Every finding on record at Driftwood Healthcare Center - Hayward

Based on interview and record review, the facility failed to ensure the infection control program policy and procedure was fully implemented when facility did not report an outbreak of COVID-19 (Coronavirus Disease 2019) to California Department of Public Health (CDPH) Licensing and Certification (L&C) according to state requirements.(COVID-19 is a contagious respiratory disease caused by a virus that spread quickly).This failure had the potential for the spread of COVID-19 infections among residents within the facility.During a review of Resident 1's Resident Face Sheet (FS), the FS indicated, Resident 1 was admitted to the facility on [DATE].(Resident Face Sheet (FS) is a document that provides overview of resident's personal and basic medical information).During a review of Resident 1's clinical records titled, SBAR, dated 8/12/26, the SBAR indicated, Resident 1 tested positive for COVID-19. SBAR indicated Resident 1's diagnoses included acute respiratory failure.(SBAR- Situation, Background, Assessment, and Recommendation-is a communication tool used by nurses to share important patient data with healthcare team).During a review of Resident 2's FS, the FS indicated, Resident 2 was admitted to the facility on [DATE].During a review of Resident 2's SBAR, dated 8/12/26, the SBAR indicated, Resident 2 tested positive for COVID-19. SBAR indicated Resident 2's diagnoses included acute respiratory failure.During a review of Resident 3's FS, the FS indicated, Resident 3 was admitted to the facility on [DATE].During a review of Resident 3's SBAR, dated 8/12/26, the SBAR indicated, Resident 3 tested positive for COVID-19. SBAR indicated Resident 3's diagnoses included acute respiratory failure and hypoxia (a condition when body tissues do not receive enough oxygen to function normally).During a concurrent interview and record review on 8/20/26 at 2:02 p.m. with Infection Preventionist/Licensed Vocational Nurse (IP), the facility's COVID-19 positive resident list, Resident 1, 2, and 3's SBARs, COVID-19 infection control policy and procedure, Infection Control reporting policy were reviewed. IP stated facility had outbreak of COVID-19 that started on 8/12/26. IP stated she was newly hired and did not know if facility reported the outbreak to L&C department.During an interview on 8/20/26 at 2:30 p.m. with Director of Nursing (DON), Administrator (Admin) and IP, DON stated facility did not report the outbreak of COVID-19 to L&C department.During a review of the facility's policy and procedure (P&P) titled, Reporting Disease, dated January 1, 2018, the P&P indicated, The designated Infection Preventionist is responsible for reporting by telephone (and/or written reporting forms via e-mail or fax transmission or website) the required diseases according to state requirements.

Based on observation, interview, and record review, the facility failed to ensure staff adherence to its infection control policies and Centers for Disease Control and Prevention recommended (CDC, lead federal agency responsible for protecting public health and safety) transmission based precautions when a Certified Nursing Assistant (CNA) 1 entered Residents 13, 14, 15, 16, 9, 8, 7, and 17's room requiring contact precautions without donning the required personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). This failure exposed residents and staff to potential cross contamination and increased the risk of transmission of infectious organisms.Findings:During a concurrent observation and interview on 6/16/26 at 3:55 pm, inside the Subacute Unit, CNA 1 entered Residents 13 and 14's room with a Contact Precaution (infection-control measures used to prevent the spread of diseases transmitted through direct or indirect contact with a patient or their environment) sign and placed linens and gowns inside the residents' closet. CNA 1 entered and exited the room wearing only a surgical mask under his chin and leaving his mouth and nose exposed. CNA 1 repeated this when he entered Resident s 15, 16, 9, 8, 7 and 17's rooms that had Contact Precaution signs without donning PPE. CNA 1 stated he should have used gown, gloves and a properly worn surgical mask for safety, to protect himself and his family.During an interview on 6/16/26 at 3:57 p.m. with Registered Nurse Supervisor (RNS), RNS stated all staff should wear PPE when entering a Contact Precaution room.During a review of the facility's line list (structured table used to track individual cases during an outbreak or infection control event) last updated June 2026, the line list indicated the following:-Resident 13 had infections with multiple organisms that included Carbapenem-resistant Pseudomonas aeruginosa (CRPA, a dangerous, multidrug-resistant strain of bacteria that does not respond to carbapenem antibiotics-a last-line treatment for serious infections), Carbapenem-Resistant Acinetobacter baumannii (CRAB, are bacteria resistant to nearly all antibiotics and difficult to remove from the environment), Multi-Drug Resistant Organism, Extended-Spectrum Beta Lactamases (MDRO ESBL, a superbug that resists multiple classes of drugs, making infections much harder to cure), Oxacillinase (OXA, an enzyme that is resistant to certain antibiotics like penicillin and oxacillin ), New Delhi [NAME] Beta-lactamases (NDM, an enzyme produced by certain superbug bacteria that makes them resistant to nearly all available antibiotics, including -lactam antibiotics and last-resort carbapenems. Bacteria carrying the NDM gene can cause severe, hard-to-treat infections in healthcare settings).-Resident 14 had infections that included CRAB, Pseudomonas aeruginosa, NDM, OXA, Methicillin-resistant Staphylococcus Aureus (MRSA, (staph) bacteria that has genetically adapted to become resistant to many standard antibiotics, including methicillin, oxacillin, penicillin, and amoxicillin (MRSA), and CRPA.-Resident 15 had infections that included OXA, CRAB, Klebsiella Pneumoniae Carbapenemase (KPC, highly dangerous, antibiotic-resistant bacteria often referred to as superbugs), NDM CRAB and CRPA.-Resident 16 had infections that included NDM/OXA, CRAB, CRPA, KPC, and Vancomycin-resistant Enterococci (VRE, a bacteria resistant to vancomycin).-Resident 9 had infections that included CRPA, Carbapenem-resistant Enterobacterales Klebsiella Pneumoniae Carbapenemase (CRE KPC, highly dangerous, antibiotic-resistant bacteria often referred to as superbugs), and OXA.-Resident 8 had CRPA.-Resident 7 had infections that included KPC MRSA, and NDM.-Resident 17 had Carbapenem-resistant Klebsiella Pneumoniae (CRO KP, a highly dangerous, multidrug-resistant strain of bacteria [Klebsiella pneumoniae] that is immune to carbapenem antibiotic).During a review of the facility's undated policy and procedure (P&P) titled Transmission-Based Precaution: Contact, the P&P indicated, contact precaution may be indicated for residents known or suspected to be infected or colonized with microorganisms that can spread by direct contact with the resident, or indirect contact with the environmental surfaces or resident care items in the resident's environment.According to Centers for Disease Control and Prevention (CDC), for contact precaution, use gown and gloves for all interactions with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. [Reference: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html].

Based on observation, interview, and record review, for nine of 22 residents (Resident 2, 3, 4, 5, 6, 7, 8, 9 and 10) who had tracheostomy (a surgically created opening [stoma] in the front of the neck and directly into the windpipe [trachea]), the facility failed to ensure that sufficient tracheostomy inner cannula (easily removable tube inside the tracheostomy's outer tube, which catches mucus, can be cleaned or disposed of without removing the entire tracheostomy tube. This prevents airway blockages) supplies were available and immediately accessible as required for safe and effective respiratory care.This failure had the potential to place the residents at risk for infection, airway obstruction and inadequate ventilation, and delayed emergency response.During a review of facility's undated record titled Resident Face Sheet (RFS), the RFS indicated the following: -Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (any disease, damage, or malfunction that alters your brain's structure or function), tracheostomy, and acute and chronic respiratory failure with hypoxia (occurs when your respiratory system cannot adequately transfer oxygen into your bloodstream). -Resident 3 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, and tracheostomy. -Resident 4 was admitted to the facility in January 2026 with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy and intracerebral hemorrhage (a life-threatening type of stroke that occurs when a blood vessel inside the brain bursts, causing blood to leak into the surrounding brain tissue). -Resident 5 was admitted to the facility in September 2025 with diagnoses that included anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes), acute and chronic respiratory failure and tracheostomy. -Resident 6 was admitted to the facility in December 2021 with diagnoses that included acute respiratory failure with hypoxia, sepsis (the body's extreme, life-threatening response to an infection and bacteremia (the presence of viable bacteria in the circulating bloodstream). -Resident 7 was admitted to the facility in March 2024 with diagnoses that included anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy, Klebsiella pneumoniae (bacteria that can cause pneumonia, UTIs, wound infections and more) and Methicillin-Resistant Staphylococcus aureus (bacteria that has developed resistance to several common antibiotics, including methicillin, making infections harder to treat). -Resident 8 was admitted to the facility in April 2026 with diagnoses that included acute respiratory failure with hypoxia, traumatic brain injury (a disruption in normal brain function caused by a sudden bump, blow, or jolt to the head, or a penetrating object), and tracheostomy. -Resident 9 was admitted to the facility October 2024 with diagnoses that included anoxic brain damage, acute respiratory failure, and tracheostomy. -Resident 10 was admitted to the facility in September 2025 with diagnoses that included tracheostomy status and chronic respiratory failure with hypoxia. During a review of Residents 2, 3, 4, 5, 6, 7, 8, 9 and 10's Physician Order Report (POR) for 6/1/26-6/30/26, the POR indicated to change the inner cannula every day and as needed. The POR also indicated all eight residents used Shiley (brand name of tracheostomy product line) size 6 except for Resident 10, who used Shiley XLT size 6.During a concurrent observation and interview on 6/15/26 at 12:02 p.m. with Registered Nurse Supervisor (RNS), in the hallway by the Respiratory Supply closets, RNS stated Respiratory Therapist (RT) 1 ensured sufficient respiratory care supplies for the subacute unit and orders stock as needed. Respiratory Supply Closet 1 contained Shiley disposable inner cannulas, sizes 7, 8, and 4; sizes 5 and 6 were not available but RNS stated they were possibly in the RT cart. Respiratory Supply Closet 2 held suction catheters, as well as an open box with 11 tracheostomy care kits. During a concurrent observation and interview on 6/15/26 at 12:17 p.m. with RT 2, RT 2 stated there was only one Shiley 6 in the RT cart, and none found in Respiratory Supply Closet 1. For trach care, inner cannulas were replaced or cleaned using trach care kits if inner cannula replacements were not available. RT stated only 11 trach care kits were available for all 22 Subacute unit residents. During an interview on 6/15/26 at 2:35 p.m. with Director of Nursing (DON), DON stated that all subacute unit residents with tracheostomies had two spare inner cannulas for emergencies. DON stated, when the unit was short of inner cannulas, RTs and RNs could use them while waiting for the supplies. During an interview on 6/16/26 at 1:07 p.m. with RNS, RNS stated working as Subacute RN Supervisor and RT that day. RNS stated disposable inner cannulas should be changed daily, but due to supply shortages, she only cleaned them before reuse. RNS stated eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) needed Shiley disposable inner cannula size 6, while Resident 10 required Shiley 6XLT, which was also unavailable. During an interview on 6/16/26 at 3:57 p.m. with Registered Nurse (RN) 1, RN 1 stated he covered the pm shift after RNS left and acted as RT since no RT was on duty. RN 1 stated a shortage of inner cannulas for some residents, making daily changes difficult despite their importance for preventing mucus plugs and infection. RN 1 stated that spare bedside inner cannulas must be reserved for emergencies and not used for routine tracheostomy care. During a review of the facility's undated policy and procedure (P&P) titled Tracheostomy Care, the P&P indicated, its purpose is to keep the airway open, maintain cleanliness and prevent infection. The procedure includes wearing clean gloves, removing and discarding the soiled dressing and disposable inner cannula, opening a sterile kit, and using a sterile hand to insert and lock a new inner cannula.

