loss of mental functions affecting daily life and activities). [Reference:https://medical-dictionary.com/]. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/24/23, the MDS, under Section D- Mood, indicated Resident 1 had trouble falling asleep, or sleeping too much and had been feeling tired or having little energy for seven to 11 days over a two-week period. During a concurrent interview and review of Resident 1's care plans with Licensed Vocational Nurse (LVN) 1 on 4/11/23 at 12:25 p.m., LVN 1 stated a care plan addressing Resident 1's trouble falling asleep should have been completed but was not. LVN 1 stated Resident 1 was on Melatonin (supplement that helps establish normal sleep pattern) for sleep aid but there was no care plan to address Melatonin use to evaluate its effectiveness as a sleep aid. [Reference:https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f8a2e032-7457-434e-bfea-84178bf1f544]. During a review of Resident 1's Order Summary Report Active Orders as of 3/1/23, the report indicated an order dated 10/27/22 to give Melatonin 3 milligram tablet :Give 2 tablets by mouth as needed for dietary supplement [to] improve circadian rhythm (physical, mental and behavioral changes that follow a 24-hour cycle). However, the order did not indicate the frequency and the time of administration. During a concurrent interview and review of Resident 1's Medication Administration Record (MAR) for March 2023 with Director of Nursing (DON), on 4/11/23 at 11:32 a.m., DON stated Melatonin should have been administered to Resident 1 on 3/28/23 to help with sleep. DON stated the MAR indicated Resident 1 was not given Melatonin. DON also stated, although Resident 1 had difficulty falling asleep and was on Melatonin as needed, the clinical record did not indicate there was monitoring to evaluate the need and effectiveness of Melatonin. During a telephone interview with Interim Director of Nursing (IDON), on 6/5/23 at 1:52 p.m., IDON stated the physician's order for Melatonin, did not specify the time of administration. IDON further stated, the attending physician should still be notified to seek clarification. During an interview with Resident 1 on 4/11/23 at 12:40 p.m., Resident 1 stated having had trouble falling asleep and did not know a medication promoting sleep could be requested as needed. During an interview with LVN 2 on 4/11/23 at 12:50 p.m., LVN 2 works the morning shift and stated having observed Resident 1 asleep past 9 a.m. LVN 2 further stated Resident 1 had complained of feeling tired in the morning. During a telephone interview with LVN 3 (night shift nurse), on 6/5/23 at 10:34 a.m., LVN 3 stated, on 3/28/23, Resident 1 yelled/screamed, and asked to be pulled up in bed, then asked to sit up at the edge of the bed, and asked for a cheese sandwich, yelling and screaming in between these requests. LVN 3 stated Resident 1 had been unable to fall asleep during the night shift but was not given Melatonin because it was already past midnight, LVN 3 stated it was Against state law to administer a sleep medication past midnight. During a telephone interview with LVN 4 on 6/5/23 at 11:22 a.m., LVN 4 stated, Resident 1's constant yelling and screaming could be heard from the other station during the night shift. LVN 4 stated if there was a written order for Melatonin, the afternoon shift charge nurse should administer the medication, not the night shift. LVN 4 also stated, if the medication was not given in the evening before night shift started, and the resident still needed it, the attending physician should be notified to write another order for that medication to be given by the night shift nurse. During a concurrent interview and record review with IDON on 7/18/23 at 10:45 a.m., IDON stated, the expectation was for the licensed nurse to clarify the medication order with the physician. IDON further stated the attending physician needed to know of Resident 1's abnormal sleep pattern so that the medication regimen could be changed. IDON stated the medical record did not indicate that such notification to the attending physician was made. During a telephone interview with Consultant Pharmacist (CP) on 7/18/23 at 11:06 a.m., CP stated the medication could still be therapeutic and will help promote sleep even if administered after 11 p.m.