Based on observation, interview and record review, the facility failed to provide a safe environment for 79 out of 79 sampled residents when the patio gate latch was zip tied.This failure had the potential to result in delay in resident's evacuation in an event of emergency.Findings:During a concurrent observation and interview on 4/27/26 at 1:50 p.m. with the Maintenance Director (MD), in the patio, a black fence surrounding the patio had a gate latch secured with a white zip tie. The MD stated, he had applied the zip tie. The MD stated, there should be no zip tie. The MD stated, he applied the zip tie to prevent unnecessary people from coming in the facility. The MD stated, the gate was an access for paramedics who picked up residents in case of emergency.During an interview on 4/28/26 at 10:33 a.m. with the Receptionist, the Receptionist stated, the patio gate was used as emergency door in case there's a fire in the facility.During an interview on 4/28/26 at 10:48 a.m. with CNA 1, CNA 1 stated the MD would sometimes place a padlock on the gate because residents tried to open the gate. CNA 1 stated, it was not necessary to lock the gate because the residents cannot go out in case of emergency.During a follow up phone interview on 4/28/26 at 1:32 p.m. with the MD, the MD stated, the patio gate was also a route for evacuation during emergencies.During a concurrent interview and record review on 4/29/26 at 1:05 p.m. with the MD, the Evacuation Route document, dated 2/7/13 was reviewed. The Evacuation Route document indicated, a black triangle arrow had the words evacuation routes next to it. The Evacuation Route document indicated, one black triangle arrow was pointing towards the word exit leading to the patio. The MD stated, the evacuation route would be followed if there was a fire. The MD stated, residents could exit the facility to the patio during emergencies. The MD stated, the patio gate was leading to the emergency parking.During a concurrent follow up interview and record review on 4/29/26 at 1:10 p.m. with the MD, the facility's policy and procedure (P&P) titled, Evacuation Guidelines, dated 2/20/26 was reviewed. The P&P indicated, There are 3 types of evacuation, and the severity of the emergency determines which is implemented. They are:. External (to the outside of the building) - An external evacuation may be declared for any threat with the potential to affect the entire facility, like: fire in the attic, fire on the roof, area permeated with natural gas, uncontrolled fire, or bomb treat. Procedure. External Evacuation. 1. Assemble residents in a predetermined area more than 35' away from the building. The MD stated, 35' meant 35 feet away from the building. The MD stated, 35 feet away from the building was outside the patio fence.

ased on interview and record review, the skilled nursing facility failed to maintain resident confidentiality for two of the three sampled residents (Residents 1 and 2) when the licensed social worker disclosed personal information without obtaining consent from Residents 1 and 2. This resulted in a violation of resident confidentiality.During a record review of Resident 1's clinical document Resident Face Sheet (RFS), the RFS indicated the facility admitted Resident 1 in February of 2025 with multiple medical diagnosis including cerebral infarction (stroke). During a review of Resident 1's clinical document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.20.1 (MDS) dated [DATE], the MDS indicated Resident 1 was alert and oriented. During a review of the document Notice of Privacy Practices (NPP), the NPP indicated Resident 1 signed a consent on 3/19/2025 acknowledging he had received a copy of the Notice of Privacy Practices which allowed the facility to release his health information for treatment only.During a record review of Resident 2's clinical document Resident Face Sheet (RFS), the RFS indicated the facility admitted Resident 2 in October2025 with multiple medical diagnosis including Multiple Sclerosis (chronic autoimmune disease of the central nervous system).During a review of Resident 2's document MDS 3.0 Nursing Home comprehensive (NC) Version 1.20.1 (MDS) dated [DATE], the MDS indicated Resident 2 was alert and oriented.During a review of the document Notice of Privacy Practices (NPP), the NPP indicated Resident 2 signed a consent on 4/9/2025 acknowledging she had received a copy of the Notice of Privacy Practices which allowed the facility to release her health information for treatment only.During an interview on 4/6/2026 at 11:32 a.m. with the Ombudsman (OMB), the OMB stated she had repeatedly asked the facility's social worker not to share personal health information with her unless consent was given by the residents. The OMB stated the social worker continued to share the information despite being asked not to. During an interview on 4/3/2026 at 9:50 a.m., the Social Services Director (SSD) confirmed she had shared personal information with the ombudsman regarding Resident 1 and 2 without their consent.During an interview on 4/3/2026 at 10:35 a.m. Resident 1 was asked if he had personal information shared without his consent. Resident 1 was not interviewable.Resident 2 is no longer at the facility.During a review of the document Resident Dignity & Personal Privacy (not dated), the policy and procedure indicated Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 3), received tracheostomy care consistent with professional standards of practice, their physician's orders and their care plan when: 1. Resident 1's tracheostomy (a surgical procedure that creates an opening in the neck to create an artificial airway) inner cannula (a removable, lockable tube inserted into the outer tube to maintain an open airway and manage secretions) was not changed for a total of five days, including three consecutive days. 2. Resident 2 did not have the necessary emergency tracheostomy equipment at bedside. This failure had the potential to cause Residents 1 and 2 increased risk for infection and respiratory distress.During a review of Resident 1's admission Record, printed 2/24/26, the Record indicated Resident 1 was admitted to the facility in 2023 with a diagnosis of Acute Respiratory Failure (a life-threatening emergency where the lungs cannot properly oxygenate the blood or remove carbon dioxide).During an interview on 2/24/26 at 1:56 p.m. with Respiratory Therapist 1 (RT 1), RT 1 stated they cleaned and reused Resident 1's inner cannula because they did not have the replacement inner cannula for a couple of weeks. RT 1 stated the inner cannula should have been changed daily because that was what the physician ordered. RT 1 stated it could have been a risk for infection when they cleaned and reused the inner cannula instead of replacing it.During an interview on 2/24/26 at 3:04 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated it was important to change the inner cannula daily so it would not be clogged and it could have been a risk for infection when they reused the inner cannula multiple times.During a review of Resident 1's Physician's Order, dated 6/8/25, the Order indicated, Tracheostomy Type: Shiley Covidien [Manufacturer brand name] Size: 4.During a review of Resident 1's Physician's Order, dated 12/7/23, the Order indicated, Change Inner Cannula Q [every] Day (Done by Respiratory Therapist) Once a Day; 07:00 AM - 03:00 P.M.During a review of Resident 1's Progress Notes, dated 2/13/26 through 2/22/24 the notes indicated, inner cannula cleaned, on 2/13/26, 2/16/26, 2/20/26, 2/21/26 and 2/22/26.During a review of the facility's policy and procedure (P&P) titled, Carrying Out Physician's Orders, undated, the P&P indicated, All physician's orders must be documented, reviewed, and carried out accurately and promptly to ensure the highest standard of patient care. The P&P indicated, This policy applies to all nursing staff and health care providers within the facility.During a review of Resident 2's admission Record, printed 2/24/26, the Record indicated Resident 2 was admitted to the facility in 2026 with a diagnosis of Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).During a concurrent observation and interview on 2/24/26 at 2:08 p.m. with RT 1, Resident 2 was observed without a spare inner cannula readily available at bedside. RT 1 stated a spare inner cannula was part of the necessary emergency tracheostomy equipment that should have been at the resident's bedside.During an interview on 2/24/26 at 3:04 p.m. with RNS 1, RNS 1 stated emergency tracheostomy equipment including the inner canula was important to have at bedside to prevent the tracheostomy hole from closing.During an interview on 2/24/26 at 5:05 p.m. with the Director of Nursing (DON), DON stated emergency equipment including the inner cannulas should have been at residents' bedside.During a review of Resident 2's Physician's Order, dated 2/12/26, the Order indicated: Tracheostomy Type: Shiley Covidien Size: 4 .During a review of Resident 2's Respiratory Care Plan, dated 1/23/26, the Care Plan indicated, Problem. Presence of tracheostomy. Risk for. Congestion. SOB [shortness of breath]. The Care Plan indicated, Goal. The resident will maintain a clear, open airway. The Care Plan indicated, Approach. Keeping all necessary emergency supplies readily available at all times.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received Oxycodone (a medication used to treat moderate to severe pain) as ordered by their physician. This failure had the potential to cause Resident 1 unnecessary frustration and pain.During a review of Resident 1's admission Record, printed 2/5/26, the record indicated Resident 1 was admitted to the facility in 2025 with a diagnosis of cerebral infarction (A stroke that occurs when the blood supply to part of the brain is blocked or reduced), and depression. During a review of 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.), dated 12/4/25, the Record indicated Resident 1's BIMS score was 14. During a review of Resident 1's Doctors Order, dated 11/10/25, the Order indicated Resident 1 had a doctor's prescription for Oxycodone. Take 1.5 tablets (7.5 mg [milligrams] total) PO [by mouth] Q [every] 4 hours PRN [as needed] for moderate to severe pain. During an interview on 1/22/26, at 11:46 a.m., with Resident 1, Resident 1 stated they had to wait for over 24 hours for their Oxycodone on 1/21/26 because the facility ran out of it. Resident 1 stated it made them feel upset and frustrated. Resident 1 stated they did not want to get out of bed without their pain medication. During a concurrent interview and record review on 1/30/26, at 1:37 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Medication Administration Record, dated January 2026 was reviewed. The Record indicated Resident 1 did not receive Oxycodone on 1/21/26. During an interview on 1/30/26, at 3:30 p.m., with Charge Nurse (CN) 1, CN 1 stated on 1/21/26 Resident 1 complained of moderate general body pain. CN 1 stated Resident 1 requested Oxycodone for their pain. CN 1 stated they did not give Resident 1 Oxycodone during their shift because they ran out of it. CN 1 stated they explained to Resident 1 that there wasn't any more Oxycodone, and it was ordered but hadn't arrived yet. CN 1 stated it did not arrive on their shift. During an interview on 2/6/26, at 4:44p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated when residents complained of pain, pain medications should have been given as ordered by their doctor. RNS 1 stated it was important to relieve resident's pain because it could have increased irritability, and vital signs. During a review of the facility's Nursing Assignment, dated 1/21/26, the Assignment indicated CN 1 worked on 1/21/26 from 7:00 a.m. to 3:30 p.m. During a review of Resident 1's Care Plan, revised 12/15/25, the Care Plan indicated Problem: Resident expressed alteration in comfort and daily activity due to presence of pain. The Care Plan indicated Goals. Improve quality of life and ability to function. The resident will be pain-free or relieved from pain. The resident's functional ability will be maintained. The Care Plan indicated Approach: Administer Pain medication as ordered. Oxycodone 5-7.6 MG During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 10/21/2025, the P&P indicated, Purpose. to identify residents experiencing pain and develop, implement, and evaluate care plans for the management of pain, and monitor and document the resident's response to pain management interventions. The P&P indicated, Administer a therapeutic intervention for pain. pain medication as ordered by the physician

Based on observation, interview, and record review, the facility failed to ensure two of six residents (Resident 1 and Resident 2) were free from physical abuse when both struck each other during a physical altercation.This resulted in Resident 1's right hand and left ear getting hurt and making him feel fearful within the facility.During a record review of Resident 1's Face Sheet (a summary of a resident's key demographics), Face Sheet indicated Resident 1 was admitted to the facility on [DATE],During a record review of Resident 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 12/24/25, MDS indicated Resident 1 had a Brief Interview for Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 13 out of 15. This score indicated Resident 1 was cognitively intact. During a record review of Resident 2's Face Sheet, Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. During a record review of Resident 2's MDS assessment, dated 12/31/25, MDS indicated Resident 2 had a BIMS score of four (4) out of 15. This score indicated Resident 2 had severe cognitive impairment.During an interview with Resident 1 outside of Resident1's room on 1/28/26 at 11:22 a.m., Resident 1 stated that Resident 2 hit him on the head with a closed fist and he was hurt. Resident 1 stated he does not know Resident 2 and was unaware of what led to the altercation. Resident 1 stated that incident left him feeling fearful and not safe at the facility.During an interview with Resident 2 outside of Resident 2's room on 1/28/26 at 11:34 a.m., Resident 2 stated he has no recollection of the altercation on 7/26/25.During a record review of Resident 1's Progress Notes, dated 7/9/25, Social services progress note indicated Social Services met [Resident 1] to discuss the incident (hitting other resident).resident acknowledged that he struck the other resident and expressed justification that he felt frustrated.During a record review of Resident 1's Progress Notes, dated 7/25/25, Nursing Progress Notes indicated, A witness [Resident 3] came to the nurse about a altercation .the residents were facing one another hitting each other.saying profanities among each others .[Resident 1] sustained a cut on right knuckle and stated pain in left ear.During a record review of Resident 2's Progress Notes, dated 7/25/25 at 2:45 p.m., Progress Notes indicated [Resident 3] had alerted LVN to [Resident 1] and [Resident 2] having a physical altercation on the patio .[Resident 1] and [Resident 2] were facing each other in their wheelchairs while hitting and yelling out profanities at one another.During a record review of facility's policies and procedures (P&P) titled, Abuse Prevention Program, P&P indicated As part of the resident abuse prevention, the administrator will: Protect our residents from anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends visitors, or any other individual.

Based on interviews and record reviews, the facility failed to ensure immediate interventions during a resident-to-resident altercation for two sampled residents (Resident 1 and Resident 2) when a verbal altercation between Resident 1 and Resident 2 escalated into a physical altercation without timely staff separation.This failure placed Resident 1 and Resident 2 at risk for escalation of aggressive behaviors, physical injury, and emotional distress.During a review Resident 1's Face Sheet, printed on 1/22/26, the Face Sheet indicated Resident 1 was admitted to the facility in November 2023 with diagnoses of acute respiratory syndrome (life-threatening lung injury that allows fluid to leak into the lungs) and anxiety disorder (a mental health condition causing excessive and persistent fear or worry).During a review of Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) dated 9/30/25 showed Resident 1's BIMS score of 15.During a review of Resident 1's Care Plan dated 11/12/24, the Care Plan showed Resident 1 had a history of Aggressive behavior towards other resident with interventions including emphasizing responsibility of physical aggression and description of possible outcome to self and others and neutralize the situation by separating involved parties.During a review of Resident 2's Face Sheet, printed on 1/22/26, the Face Sheet indicated Resident 2 was admitted to the facility in June 2025 with diagnosis of late-onset cerebellar ataxia (gradual loss of muscle coordination).During a review of Resident 2's BIMS record dated 9/26/25, Resident 2's BIMS score of 12. (A BIMS score of eight to twelve is an indication of moderate impairment of cognitive status)During an interview on 1/22/26 at 12:46 p.m. with Resident 2, Resident 2 stated the altercation with Resident 1 happened last November 2025. Resident 2 stated it occurred early in the morning when Resident 2 used the shared bathroom and heard another resident yelling loudly in the adjacent room. Resident 2 stated they entered the room through the shared bathroom door to address the yelling. Resident 2 stated a staff member was present in the room and that Resident 2 told the staff to address the resident's yelling. Resident 2 stated Resident 1 began yelling and instructed Resident 2 to leave the room. Resident 2 stated they approached Resident 1 and a verbal argument occurred. Resident 2 stated they were challenging each other and that the argument escalated to physical altercation when Resident 1 struck Resident 2 on the head with a cane. When asked if the staff who was present in the room intervened during the altercation, Resident 2 stated I don't think so. Resident 2 further stated they were separated from each other only after the physical altercation had occurred by male nursing staff.During an interview on 1/22/26 at 2:05 p.m. with CNA 1, CNA 1 stated she was providing care to Resident 1's roommate in room [ROOM NUMBER] when Resident 2 entered the room through the shared bathroom and told her to make Resident 1's roommate to stop yelling. CNA 1 stated she was unfamiliar with the residents as it was her first time working at the facility. CNA 1 stated she did not know Resident 2 was assigned to another room and informed Resident 2 she was almost finished providing care to Resident 1's roommate. CNA 1 stated Resident 1 became upset and began arguing with Resident 2 and was telling Resident 2 to get out of the room. CNA 1 stated she also instructed Resident 2 to leave the room; however, Resident 1 and Resident 2 continued to yell at each other. CNA 1 stated Resident 1 got up from the bed, and Resident 1 and Resident 2 began shoving each other. CNA 1 stated she did not intervene physically as she did not want to get in the middle of Resident 1 and Resident 2. CNA 1 stated she attempted to de-escalate the situation verbally by telling them to calm down, and stated she was keeping an eye on them while Resident 1 and Resident 2 continued to argue. CNA 1 stated she witnessed Resident 1 grab a cane and hit Resident 2 on the head and that was the time she called for assistance. CNA 1 stated a couple of male nursing staff entered the room and assisted with separating Resident 1 and Resident 2. CNA 1 further stated she believed the incident could have been prevented if she had been informed of potential conflicts between Resident 1 and Resident 2 and behaviors that could lead to aggression.During an interview on 1/22/26 at 2:48 p.m. with the Director of Nursing (DON), DON stated during a resident-to-resident altercation, facility staff, including registry (personnel supplied by an agency) staff, were expected to immediately separate the residents as soon as a verbal altercation occurs. DON further stated if a staff member was unable to handle the safely manage the situation, the staff member was expected to immediately call for assistance to prevent escalation to a physical altercation.During a review of the facility's policy and procedure (P&P), titled, Abuse Prevention Program, dated on 5/12/25, the P&P indicated, Our residents have the right to be free from abuse.This includes but is not limited to freedom from.verbal.or physical abuse.1. Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse.and handling verbally or physically aggressive resident behavior. Follow the required training frequency and requirements by regulatory agencies.During a review of the facility's undated P&P, titled, Resident-to-Resident Altercations, the P&P indicated, 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation.