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for one ( Resident 1) of three sampled residents when Resident 1's section M skin condition did not address wounds on the mid back and right buttock accurately. This failure had the potential for Resident 1 to not receive appropriate care and treatments. Definition: Pressure ulcers also known as pressure sores. decubitus ulcers, and bedsores and now referred to as pressure injuries are localized damage to the skin and /or underlying tissue that usually occur over a bony prominence because of pressure or pressure in combination to shear and/or friction. Reference: [National Pressure Ulcer Staging System - https://npiap.com] Findings: Review of the Minimal Data Set (MDS - an assessment screening tool used to guide care), dated 6/23/22, section M indicated Resident 1 had no unhealed pressure ulcers/injuries or surgical wounds. Review of skin evaluation indicated that Resident 1 had the following wounds: - 2/3/22 lower mid back wound length 2.0 cm (centimeter) width 1.5 cm and depth 0 cm with granulation, thin drainage - 3/31/22 lower mid back length 1.2 cm width 0.6 cm depth unable to determine, wound bed with slough (yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound exudate) and thin watery drainage - 6/2/22 lower mid back length 5.5 cm width 3.8 cm depth unable to determine noted with slough and serous (thin, watery fluid producted in response to local inflammation) drainage. - 6/10/22 lower mid back length 5 cm width 3 cm with slough and wound debridement (removal of damaged tissue) was done. -7/7/22 lower mid back length 4.0 cm width 3.5 cm depth 0 cm - 8/25/22 lower mid back length 7.5 cm width 4.1 cm depth UTD (unable to determine), wound bed with slough with thin watery, clear drainage with undermining (tunneling). Review of the surgical consult note dated 6/23/22 indicated Resident 1 was evaluated by the Wound Doctor (WD). Resident 1 had a right buttock wound that had increased in size-length 3.5 cm width 1.0 cm and 0 depth. Further review of surgical consult notes indicated Resident 1 had surgical debridements as follows: - 6/23/22 lower mid back noted with 50% slough on wound there was evidence of tissue decline debridement conducted using 5 mm (millimeter) surgical steel curette. - 2/17/22 lower mid back noted with 100% slough surgical debridement performed using 5mm surgical steel curette. During an interview on 2/1/23 at 12:49 p.m., Registered Nurse - MDS Coordinator (RN2) stated the wound on Resident 1's mid back was coded as a shear (mechanical force that acts internally on the skin tissue in a direction parallel to the body's surface. Shearing forces occur between the internal body structures and skin tissuees typically moving in opposite directions) injury. RN 2 stated she was not aware of the presence of slough on the mid back wound. During an interview on 2/6/23 at 10:07 a.m., with the Wound Doctor (WD), WD stated the mid back wound started as a shear injury that worsened with pressure, and the buttock wound, started as MASD (moisture-associated skin damage describe a spectrum of injury characterized by the inflammation and erosion of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants e.g. urine, stool, perspiration, wound exudate) but worsened from pressure when Resident 1 lay in the same position on the same body area, due to the presence of contractures. If a pressure injury is forming withing the MASD, it will have granulation, slough, and/or eschar tissue. The Long term care facility Resident Assessment Instrument -RAI 3.0 dated October 2019 indicated MDS, section M skin conditions report is based upon the highest stage of existing ulcers/injuries (at their worst), and do not reverse stage. RAI Process require the assessment accurately reflects resident status.