Based on observation, interview and record review, the facility failed to ensure infection control policy and procedure was followed for 10 of 23 sampled (Residents 21, 16, 32, 60, 3, 27, 51, 273, 272 and 59) residents when: 1. staff did not use sterile gloves when performing sterile tracheostomy (artificial airway at the throat which is kept open with a tube inserted into the opening) suctioning (procedure to remove secretions from the respiratory tract by vacuum) on Resident 21, 2. staff did not perform hand hygiene when switching between three residents (Resident 16, 32, and 60) who needed tracheostomy care, 3. facility did not have equipment to change suction canisters (a plastic container connected to a vacuum which stores liquid from suctioning) for Resident 3, 32 and 60 and did not have equipment to change the ventilator circuit (plastic tubing which connects a tracheostomy to a ventilator [a machine used to help a resident breath mechanically]) for Resident 51, 4. staff allowed open system tube feeding lines (a system to deliver tube feed fluid which includes a bag that can be opened to add more tube feed fluid) to be used for more than 24 hours for Residents 32, 273, 272 and 44, 5. licensed nurse did not cleanse wound with normal saline before applying wound treatment. These failures placed the residents at risk of wound, respiratory and gastrointestinal infection and had the potential for residents to be hospitalized . Findings: 1. A review of Resident 's admission record indicated Resident 21 was admitted for acute respiratory failure, attention for tracheostomy, seizures, dysphagia and type 1 diabetes. During a record review of Resident 21's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 7/4/2024, indicated Resident 21 received tracheostomy care including suctioning, oxygen therapy. During a record review of Resident 21's care plan titled, Respiratory Presence of tracheostomy, dated 6/3/24, the care plan indicated Resident 32 receive tracheostomy care which included suctioning as needed. During a concurrent observation and interview on 8/6/24, at 11:15 a.m., Resident 21 was in their room in bed waiting for a nurse to perform tracheostomy suctioning. Resident 21 stated they were sounding junky and needed to be suctioned. Resident 21 stated they were not in respiratory distress. As Resident 21 spoke they sounded like phlegm was partially occluding the tracheostomy. During a continuous observation on 8/6/24, at 11:29 a.m., Registered Nurse Supervisor 2 (RNS 2) was at Resident 21's bedside preparing to perform tracheostomy suctioning with a disposable suction catheter (a sterile one time use catheter used to suction tracheostomy openings). Wearing non-sterile gloves, RNS 2 opened the disposable suction catheter packaging. With the same gloves, RNS 2 grasped the suction catheter, removed it and attached it to the suction machine. The sterile gloves remained in the package. Continuing to use the same gloves, RNS 2 uncoiled the suction catheter, inserted the suction catheter into Resident 21's tracheostomy and began suctioning. Respiratory therapist (RT) entered the room and observed the suctioning process. After suctioning Resident 21's tracheostomy, RNS 2 discarded the suction catheter. RNS 2 then discarded the packaging with the sterile gloves still in the packaging. During an interview on 8/6/24, at 2:33 p.m., with RNS 2, RNS 2 stated nursing staff were expected to wear sterile gloves when performing tracheostomy cleaning using disposable suction catheters. RNS 2 stated disposable suction catheter came packaged with sterile gloves. RNS 2 stated sterile gloves would keep the suction catheter sterile when inserted into the tracheostomy. RNS 2 stated the suction catheter needed to remain sterile to avoid respiratory infection. During an interview on 8/7/24, at 12:38 p.m., with Respiratory Therapist (RT), RT recalled observing RNS 2 perform tracheostomy suctioning on Resident 21 without use of sterile gloves. RT stated nursing staff were expected to use sterile gloves and sterile technique when using disposable suction catheters. RT stated after she started overseeing the respiratory practice of the nursing staff, she had observed nursing staff were not consistently using sterile gloves when performing tracheostomy suctioning. During an interview on 8/7/24, at 2:51 p.m., with infection preventionist (IP), the IP stated nursing staff were expected to adhere to sterile technique including using sterile gloves when performing tracheostomy suctioning using disposable suction catheters to prevent respiratory illness. During an interview on 8/9/24, at 9:23 a.m., with the Director of Nursing (DON), the DON stated all staff were expected to adhere to hand hygiene policy during which included performing hand hygiene when moving to care for another resident in the same room. The DON stated nursing staff were expected to use sterile gloves to prevent residents from contracting respiratory illness. During a record review of facility policy and procedure titled, Procedure-sterile suctioning, undated, indicated when using a disposable suction catheter, nursing staff put sterile glove on your dominant hand. 7. Grasp sterile suction catheter with gloved hand and suction tubing attached to the suction source with your ungloved hand .do no touch the sterile catheter with your ungloved hand. 2. A review of Resident 32's admission record indicated Resident 32 was admitted for anoxic brain damage (brain damage due to lack of oxygen), attention for tracheostomy, attention to gastrostomy, dysphagia and chronic respiratory failure. The record also indicated Resident 32 was on transmission-based precautions (also called Isolation Precautions, are actions implemented in addition to standard precautions that are based upon the means of transmission for the infectious agent in order to prevent or control infections), for methicillin resistant staphylococcus aureus (MRSA, an antibiotic resistant bacteria), carbapenem resistant enterobacterales (CRE, an antibiotic resistant bacteria) and carbapenem resistant Acinetobacter baumannii (CR-AB, an antibiotic resistant bacteria) in the sputum. During a record review of Resident 32's MDS, dated [DATE], indicated Resident 32 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a record review of Resident 32's physician order set titled, Physician Order Report: 8/1/24-8/31/24, undated, the order set indicated Resident 32 had physician orders for isolation contact precaution (a type of transmission-based precaution requiring nursing staff to wear gown and gloves to prevent spread of infection) due to MRSA, ordered on 6/25/2020, and suction tracheal secretions every two hours PRN (as needed), ordered on 8/15/2022. During a record review of Resident 32's care plan titled, Respiratory Presence of tracheostomy, dated 6/3/24, the care plan indicated Resident 32 receive tracheostomy care as ordered and per protocol. A review of Resident 60's admission record indicated Resident 60 was admitted for anoxic brain damage, respiratory failure, care for tracheostomy and care for gastrostomy. During a record review of Resident 60's MDS, dated [DATE], indicated Resident 60 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a record review of Resident 60's physician order set titled, Physician Order Report: 8/1/24-8/31/24, undated, the order set indicated Resident 60 had physician orders for suction tracheal secretions q2h, ordered on 7/23/24. The order set indicated Resident 60 had a medication order for ipratropium-albuterol (a mediation to help breathing) nebulization (a method to administer medication by inhalation of a gaseous form of medication) every 6 hours including an administration time at 9:00 a.m A review of Resident 16's admission record indicated Resident 16 was admitted for respiratory failure, care for tracheostomy and care for gastrostomy. During a record review of Resident 16's MDS, dated [DATE], indicated Resident 16 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a concurrent observation and interview on 8/5/24, at 9:46 a.m., with Respiratory Therapist (RT), RT was in Resident 32, 16 and 60's room performing respiratory care on Resident 16. RT was wearing a gown and gloves. While performing tracheostomy care on Resident 16, Resident 32 could be heard coughing and had coarse breath sounds. RT paused Resident 16's care and Resident 32 needed to be suctioned. RT removed their gloves and disposed of them in a trash receptacle. Without performing hand hygiene, RT donned a new pair of gloves and went over to Resident 32 to perform tracheostomy suction. After suctioning Resident 32, RT removed their gloves and without performing hand hygiene, donned a new pair of gloves. RT stated they would perform tracheostomy suctioning prior to administering Resident 60's ipratropium-albuterol nebulizer medication. RT walked to Resident 60's bedside and began to setup oxygen tubing to administer the nebulizer treatment. Using the same pair of gloves and without performing any hand hygiene, RT suctioned Resident 60's tracheostomy. RT administered the ipratropium-albuterol to Resident 60. After administering the nebulizer treatment, RT removed their gown and gloves and exited the room. During an interview on 8/7/24, at 2:51 p.m., with the IP, the IP stated all staff were expected to perform hand hygiene when changing care between residents whether they were on transmission-based precautions or not. IP stated residents with tracheostomies were at higher risk of respiratory infection and adherence to hand hygiene was important to prevent infection. During an interview on 8/9/24, at 9:23 a.m., with the Director of Nursing (DON), the DON stated all staff were expected to follow infection prevention policy including hand hygiene policy when changing care between residents. During a review of facility P&P titled, Policy: Hand Hygiene, dated 2/2017, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .use an alcohol-based hand rub .for the following situations .before and after direct contact with residents; .before preparing or handling medications .before and after handling an invasive device .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .after removing gloves .the use of gloves does not replace hand washing/hand hygiene. 3. During an observation on 8/5/24, at 9:39 a.m., Resident 60's suction canister attached to Resident 60's dedicated suction equipment was inspected. The lid of the canister had a date 7/21/24 written on it and the canister was approximately half full with cloudy white liquid. During an observation on 8/5/24, at 10:04 a.m., Resident 32's suction canister attached to Resident 32's dedicated suction equipment was inspected. The lid of the canister was undated, and the canister was half full with a cloudy white liquid. A review of Resident 's admission record indicated Resident 3 was admitted for respiratory failure, attention for tracheostomy, seizures, dysphagia and type 1 diabetes. During a record review of Resident 3's MDS, dated [DATE], indicated Resident 3 received tracheostomy care including suctioning, oxygen therapy. The MDS indicated Resident 3 had was able to use their upper extremities for cares of living such as eating and drinking but was completely dependent on staff to transfer out of bed and to get dressed. During a concurrent observation and interview on 8/5/24, at 7:49 a.m., with Resident 3, Resident 3's suction canister was inspected. Resident 3 stated he was able to perform suctioning of his mouth by himself. Resident 3 stated the staff were responsible for changing the suction canister. The lid of the canister had a date 7/6 written on it and the canister was approximately 75% full with cloudy white liquid. A review of Resident 's admission record indicated Resident 51 was admitted for respiratory failure and attention for tracheostomy. During a record review of Resident 51's MDS, dated [DATE], indicated Resident 51 received tracheostomy care including tracheostomy care, suctioning and oxygen therapy. The MDS indicated Resident 51 had was non-verbal and was completely dependent on staff for all aspects of care. During an observation on 8/5/24, at 9:26 a.m., Resident 51 was in their room in bed with a ventilator circuit attached to their tracheostomy. At the end closest to the resident, the ventilator circuit had a mix of dry and wet red-brown residue on inside of the tube. During a concurrent observation and interview on 8/7/24, at 12:45 p.m., with RT, the storage closet for respiratory supplies was observed. RT stated the facility did not have enough supplies to change respiratory care equipment as required by the facility policy. Inspection of the storage closet indicated there were no ventilator circuits or suction canisters. RT stated there were suction canisters were expected to be changed weekly. RT stated Resident 51's ventilator circuit was soiled and needed to be changed but there were no ventilator circuits to change it. RT stated she did not know how long Resident 51's current ventilator circuit was in use because it was not dated. RT stated there were many rooms which needed suction canister changes, but the respiratory supply closet did not have any suction canisters. During an interview on 8/7/24, at 2:51 p.m., with IP, the IP stated equipment related to tracheostomy care needed to be changed regularly to prevent bacterial growth in the equipment which could potentially lead to respiratory infection. IP stated staff needed to label the equipment with a date to ensure equipment was replaced appropriately. During an interview on 8/9/24, at 9:23 a.m., with the DON, the DON stated the respiratory care contractor was responsible for stocking and ordering respiratory care equipment. The DON stated there had been past issues with a previous respiratory therapist ordering enough respiratory care equipment. During a review of facility P&P titled, Changing Disposable Equipment, Respiratory, Infection Control, undated, the P&P indicated disposable equipment must be labeled with a date and respiratory equipment such as suction canisters were changed every week on Sunday nights and ventilator circuits were changed on the first Sunday of each month. During a review of facility P&P titled, Policy: Hand Hygiene, dated 2/2017, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .use an alcohol-based hand rub .for the following situations .before and after direct contact with residents; .before preparing or handling medications .before and after handling an invasive device .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .after removing gloves .the use of gloves does not replace hand washing/hand hygiene. 4. During a record review of Resident 32's enteral feeding administration record titled, Enteral Administration History: 8/1/24-8/8/24, dated 8/8/24, the record indicated on 8/4/25, at 1:31 p.m., Resident 32 received Jevity (a type of tube feed) 1.5. The record indicated Resident 32 received Jevity 1.2 on 8/2/24, 8/3/24 and 8/4/24. During an observation on 8/5/24, at 7:15 a.m., Resident 32's tube feeding lines and pump was inspected. Resident 32's tube feeding circuit was administered through an open system and contained two bags which was filled with water and approximately 75 mL of tube feeding liquid. Resident 32 was receiving tube feed fluid through the gastric tube at a rate of 50 ml/hour. A label affixed to the bag with tube feed liquid indicated the tube feeding circuit was initiated on 8/3/24 with no start time. A review of Resident 273's admission record indicated Resident 273 was admitted for anoxic brain damage, lack of coordination, care for gastrostomy, care for tracheostomy and dysphagia. During a record review of Resident 273's MDS, dated [DATE], indicated Resident 273 received nutrition through a feeding tube. The MDS indicated Resident 272 was not able to make their needs known and was completely dependent on nursing staff for all aspects of medical and personal care. During a record review of Resident 273's enteral feeding administration record titled, Enteral Administration History: 8/1/24-8/8/24, dated 8/8/24, the record indicated Resident 273 was administered Jevity 1.5 at 65 mL/hr from 8/1/24 to 8/6/24. During an observation on 8/5/24, at 7:15 a.m., Resident 273's tube feeding lines which led into Resident 273's gastric tube was inspected. Resident 273's tube feeding line was administered through an open system and contained two bags which was filled with water and approximately 100 mL of tube feeding liquid. Resident 273 was receiving tube feed fluid through the gastric tube at a rate of 65 ml/hour. A label affixed to the bag with tube feed liquid indicated the tube feeding line was initiated on 8/3/24 at 11:00 a.m. A review of Resident 272's admission record indicated Resident 272 was admitted for disorder of muscle, care for tracheostomy, failure to thrive, dysphagia and care for gastrostomy. During a record review of Resident 272's MDS, dated [DATE], indicated Resident 272 received nutrition through a feeding tube. The MDS indicated Resident 272 was able to make their needs known but was completely dependent on nursing staff for all aspects of medical care. During a record review of Resident 272's tube feeding record titled, I&O Monitoring Administration Record: 8/1/24-8/9/24, dated 8/9/24, the record indicated Resident 272 received tube feeding from 8/1/24 to 8/9/24 on all three shifts. During an observation on 8/5/24, at 7:46 a.m., Resident 272's open system tube feeding line and tube feeding pump was inspected. The pump indicated Resident 272 was receiving tube feed at a rate of 50 mL/hr. The label affixed to the bag containing tube feed was dated 8/3/24 with no time. During a concurrent interview and record on 8/7/24, at 2:51 p.m., with IP, images of tube feeding lines observed on 8/5/24 were reviewed. IP stated the images showed residents were using an open system tube feed line, and the tube feed lines needed to be changed every 24 hours. IP stated open system feeding lines were at risk for bacterial growth in the system and could cause gastrointestinal issues and was an infection risk. During an interview on 8/9/24, at 9:23 a.m., with the DON, the DON stated nursing staff were expected to change tube feeding lines every 24 hours for residents who received tube feeding through open system systems. During a review of facility P&P titled, Enteral Feedings - Safety Precautions, dated 1/8/24, the P&P indicated nursing staff change administration sets for open-systems enteral feedings at least every 24 hours. 36087 5. A review of Resident 59's Face Sheet, printed 8/7/24, indicated Resident 59 was admitted to the facility with multiple diagnoses which included diabetes mellitus (high blood sugar in the body) with diabetic neuropathy (diabetic nerve damage which often affect the legs and feet). A review of Resident 59's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/24, indicated Resident 59 had clear speech, was understood, and was able to understand others. Further review of the MDS showed Resident 59 was at risk of developing pressure ulcers/injuries related to his diagnoses. A review of Resident 59's Physician Order, start date 8/7/24, indicated right lateral foot venous stasis ulcer (wound caused by problems with blood flow): Clean area with normal saline (NS, mixture of water and salt with a salt concentration of 0.9%), pat dry, paint area with betadine (a topical antiseptic used for skin disinfection) then leave air to dry daily x 14 days then re-evaluate. A review of Resident 59's Care Plan, dated 5/14/24, indicated Right Lateral Foot Border Venous Stasis, Treatment (Tx) as ordered: cleanse with NS . During Resident 59's concurrent wound treatment observation and interview on 8/7/24, at 9:32 a.m., with the Treatment Nurse (TN), resident's wound to right lateral foot venous stasis ulcer treatment was performed. TN painted resident's right lateral foot with the betadine-soaked gauze directly to the resident's foot without cleansing the area with NS, as indicated in the treatment order. TN stated she should have cleansed the wound before applying the betadine solution to avoid infection. During an interview on 8/7/24, at 2:24 p.m., with the Director of Staff Development (DSD), DSD stated Wound Treatment Procedure should be followed according to the physician's order. If there was an order for NS, then the wound should be cleansed with NS before the application of the ordered solution or ointment. A review of the facility's policy and procedure (P&P) titled, Wound Care and Treatment, undated, indicated, . Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water .Apply treatments as indicated .

Based on observation, interview and record review, the facility failed to ensure nursing staff had physician order, facility policy and training to use enteral tube (tube placed into a surgically create hole leading into the gastrointestinal tract) clog removal tool and followed facility expectations when performing enteral tube clog removal care for two of 16 sampled residents (Resident 274 and 45) who were receiving medications through an enteral tube. This failure had the potential for enteral tube perforation or gastrointestinal damage when nursing staff inserted plastic clog removal tool into Resident 274 and 45's enteral tube without physician order, facility policy or training on use of the clog removal tool. Findings: A record review of Resident 274's admission record indicated Resident 274 was admitted for gastrostomy care, tracheostomy care, muscle wasting and atrophy, and chronic respiratory failure. During a review of Resident 274's physician orders set titled, Physician Order Report: 8/1/24-8/31/24, undated, the orders set indicated Resident 274 had enteral tube orders to Check tube for placement/patency every shift. Special Instructions: Verifying for enteral tube placement: 1. Physical assessment, 2. Aspiration of gastric contents, 3. Auscultation (injection of air into the enteral tube). During a review of Resident 274's physician orders titled, General Order: Resident 274, undated, the orders indicated Resident 274 had a physician's order for may use a declogger when indicated if unable to declog, may change the g-tube dated 8/8/24, at 10:36 a.m., created by the Director of Nursing (DON). A review of Resident 45's admission record indicated Resident 45 was admitted for gastrostomy care, tracheostomy care, chronic respiratory failure and dysphagia (difficulty swallowing). During a review of Resident 45's physician orders set titled, Physician Order Report: 8/1/24-8/31/24, undated, the orders set indicated Resident 45 had enteral tube orders to Check tube for placement/patency every shift. Special Instructions: Verifying for enteral tube placement: 1. Physical assessment, 2. Aspiration of gastric contents, 3. Auscultation (injection of air into the enteral tube). Resident 45 did not have an order to use a clog removal for an occluded enteral tube. The order set indicated Resident 45 did not have a physician order to use the plastic clog removal tool. During a concurrent observation and interview on 8/7/24, at 11:10 a.m., with Registered Nurse 3 (RN 3), RN 3 was at Resident 274's bedside performing a medication pass. Using a large syringe with the plunger pulled out, RN 3 attached the syringe in Resident 274's enteral tube and poured 40 mL of water into the syringe body. RN 3 stated the enteral tube was clogged because the water did not instill into the enteral tube. RN 3 then massaged the enteral tube itself but was unsuccessful in unclogging it. RN 3 stated they would obtain a device to unclog Resident 274's enteral tube and left the room. RN 3 returned with a plastic clog removal tool. The packaging on the device indicated it was 39.5 centimeters in length and was used to unclog occluded enteral tubes. RN 3 inserted the clog removal tool approximately 2/3 of its length into Resident 274's enteral tube to unclog it but was unsuccessful in removing the occlusion. RN 3 used the clog removal tool a second time and inserted the clog removal tool into Resident 274's enteral tube until the handle of the tool reached the opening of the enteral tube. RN 3 had successfully unclogged the tube and finished the medication pass. During a concurrent observation and interview on 8/7/24, at 11:32 a.m., with RN 3, RN 3 was at 45's bedside performing a medication pass. Using a large syringe with the plunger pulled out, RN 3 attached the syringe in Resident 45's enteral tube and poured 40 mL of water into the syringe body. RN 3 stated the enteral tube was clogged because the water did not instill into the enteral tube. RN 3 then massaged the enteral tube itself but was unsuccessful in unclogging it. RN 3 exited the room obtained another clog removing tool and entered Resident 45's room. RN 3 inserted the clog removing tool into Resident 45's enteral tube and was able to unclog the tube. During a concurrent record review and interview on 8/8/24, at 8:48 a.m., with the Director of Nursing (DON), the facility inservice records for enteral tube management was reviewed. The DON stated she had not performed any inservice or training on the use of the clog removal tool and was unaware it was being used in non-emergency situations. The DON was unable to describe the procedure in its use but stated it was used in emergencies only. The DON stated nursing staff were expected to unclog an enteral tube by massaging the tube or instilling warm water or an enzymatic solution to unclog the tube. The DON stated if an enteral tube remained clogged nursing staff were expected to contact the provider for enteral tube replacement or obtain an order to use the plastic clog removal if there is an emergency. During a concurrent interview and record review on 8/8/24, at 8:48 a.m., with the DON, two facility policy and procedures (P&P) both titled, Enteral Feedings - Safety Precautions RC3 0406.02, one dated 1/8/24 and other undated, were reviewed. The DON stated the P&P dated 1/8/24 was the P&P staff were expected to follow and did not have a procedure for the use of the clog removal tool. The DON stated the undated P&P had an additional section which included clog removal tool indications for use and instructions for use. The DON stated she was unable to access the undated version at the online resource typically used to obtain P&P and the undated P&P was given to her by the facility's corporate office. During a concurrent record review and interview on 8/8/24, at 9:05 a.m., with Director of Staff Development (DSD), RN 3's orientation record was reviewed. The orientation record did not include training on the use of the clog removal. The DSD stated she did not perform any training on the use of the plastic clog removal tool. During a concurrent interview and record review on 8/8/24, at 9:30 a.m., with RN 3, the P&P titled, Enteral Feedings - Safety Precautions RC3 0406.02, undated, was reviewed. RN 3 stated the facility did not have training or inservice on the use of the plastic clog removal tool and had not reviewed the P&P. RN 3 stated the tool was intended to be used for emergency purposes. RN 3 stated if an enteral tube remained clogged after massage or instilling warm fluid, the provider needed to change the tube.

Based on observation, interview and record review, the facility failed to ensure 14 controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) from the Director of Nursing (DON) controlled medications cabinet were documented and destroyed according to state law and facility policy. This failure had resulted in 14 controlled medications not being destroyed and had the potential for drug diversion. Findings: During an interview on 8/8/24, at 10:45 a.m., with the DON, the DON stated Pharmacist Consultant 1 (PC 1) was the primary pharmacist who performed monthly destruction of controlled medications with the DON. The DON described the procedure for the disposal of controlled medications: 1. Nurse brings the discontinued controlled medications to the DON. 2. Every month, the DON and PC 1 reconciled and destroyed the controlled medications. 3. PC 1 destroyed controlled medications by placing the substance in plastic bucket and pouring water in until the controlled medications were dissolved. 4. The plastic bucket would be covered and locked in a biohazard container room for monthly pickup by a biohazardous waste disposal company. During a concurrent observation, interview and record review on 8/8/24, at 11:11 a.m., with the DON, the controlled medications cabinet in the DON's office was inspected. Upon inspection of the controlled medications cabinet the following medications were found: 1. One bottle of Norco (a pain relieving medication) 5-325 mg (milligram, unit of measurement) tablets with 45 tablets and two boxes of fentanyl patches containing 5 patches each box for a discharged resident. The associated count sheet did not indicate date of receipt of the medication, 2. One bottle of Hydromorphone (a pain relieving medication) 4 mg tablets with 60 tablets in the bottle for a discharged resident. The label on the bottle indicated an expiration date of 9/23/2023. There was no documentation associated with the bottle, 3. One bottle of lorazepam (a medication to reduce anxiety) 2mg per mL (milliliter, unit of measurement) liquid solution with 19 mL in the bottle with no resident label. The label indicated an expiration date of March 2024. There was no documentation associated with the bottle, 4. One bottle of Norco 5-325 and one bottle of Norco 10-325 for a discharged resident. The label on the Norco 5-325 indicated an expiration date of 8/2023. There was no documentation associated with the bottle, 5. One bottle of morphine (a pain relieving medication) 20mg/5mL liquid solution with 275mL in the bottle for a discharged resident. A note, dated 8/19/21, was affixed to the bottle and read No count sheet. Hospice Supply, 6. One box containing a bottle of morphine 100mg/5mL liquid solution for a discharged resident. A label on the box indicated an expiration date of 2/2023. There was no documentation associated with the bottle, 7. One empty bottle of morphine liquid solution for a discharged resident. There was no documentation associated with the bottle, 8. One bottle of morphine liquid solution and one bottle of lorazepam liquid solution for a discharged resident. The label on the morphine bottle indicated an expiration date of 8/2022. The label on the bottle of lorazepam indicated an expiration date of 9/2022. There was no documentation associated with the two medications, 9. A plastic bag with one empty bottle of lorazepam with a worn out illegible label for a discharged resident. A document found in the bag titled Controlled Drug Record, undated, indicated the medication was received by a nurse on 1/2/21, 10. One bottle of morphine 20 mg/mL liquid solution for a discharged resident. There was no documentation associated with the bottle. 11. One sheet of packaged alprazolam (a medication to reduce anxiety) 0.25 mg tablets containing 53 tablets for a discharged resident. The DON stated an associated record titled Controlled Drug Record, undated, indicated no tablets were administered and the sheet originally contained 56 tablets. The record indicated an expiration date of 2/2022. 12. One sheet of packaged Norco 5-325 mg tablets for a discharged resident. The label on the sheet indicated a package date of 9/26/2019, there was no expiration date on the label. There was no documentation associated with the medication. The DON stated she did not destroy the controlled medications because she did not know the procedure for destroying controlled medications without documentation of its receipt and date of discontinuation. During a concurrent observation and interview, on 8/8/24, at 2:17 p.m., with Pharmacist Consultant 2 (PC 2), the 14 controlled medications were observed on the DON's office desk. PC 2 was completing documentation to destroy the controlled medications. PC 2 stated the facility was expected to destroy controlled medications 90 days after receiving them. PC 2 stated the facility's use of water to dissolve controlled medications was not an acceptable destruction method. During a review of facility policy and procedure (P&P) titled, Medication Destruction, undated, the P&P indicated the facility destroy controlled medications in accordance with state and federal guidelines .the pharmacist and Director of Nursing/registered nurse designee document that drugs were destroyed .record the destruction of controlled substances in the drug destruction log book, as required by state and federal law. During a review of facility P&P titled, Disposal of medications, syringes, and needles Disposal of Medications, dated 1/23, the P&P indicated the director of nursing and consultant pharmacist will monitor for compliance with federal and state law and regulations regarding the disposal of medications .mixing medications with an undesirable substance, such as used coffee grounds or kitty litter .will further ensure the drugs are not diverted .dispose of discontinued medications within 90 days of the date the medication was discontinued .outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. The policy did not indicate water was an appropriate substance for destruction of controlled medications.