Based on interview and record review, the facility failed to meet professional standards of care when a nurse failed to follow their policy and procedure for clarifying and transcribing a physician's orders [REDACTED]. A physician wrote an unclear order for the use of [REDACTED]. Findings: According to the medical record, reviewed 4/11/12, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 3/28/12, showed that Resident 1 had "poor balance and required extensive assistance in all activities of daily living." The "Fall Risk Assessment," dated 3/28/12, showed a score of 16, where greater than a score of 10 is considered high risk. There was a physical therapy evaluation, dated 3/29/12, that revealed "Reason for Referral: Patient referred to PT (physical therapy) by M.D. due to decline in functional mobility/ strength/ endurance. Primary diagnosis- multiple falls at home and subdural hematoma..." After a documented fall on 3/28/12, the interdisciplinary team meeting notes, dated 3/29/12, showed new interventions to prevent falls and the care plan was updated to include "more frequent monitoring and move to room across from nurses' station." Further record review showed a form titled "[MEDICAL TREATMENT] Orders" that showed "OK lab belly vest to prevent falls" with a physician's signature. Beneath it, was written "3/29/12 noted." There was no time or signature of the licensed nurse who noted it. The treatment administration record, dated 3/29/12, showed "Lab body vest to prevent falls FYI" with no signature or time or date when this was to begin. There was a nurses note, dated 3/29/12, that showed "Received order for lab body vest to prevent falls." The following nurses note, dated 3/30/12, showed "At around 6:40 a.m., Resident was in front of nursing station. Stood up alone. Alarm went on. LN (licensed nurse) stated he was able to catch resident...Assessed by 3 nurses while resident was on the floor." Resident 1 had an x-ray of the painful left hip, was sent to the hospital and underwent surgery for [REDACTED]. During interview on 4/11/12 at 10:20 a.m., the ADON (assistant director of nurses) stated, "The order is for lab belly vest. I don't know what that is. The doctor must have meant a 'lap buddy' which is a restraint so a consent is required. There is no consent form. The resident did not have the lap buddy when she got up and fell the following day. There's no time or signature on the order. I'll ask HR (human resources) to say who the nurse was." The ADON explained that, when a restraint order was written, the physician must be asked about the responsible party giving consent for restraints. The ADON stated, "The order should have been clarified, re-written clearly and a consent form should have been put in the chart for the physician to complete at the time it was written." The facility's policy titled "Physican Orders," revised 6/07, showed "Purpose- Physician orders [REDACTED]. 2.The licensed nurse must verify to ensure the order is complete and accurate." Verify means to establish the truth, accuracy or reality of. (reference: Merriam Webster Dictionary, copyright 2006, page 1156) " 3. Transcribing the written order: a. Once the order is verified, the receiving licensed nurse documents the word "noted' next to the order along with his or her signature, title and the date. b. Immediately after noting an order, the receiving licensed nurse transcribes it...on the TAR (treatment administration record). c. Draw an arrow to the box signifying the day and time the order is initiated." During interview on 4/11/12 at 10:35 a.m., the physical therapist who evaluated Resident 1 stated,"I don't know what a lab buddy vest is. (Resident 1) was very impulsive and Spanish speaking only. He needed maximum assist to stand." During phone interview with RN 1 on 4/11/12 at 11:50 a.m., she was asked to explain the meaning of the order received and noted on 3/29/12. RN 1 stated, "It's spongy like a table. We call it a vest. I told the next shift nurse." RN 1 said she was driving and could not speak further. The ADON was asked how this information would be passed to the next shift nurse. She produced a form titled "24 hour Report." For the date 3/29/12 was written "Find lab buddy vest." The ADON said, "It doesn't say to follow up." During interview on 4/30/12 at 2:55 p.m., LVN 2 stated, "I was just arriving and was behind the desk. The (tab) alarm sounded and another staff caught him and lowered him to the floor and then helped him back to the chair." During interview on 4/30/12 at 3:10 p.m., RN 1 stated, "Resident 1 was confused and restless when his family wasn't there. He tried to get up by himself a lot from the bed and the chair. We kept him in front of the nurses' station. When the alarm beeps, we rush to him. We are usually behind the counter. I took off this order. I didn't sign it. I didn't think it was a restraint. On the treatment form, I meant 'for your information'." During interview on 4/30/12 at 3:35 p.m., Physician 1 was asked about his order written on 4/29/12. He stated, "I was thinking of a restraint to prevent falls, something to keep him sitting in the chair. (He motioned something that went around or over him.) I sat beside him and he kept standing up. I saw he was high risk. He was constantly standing up." During interview on 4/30/12 at 4:20 p.m., CNA 1 stated, "I remember he constantly got up. He had the tab alarm in the wheelchair that would alarm. He always wanted to hop up. I think he was looking for his wife. He was very ansy."