Based on observation, interview, and record review. the facility failed to ensure cooks had education and skill to puree food properly for 11 of 11 residents receiving a pureed diet when they over processed and over mechanicalized food, which was watery, bland and without flavor. This failure resulted in residents being at risk for decreased satiety and nutrition intake which could result in weight loss. Findings: During an observation on 8/5/24, at 11:30 a.m., [NAME] 1 (C-1) used a handheld slotted strainer to place vegetables (mixed vegetables-cauliflower and broccoli) from cooking vessel into the blender. C-1 proceeded to puree the vegetables, periodically checking the consistency. Upon completion C-1 poured the remaining liquid into the blender which resulted in 6 cups of product. The end result was a pourable product, which resembled a slightly thick cream soup. C-1 was required to add 3-ounces of thickener, yielding vegetables which resembled a thin, pourable pudding texture. This resulted in the addition of excess cooking water being inadvertently added to blender, diluting the nutritional value of the pureed item. The C-1 did not taste vegetable puree upon completion according to procedure. During an observation on 8/6/24, at 11:20 a.m., in the kitchen, C-1 transferred carrots from the cooking vessel into the blender without draining them, resulting in cooking water being added to the blender. The added cooking water diluted the carrot puree. C-1 did not taste the vegetable puree after completion. During a concurrent observation and interview on 8/6/24, at 12:30 p.m., with Kitchen Manager (KM) and Registered Dietician (RD) in the conference room, a test tray was provided. Two Surveyors and KM stated the pureed carrots lacked flavor, were watery, and needed seasoning. RD chose not to perform taste test. During a review of a facility quantified recipe titled, Seasoned Carrots FRZ PU, dated April 4, 2024, the recipe indicated carrots and food thickener as the only ingredients. The recipe did not include water listed as an ingredient. During a review of Inservice/Training Attendance Record for Pureed Food,dated 1/6/2022, the training record and roster indicated education on how to puree food and adherence to recipe was delivered to dietary staff. During review of Lesson Plan Pureed Food, undated, the lesson plan described the expected procedure for pureed food. Steps included review of recipe, following recipe, and tasting food to make sure the texture, consistency and flavor is appropriate for palatability.

Based on observation and record review, the facility failed to follow menu portions when serving orzo, baked apples and Boston cream pie. This failure resulted in residents receiving portion sizes in excess or below their required needs per physician order or dietician recommendation, potentially putting residents at risk for inability to maintain normal body weight and receiving acceptable nutritional values. Findings: During a concurrent observation and record review on 8/5/24, at 12:15 p.m., in the kitchen, Dietary Aide (DA-1) served 1/2 cup of orzo to 24/24 Controlled Carbohydrate (CCHO - a diet to keep carbohydrate consumption at a steady level) diet residents. The Spring/Summer 2024 Diet Spreadsheet, indicated CCHO diet residents should receive 1/3 cup of orzo. During a concurrent observation and record review on 8/5/24, at 12:30 p.m., in the kitchen, DA-1 used a #12 scoop (2.5-3 oz) to serve baked apples for both regular and CCHO diets. The Spring/Summer 2024 Diet Spreadsheet indicated a #10 scoop (3-4 oz) is required for serving baked apples for both regular and CCHO diets. During a concurrent observation and record review on 8/6/24, at 12:30 p.m., in the kitchen, DA-1 served residents a 1x2 inch square of Boston cream pie. The Spring/Summer 2024 Diet Spreadsheet indicated residents should receive a 2x3 inch square of Boston cream pie.

Based on observation, interview, and record review, the facility failed to ensure the juice machine was cleaned according to manufacturer's instructions when the machine was not flushed weekly and the bar gun was soaked in hot water. This failure resulted in improper sanitation and the risk for transmission of foodborne illness to 56 residents receiving juice. Findings: During a concurrent observation and interview on 8/5/24, at 10:00 a.m., in the kitchen, Kitchen Aide 1 (KA-1) soaked the juice bar gun from the juice machine in a large pitcher of hot water (water with steam emanating from vessel). KA-1 stated the required cleaning included submerging and soaking the bar gun (nozzle) daily to prevent blockages or clogs caused by sugar build-up. KA-1 stated the juice bag junction (connection to juice bag) is disconnected and rinsed when each juice bag is empty. KA-1 stated they do not use a log to document the cleaning or a cleaning schedule. During a review of [NAME] Bag in the Box Equipment Cleaning Procedure, the procedure indicated the bar gun should be soaked daily in luke warm water (water that is neither hot nor cold) only. The procedure also stated weekly flushing of all hoses, pumps and bar gun lines was required.

Based on interview and record review, the facility failed to ensure the Kitchen Manager (KM) had completed the required six hours of inservice training on the specific California dietary service requirements contained in California Code of Regulations (CCR) Title 22 prior to assuming full time duties as a dietetic services supervisor at the health facility, This failure resulted in the KM not possessing competencies and skills for California to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness. Findings: During an interview on 8/5//24, at 11:00 AM, with KM, KM stated she worked full time and was certified as a dietary manager. KM stated she does not have 6 hours of inservice training on the specific California dietary service requirements. During an interview on 8/5//24, at 11:00 AM, with Registered Dietician (RD), RD stated she had not administered or developed the required six hour inservice training for the KM.

Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 25) received good grooming and personal hygiene care when resident did not receive complete fingernail care. This failure resulted in Resident 25 to feel helpless and placed him at risk for developing infections and hurting himself with long, pointed fingernails. Findings: A review of Resident 25's Face Sheet, printed 8/7/24, indicated resident was originally admitted to the facility on [DATE] with diagnoses of quadriplegia (loss of strength on all four limbs) and cerebrovascular disease (a condition that affects flow of blood in the brain and spine). A review of Resident 25's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/8/24, indicated Resident 25 was understood and was able to understand others. The MDS indicated Resident 25's Brief Interview of Mental Status (BIMS, an assessment for cognition status) score was eight out of 15 which indicated moderately impaired cognition. Further review of the MDS showed resident was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two [2] or more helpers is required for the resident to complete the activity) for personal hygiene and grooming. During a review of Resident 25's Care Plan for Activities of Daily Living (ADL, activities related to personal care), dated 6/24/16, indicated Resident 25 would be provided with needed assistance to maintain comfort and dignity. During a concurrent observation and interview on 8/5/24, at 7:12 a.m., with Resident 25, resident was awake lying in bed, watching the television. Resident's bilateral hands were contracted without any brace or splint applied, with long and pointed (shaped like a rounded inverted letter V) fingernails to left hand (1/8 inch beyond the tip of his fingers). Resident 25 stated he did not remember why his right-hand fingernails were clipped and the left-hand fingernails were not. Resident 25 stated he preferred all his fingernails clipped evenly. During a concurrent observation and interview on 8/5/24, at 7:35 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated fingernails of non-diabetic residents are trimmed by the CNAs. CNA 1 stated resident fingernails should be trimmed short to prevent scratches that can lead to infection. During an interview on 8/7/24, at 2:28 p.m., with the Director of Staff Development (DSD), DSD stated staff were expected to assist dependent residents to perform ADL care and provide nail care. The DSD stated it was very important for the dignity of the residents. DSD also stated fingernail care when not provided, could result in skin injury from scratching and possible infection. A review of the facility's undated Lesson Plan titled, Fingernails/Toenails, Care of, indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming. Proper nailcare can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of 17 sampled residents (Resident 43, receiving hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally] treatment) when: 1. Licensed Nurse (LN) was not fully knowledgeable about the management of care in the event of Resident 43's arterial-venous fistula (a direct connection between the artery and a vein for dialysis access) site complications, post dialysis treatment. This failure resulted in the potential that staff may not correctly perform the proper intervention and prompt physician notification for a resident's dysfunctional access site condition after return from dialysis treatment. 2. LNs failed to ensure Resident 43 received Renagel (a phosphate binder used to lower high blood phosphorus [an essential mineral found in the blood to help form strong bones, teeth, and muscles] levels in patients who are in dialysis due to severe kidney disease) as ordered three times a day with meals, and to inform the physician of missed doses during dialysis treatment days. This failure resulted in Resident 43's elevated phosphorus level and had the potential to cause harm to resident's heart. Findings: 1. A review of Resident 43's Face Sheet, printed 8/7/24, indicated resident was originally admitted to the facility on [DATE] with diagnoses of diabetes mellitus (high blood sugar) and end-stage renal disease (ESRD, permanent kidney failure that requires dialysis or kidney transplant). A review of Resident 43's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/29/24, indicated Resident 43 was dependent on renal dialysis due to diagnosis of ESRD. A review of Resident 43's Physician Order Report, for 7/7/24 - 8/7/24, indicated: Start date 6/11/24 - new dialysis schedule starting 6/8/24 (Tuesday and Saturday) from 9:30 a.m. - 1 p.m. Start date 4/8/24 - AV shunt fistula to left upper arm check for bruit (auscultation of shunt for swooshing sound), and thrill (lightly palpate for vibration of shunt), signs and symptoms of bleeding, and infection every shift. A review of Resident 43's Care Plan, dated 9/19/22, indicated Diagnosis: ESRD (on renal dialysis) Risk for: electrolyte imbalance (too much or not enough of certain minerals in the body), infection, bleeding, and fatigue. Access site: left arm. Approach start date: 9/19/22, indicated check access site for any signs/symptoms (s/s) of bleeding, swelling, infection, and inform Assistant Physician (AP). During a concurrent interview and record review on 8/6/24, at 9:45 a.m., with Registered Nurse Supervisor (RNS), Resident 43's electronic clinical records indicated resident went to Dialysis Center every Tuesday and Saturday, between 9:30 a.m. to 1 p.m. RNS stated upon Resident 43's return from dialysis, post-dialysis form was checked for new orders, resident vital signs checked, and AV fistula site/dressing assessed. RNS stated she was unsure of what interventions to do with the AV fistula in case of major bleeding to the site. RNS stated she would put a tourniquet (to temporarily constrict and control blood flow and should only be used when other methods, such as pressure dressings have failed) on the resident's arm. RNS stated she needed further training on dialysis. During an interview on 8/7/24, at 2:32 p.m., with the Director of Staff Development (DSD), DSD stated post-dialysis, residents' AV fistula should be assessed and monitored for bruit and thrill, bleeding, and infection to the site. DSD further stated, with heavy bleeding put pressure on the fistula site and call 911. DSD stated all licensed staff needed to be in-serviced on hemodialysis. 2. A review of Resident 43's Physician Order Report, for 7/7/24 - 8/7/24, indicated: Start date 7/22/24 - Renagel tablet 800 milligrams (mg) - take two (2) tabs (1600 mg total) by mouth three times a day with meals for phosphate binder. With meals: 8:00 a.m., 12:00 p.m., and 5:30 p.m. A review of Resident 43's Medication Administration History (MAH), for 7/1/24 - 7/31/24, indicated LN initials on Renagel tablet doses were parenthesized (not administered or not charted, see Reasons/Comments) on the following dates during 12 p.m. administration time: 7/23/24, 7/27/24, and 7/30/24, with Reasons/Comments that indicated, Not administered: Resident unavailable. Comment: out for dialysis. Further review of Resident 43's MAH, for 8/1/24 - 8/7/24, indicated LN initials on Renagel tablet doses were parenthesized on the following dates during 12 p.m. administration time: 8/3/24 and 8/6/24, with Reasons/Comments that indicated, Not administered: Resident unavailable. Comment: out for dialysis. A review of Resident 43's Dialysis Center's Lab Draw Report, Result Release Date 5/30/24, indicated a phosphate level of 5.3 mg/deciliter(dL) high (H), (normal range 2.4-5.1). Result Release Date 6/08/24, indicated phosphate level of 5.2 mg/dL H, and Result Release Date 7/4/24, indicated phosphate level of 5 mg/dL. A review of Resident 43's Care Plan, dated 9/19/22, indicated Diagnosis: ESRD (on renal dialysis) Risk for: electrolyte imbalance (too much or not enough of certain minerals in the body), infection, bleeding, and fatigue. During a concurrent interview and record review on 8/7/24, at 10:14 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 43's electronic clinical record indicated an order for Renagel 1600 mg three times a day with meals. LVN 1 confirmed that on Tuesdays and Saturdays, Resident 43 left for dialysis after breakfast, takes a snack bag with her, and returned to facility around 2 p.m. during the morning shift. LVN 1 stated resident does not take the 12 p.m. dose of Renagel during dialysis days as shown on the MAH. LVN 1 stated Renagel, when not taken as ordered, can increase resident's level of phosphorus, and can cause hypocalcemia (low calcium level in the blood). LVN 1 confirmed she does not send Renagel with Resident 43 whenever resident went to dialysis. LVN 1 was unable to provide documentation that Medical Doctor 1 (MD 1) or Dialysis Center were informed of multiple missed 12 p.m. Renagel doses during dialysis days. During a concurrent telephone call and record review on 8/7/24, at 12:51 p.m., with MD 1, Resident 43's medication and lab results were discussed. MD 1 stated he was aware of resident's missed 12 p.m. doses of Renagel on multiple dialysis days but could not recall who informed him or when facility had last informed him. Resident 43's high levels of phosphorus were discussed and MD 1 stated resident's phosphorus level run on higher end of normal (normal range 2.4 - 5.1). For June 2024 - resident's phosphorus level was 5.2 mg/dL, July 2024 - 5 mg/dL, and on May 2024, a phosphate level of 5.3, which was outside the normal range. MD 1 stated since Resident 43 was constantly on high side of phosphorus levels, resident will have to take her 12 p.m. dose of Renagel with meals when at the dialysis center. A review of the facility's policy and procedure (P&P) titled, Hemodialysis, printed 8/7/24, dated 10/12/23, indicated, To provide residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. Hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices .Hemodialysis access devices are surgically placed and removed .Vascular access may be accomplished in one of three ways: a. Arterio-venous fistula (AVF) .Post Hemodialysis Care .3. Mild bleeding from site (post dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. 4. If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is an emergency. Do not leave resident alone until emergency services arrives .8. Monitor laboratories work up. Notify Physician as ordered or when laboratory values are abnormal .Pre and post Dialysis Documentation .Medication given, Medications sent with resident to the dialysis center, meal provision during dialysis . Resident 43 was unavailable for interview during the time of survey.

Based on observations, interviews, and record reviews, the facility failed to ensure consistent intervention and recommendation was carried out for tube feeds according to patient needs for (Resident 44) while tube feeds was the sole source of nutrition. This failure resulted in an unintended, unplanned weight gain of 21.27% in one year creating potential risks including: 1. Increased Risk of Cardiovascular Disease: Excess weight can lead to increased strain on the heart, potentially causing or worsening conditions such as hypertension, heart disease, and stroke. 2. Development or Worsening of Diabetes: Weight gain, particularly in the abdominal area, can lead to insulin resistance and increase the risk of developing type 2 diabetes or exacerbate existing diabetes. 3. Worsening of Respiratory Issues: Extra weight can compress the chest and diaphragm, making it harder for bed-bound patients to breathe and increasing the risk of respiratory problems, including sleep apnea. 4. Pressure Ulcers (Bedsores): Increased body weight can put additional pressure on areas of the body that are in constant contact with the bed or wheelchair, raising the risk of developing pressure ulcers. 5. Mobility and Joint Issues: Although bed-bound patients may have limited mobility, weight gain can put additional stress on joints and muscles, potentially leading to or exacerbating joint pain and mobility issues. 6. Increased Risk of Infections: Excess weight can lead to compromised immune function, making it harder for the body to fight infections and increasing susceptibility to illnesses. 7. Psychological Impact: Weight gain can affect a patient's self-esteem and mental health, potentially leading to feelings of depression or anxiety. 8. Wound Healing : Weight gain can affect blood flow to tissues, which can slow down the healing process of wounds or surgical sites. During review of Resident 44's Resident Face Sheet dated 8/7/2024, the Resident Face Sheet indicated Resident 44 was admitted to the facility on [DATE] and readmitted after hospitalization [DATE]. Past medical history included Chronic Respiratory failure with ventilator (breathing machine) dependency and tracheostomy (surgical opening in the windpipe for breathing), hypertension (high blood pressure), hyperlipidemia (high fat levels the blood) , diabetes, gastrostomy tube (tube in stomach for feeding), difficulty swallowing. A review of Resident 44's Weight Report dated 8/6/24 indicated: weight change from admit % change from admit 7/1/24 191 33 21.27% 6/1/24 190.5 33 20.95% 5/3/24 192 34.5 21.90% 4/2/24 189 31.5 20.00% 3/2/24 186.5 29 18.41% 2/3/24 185.5 29.3 17.97% 1/2/24 183 25.5 16.19% 12/4/24 177.5 19.7 12.51% 11/4/24 175.6 18.1 11.497.56% 10/3/24 169.4 11.9 7.56% 9/3/24 168 10.5 6.67% 8/1/23 166 0.5 5.40% 7/1/23 157.2 -0.3 -0.19% 6/1/23 156.8 -0.7 -0.44% 5/1/23 158 0.5 0.32% 4/3/23 158.5 1.3 0.83% 3/16/23 157.5 During review of Resident 44's Registered Dietician Notes dated 8/25/2023, indicated Resident 44 received Glucerna 1.5 at 75 ml/hour x24 hours. Registered Dieticiaan (RD) recommended a rate change to 70 ml/hr x24 hours. During review of Resident 44's Registered Dietician Notes dated 9/19/2023, indicated Resident 44 received Glucerna 1.5 at 75 ml/hour x24 hours. Registered Dieticiaan (RD) recommended a rate change again to 70 ml/hr x 24 hours. During review of Resident 44's Resident Progress Notes dated 9/21/2023, indicated physician was notified of RD recommendation and approved. Rate was changed to 70 ml/hr x24 hours During review of Resident 44's Registered Dietician Notes dated 11/02/2023, indicated Resident 44 had 7.76% weight increase over 3 months. Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. RD documented significant weight gain 7.6% over 3 months. During review of Resident 44's Registered Dietician Notes dated 3/05/2024, indicated Resident 44 received Glucerna 1.5 at 70 ml/hour x24 hours. Registered Dietician (RD) recommended changing rate to Glucerna 1.2 70 ml/hr x22 hours. Also indicates Notable weight gain changes r/t edema. During review of Resident 44's Enteral Administration History dated 3/01/2024-3/31/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Observation Detail list report date 03/07/2024, indicated significant 11.01% weight gain over previous six months. During review of Resident 44's Enteral Administration History dated 4/01/2024-4/30/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Enteral Administration History dated 5/01/2024-5/31/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Registered Dietician Notes dated 5/30/2024, indicated RD was notified facility out of stock of Glucerna 1.5. RD recommends Nephro 65 ml/hr for 20 hours. During review of Resident 44's Enteral Administration History dated 5/31/2024-6/04 /2024, indicated Resident 44 was received Nephro at 65 ml/hour x20 hours twice per day. During review of Resident 44's Registered Dietician Notes dated 7/01/2023, indicated Resident 44 was receiving Nephro 65 ml/hour x20 hours. Registered Dieticiaan (RD) recommended changing tube feeding to Glucerna 1.5 at 67 ml/hr x22 hours During review of Resident 44 Registered Dietician Notes dated 7/8/2024, indicated RD notified facility out of stock of Glucerna 1.5. RD recommends Glucerna 1.2 850 ml/hr for 22 hours. A review of facility policy and procedure (P&P) titled, Weight Measurements - indicated weights should be obtained weekly, monthly or according to physician order. Additionally the policy indicates progressive weight loss or gain is noted and reported to residents attending physician, family or responsible party and documented in medical record.