Based on staff interview and record review, the facility failed to prevent an accident when a physician's order for a device to prevent falls was not implemented. One (Resident 1) of three sampled residents had an order for [REDACTED]. As a result of this failure, Resident 1 did not receive this device and fell out of the wheelchair, fractured a hip and required surgery. Findings: According to the medical record, reviewed 4/11/12, Resident 1 was an [AGE] year old admitted to the facility on [DATE] after a hospital stay. The physician's discharge summary from the hospital showed that Resident 1 was admitted to the hospital due to "recurrent falls." The admitting [DIAGNOSES REDACTED]. The admission nursing assessment, dated 3/28/12, showed that Resident 1 had "poor balance and required extensive assistance in all activities of daily living." The "Fall Risk Assessment" showed a score of 16, where greater than a score of 10 is considered high risk. There was a physical therapy evaluation, dated 3/29/12, that revealed "Reason for Referral: Patient referred to PT by M.D. due to decline in functional mobility/ strength/ endurance. Primary diagnosis- multiple falls at home and subdural hematoma..." Further medical record review showed an Interdisciplinary Post-Fall Review, dated 3/29/12, that showed "Found sitting on floor next to bed at 1 a.m., the previous night." New interventions were "More frequent observation and moved to 119B" which was located across from the nurses station. The care plan for Risk for Falls was updated with these new interventions. In the medical record, a form, "Dialysis Orders," showed "OK lab belly vest to prevent falls" with Physician 1's signature. Beneath the order was written "3/29/12 noted." There was no signature of the licensed nurse who noted it or time when it was written or noted. The ADON confirmed that RN 1 transcribed this order. Further record review showed a Treatment Administration Record written by RN 1: "3/29/12 -Lab body vest. To prevent fall." "FYI" was written in the column heading of "Time." There was no signature or date to begin this intervention. There was a nurses note, also signed by RN 1, dated 3/29/12, that showed "Received order for lab body vest to prevent falls." The following nurses note, signed by LVN 2, dated 3/30/12, showed "At around 6:40 a.m., resident was in front of nursing station. Stood up alone. Alarm went on... Assessed by 3 nurses while resident was on the floor." Resident 1 had an x-ray of the painful left hip, was sent to the hospital and underwent surgery for [REDACTED]. During interview on 4/11/12 at 10:20 a.m., the ADON (assistant director of nurses) stated, "The order is for lab belly vest.The doctor must have meant a 'lap buddy.' The resident did not have the lap buddy when he got up and fell the following day." During interview on 4/11/12 at 10:35 a.m., the physical therapist who evaluated Resident 1 stated,"(Resident 1) was very impulsive and Spanish speaking only. He needed maximum assist to stand." During interview on 4/30/12 at 2:35 p.m., RN 2 stated, "I was just arriving for day shift. I saw him (Resident 1) in a wheelchair in front of the nurses' station. We heard the (tab) alarm on the chair. I was in back of the desk. I saw him stand and go down. Another nurse was standing closer to him and ran to catch him. We got a Spanish speaking staff to ask if he had pain. He pointed to his hip and said 'yes' to pain." During interview on 4/30/12 at 2:55 p.m., LVN 2 stated, "I was just arriving and was behind the desk. The (tab) alarm sounded and another staff caught him and lowered him to the floor and then helped him back to the chair." During interview on 4/30/12 at 3:10 p.m., RN 1 stated, "Resident 1 was confused and restless when his family wasn't there. He tried to get up by himself a lot from the bed and the chair. We kept him in front of the nurses' station. When the alarm beeps, we rush to him. We are usually behind the counter. I took off this order. I didn't sign it. I didn't think it was a restraint. On the treatment form, I meant 'for your information'." During interview on 4/30/12 at 3:35 p.m., Physician 1 was asked about his order written on 4/29/12. He stated, "I was thinking of a restraint to prevent falls, something to keep him sitting in the chair. (He motioned something that went around or over him.) I sat beside him and he kept standing up. I saw he was high risk. He was constantly standing up." During interview on 4/30/12 at 4:20 p.m., CNA 1 stated, "I remember he constantly got up. He had the tab alarm in the wheelchair that would alarm. He always wanted to hop up. I think he was looking for his wife. He was very ansy." On 4/30/11 at 4:30 p.m., The ADON stated, "He fell twice at home before he came to us. That's how he got the subdural hematoma."