Based on interview and record review, the facility failed to provide pressure ulcer (a tissue injury resulting from unrelieved pressure over an area of the body) prevention and treatment for one of two sampled residents (Resident 1) when the facility failed to: develop a care plan for Resident 1 ' s pressure ulcer upon discovery, monitor Resident 1 ' s pressure ulcer, provide a pressure reducing mattress, and reposition Resident 1 off the pressure ulcer. This failure resulted in Resident 1 developing a 1 cm (centimeter, a unit of measurement) x 1cm stage 2 (a classification of the severity of the pressure ulcer, stage 1 being a reddened area with intact skin, stage 2 indicating broken skin, stage 3 indicating an injury extending into tissue under the skin, and stage 4 indicating an injury extending into muscle and/or bone) pressure ulcer on the right buttock which grew to 7 cm x 7 cm over the course of 25 days and had become abscessed (a pocket of fluid resulting from infection). Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted on [DATE] for pain management and rehabilitation after a left hip fracture. The admission record indicated Resident 1 was not self-responsible, and Resident Representative 1 (RRP) was Resident 1 ' s representative. A record review of Resident 1 ' s nursing progress note, dated 3/31/23, indicated Resident 1 had an admission assessment performed by nursing staff. The progress note indicated Resident 1 did not have any open areas on the skin. A record review of Resident 1 ' s observation report titled, Braden Scale (scale to assess risk for developing pressure ulcers) for predicting Pressure Sore Risk, dated 3/31/23, indicated Resident 1 had a Braden score of 12, indicating a high risk of developing pressure ulcers. The report indicated Resident 1 had very limited mobility and was not able to independently reposition oneself to prevent pressure ulcers. The reported indicated Resident 1 was Bedfast - confined to bed. During a concurrent interview and record review on 8/10/23, at 1:45 p.m., with the Director of Nursing (DON), Resident 1 ' s progress notes for April 2023 were reviewed. A progress note dated 4/2/2023, 5:49 p.m., indicated Licensed Nurse 2 (LN 2) identified an open area measuring 1cm x 1cm on the right buttock. The DON clarified the open area was a pressure ulcer. The DON stated LN 2 was the facility ' s wound care nurse. During a concurrent interview and record review, on 8/10/23, at 2:15p.m., with the DON, Resident 1 ' s minimum data set (MDS, an assessment tool to guide a resident ' s care), dated 4/5/23, was reviewed. The MDS indicated Resident 1 had a stage 2 pressure ulcer. The DON stated the stage 2 pressure ulcer was the right buttock wound identified on 4/2/23. The MDS indicated Resident 1 had a Brief Interview for Mental Status score of 13 (BIMS, a tool to assess a resident ' s status of memory and cognition, a score of 13-15 indicates intact cognition, 13-11 indicates moderate impairment.) A record review of Resident 1 ' s care plan for pressure ulcer, dated 5/2/23, indicated Resident 1 had four pressure ulcers including two on her left buttock and two on the right buttock. The care plan indicated Resident 1 had interventions for a pressure relief mattress, weekly wound assessments and skin checks and repositioning started on 5/5/23. Resident 1 did not have a pressure ulcer care plan in 4/2023. During a phone interview on 5/15/23, at 2:55 p.m., with RRP 1, RRP1 stated Resident 1 developed a pressure ulcer after she was admitted to the facility on [DATE]. RRP 1 stated she was admitted because of a hip fracture and had difficulty getting up. RRP1 stated Resident 1 did not have any wound on her buttock before admission. RRP 1 stated the facility needed a special mattress to prevent pressure ulcers, but the facility did not get one until over three weeks later. RRP 1 stated the facility did not monitor the wound and rarely repositioned her until it grew larger and became infected. During a record review of Resident 1 ' s Physician Orders Report, for dates 3/31/23 to 5/9/23, Resident 1 ' s physicians orders related to pressure ulcer treatments were reviewed. The report indicated Resident 1 had a physician order, dated 3/31/23, for a Weekly Nursing Summary which included skin monitoring. The report indicated Resident 1 had an order, dated 4/27/23, to monitor Pressure Ulcer site: right buttock. The report did not indicate an order for monitoring the pressure ulcer or right buttock wound site prior to 4/27/23. A review of Resident 1 ' s nursing progress notes, dated 4/1/23 to 4/27/23, indicated Resident 1 was on PUI (pressure ulcer injury) monitoring on dates, 4/3/23, 4/9-4/14, but the notes did not identify, describe, or measure a pressure injury. During a concurrent interview and record review, on 6/1/23, at 2:33 p.m., with Licensed Nurse 3, Resident 1 ' s weekly nursing summary, dated 4/17/23 and 4/24/23 were reviewed. The summaries indicated Resident 1 ' s skin was free of open areas for both dates. The 4/17/23 summary indicated turning/positioning was not monitored and lower extremities were not offloaded while in bed. LN 3 did not locate weekly nursing summaries prior to 4/17/23. During a concurrent interview and record review, on 8/10/23, at 1:00 p.m., with the DON, Resident 1 ' s weekly nursing summary and wound management sheets for 4/2023 was reviewed. The DON stated weekly nursing summary reports were done on 4/17/23 and 4/24/23. The DON stated two wound management sheets dated 5/2/23 were completed by nursing staff. The DON stated there were no other weekly nursing summary or wound management sheets reports for 4/2023. The DON stated the wound care nurse and nursing staff would be expected to document the pressure ulcer status in a weekly nursing summary, in progress notes or on a wound management sheet. A record review of Resident 1 ' s nursing progress notes from 4/1/23 to 4/27/23, indicated Resident 1 was repositioned to a comfortable position on 4/3/23. A review of progress notes from 4/4/23 to 4/26/23 did not indicate Resident 1 was repositioned, and the notes did not indicate Resident 1 refused repositioning or wound care. During an interview on 6/1/23, at 11:06 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated residents were typically turned and positioned if there was instruction by the nurse to do so. CNA 1 stated the CNAs did not document the times or the position of the turning and positioning but stated residents were turned and positioned every two hours. CNA 1 stated the nurse was responsible for documenting the turning and positioning. During an interview on 6/1/23, at 11:25 a.m., with Licensed Nurse 1 (LN 1), LN 1 stated nursing staff will instruct certified nursing assistants (CNA) to reposition residents who need to be turned. LN 1 stated the turning and positioning could be initiated without a physician ' s order. LN 1 stated CNA staff didn ' t document timing or position of turning and positioning. LN 1 stated nursing staff were responsible for documentation of turning and positioning. During a concurrent interview and record review on 6/1/23, at 11:25 a.m., with Licensed Nurse 3 (LN 3), Resident 1 ' s progress notes related to turning and repositioning for 4/2023 were reviewed. LN 3 stated if a resident was repositioned for wound management or prevention nursing staff would document the resident was repositioned. LN 3 stated she could not determine if Resident 1 was regularly repositioned off the pressure ulcer in 4/2023 after reviewing Resident 1 ' s progress notes. LN 3 stated she provided wound care nurse for Resident 1 but could not recall details of care provided. During a concurrent interview and record review on 8/10/23, at 12:50 p.m., with the DON, Resident 1 ' s physician order for a low air loss (LAL, an air mattress use to reduce pressure at areas for risk of pressure injury) mattress, dated 4/3/23, was reviewed. The DON stated if a resident needed a LAL mattress, the expectation was for the resident to be on a LAL mattress the same day if available. The order indicated nursing staff needed to document once a shift if the resident was on the LAL. A record review of a LAL mattress record titled, Special Bed/Mattress Report, dated 5/3/23, indicated Resident 1 had a LAL mattress initiated on 4/4/23, but did not indicate if Resident 1 was placed on a LAL mattress. During a concurrent interview and record review on 8/10/23, at 12:50 p.m., with the DON, Resident 1 ' s treatment administration record (TAR) for a LAL mattress for wound management and prevention, dated 4/3/2023, was reviewed. The TAR did not indicate Resident 1 was on a LAL mattress from 4/3/23 until 4/27/23. The DON stated the nursing staff were expected to document if Resident 1 was on a LAL mattress every shift according to the physician order. A review of Resident 1 ' s nursing progress notes, dated from 4/1/23 to 4/26/23, did not indicate Resident 1 was placed on a LAL mattress. A progress note, dated 4/27/23, by LN 2 indicated Resident 1 was on a LAL mattress. A record review of a LAL mattress record titled, Order Summary: Delivery 4501236869, dated 6/30/23, indicated a Dermafloat LAL mattress was rented for Resident 1 on 4/24/23 at 11:59 a.m. and was delivered on 4/24/23, at 6:10 p.m. The summary did not indicate if Resident 1 was placed on the Dermafloat mattress upon delivery. A record review of Resident 1 ' s nursing progress note, dated 4/27/23, at 2:43 p.m., by LN 2, indicated Resident 1 was ordered to start a five day course of antibiotics for a possible infection of the wound and received the first dose of Bactrim (a medication to treat bacterial infection) from the facility ' s e-kit (an emergency medication kit containing medications to treat immediate and/or serious medical issues) on 4/27/23. A record review of Resident 1 ' s nursing progress note, dated 4/27/23, at 2:06 p.m., by LN 2, indicated Resident 1 ' s open area on the right buttock was possibly infected. The progress note indicated the wound was red, tender and painful to touch. During a concurrent interview and record review, on 6/1/23, with LN 3, Resident 1 ' s Wound Management Detail Report, dated 5/2/23, by LN 2, was reviewed. The report indicated Resident 1 had a pressure ulcer on the right buttock which measured 7x7 cm and was not present on admission. The report indicated an incision and drainage (a surgical procedure to drain a wound of fluid) was performed on the wound. LN 3 stated this was the same wound identified on 4/2/23. During a phone interview on 10/5/23, at 11:00 a.m., with nurse practitioner 1 (NP 1), NP 1 stated she did not recall the condition of Resident 1 ' s right buttock pressure ulcer prior to the wound becoming infected on 4/27/23. NP 1 stated Resident 1 was at high risk of pressure ulcer development and worsening of existing wounds and expected nursing staff to closely monitor the resident for skin changes. During a phone interview on 10/5/23, at 11:45 a.m., with LN 2, LN 2 stated he did not regularly work at the facility and was on-call (working only when he was available). LN 2 stated nursing staff needed to monitor Resident 1 ' s wound weekly according to the physician order. LN 2 stated he did not recall the condition of the wound prior to his assessment on 4/27/23 but stated his documented assessment on 4/2/23 of an open area measuring 1cm x 1cm on the right buttock was accurate. LN 2 recalled the right buttock wound was obvious and could not be missed. A review of facility policy and procedure (P&P) titled, Pressure Ulcer and Skin Care Management, undated, indicated after a pressure ulcer is identified the facility develops the care plan using the clinical conditions and risk factors identified .considers and includes interventions for pressure ulcer .treatment to provide an aggressive program of consistent interventions by all staff involved. The P&P indicated a licensed nurse completes a pressure ulcer or skin report: when a pressure ulcer .is identified and weekly until healed.

Based on interview and record review, the facility failed to provide supervision to prevent an accident when Certified Nurse Assistant (CNA) 1, without assistance of a second staff person, transferred one of four sampled residents ( Resident 2 ) with a Hoyer lift (a mechanical device used to lift people) from his wheelchair to bed. The loop on the sling of the hoyer lift malfunctioned and Resident 2 slid unto the floor. This deficient practice resulted in Resident 2 sustaining a fractured (broken bone), left eighth rib, hitting his head and the left side of his torso (trunk of the body), pain and having to go to the emergency room for treatment. Findings: Review of the Resident Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/10/17, indicated Resident 2's Brief interview for mental status was 14 (indicated he was able to recall events and knew the correct year and month). The MDS also indicated Resident 2 was totally dependent and required total assistance of two plus persons when transferring to and from bed to wheelchair. Further review of the MDS indicated Resident 2's active [DIAGNOSES REDACTED]. During an interview with Resident 2 on 7/5/17, at 1:05 p.m., Resident 2 stated the sling broke on the Hoyer lift when CNA 1 was transferring him from the wheelchair to the bed on 6/12/17. Resident 2 stated he fell and hit the left side of his head and the left side of his trunk on the footboard of his roommate's bed. Resident 2 stated he was hurting and asked to go to the hospital. During an interview with CNA 1 on 7/5/17, at 1:50 p.m., CNA 1 stated while transferring Resident 2 from the wheelchair to the bed on 6/12/17 one of the hooks on the sling came off the lift. When Resident 2 was lifted from the wheelchair, CNA 1 saw the sling come off the lift, and Resident 2 was leaning to the left. CNA 1 stated she moved Resident 2's wheelchair out of the way and the Hoyer lift was used to guide the sling down until Resident 2 reached the floor in a sitting position. CNA 1 stated she used the Hoyer lift without assistance. She stated she had been trained on how to use the lift before the incident, and she was aware two people were required when using the Hoyer lift. Review of the facility's investigation summary dated 6/16/17, indicated CNA 1 was operating the Hoyer lift, and the sling loop came off from the mechanical lift's hook during transfer. Further review indicated Resident 2 slid down and ended in a sitting position on the floor. During an interview on 7/5/17 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 3, he stated on 6/12/17, Resident 2 was on the floor in a sitting position when he entered the room after the fall. LVN 3 stated CNA1 told him Resident 2 had slid from the wheelchair to the floor. LVN 3 stated he assessed Resident 2 and with the help of facility staff, Resident 2 was transferred to bed using a sheet to lift him. LVN 3 stated Resident 2 complained of pain on his left side. He notified the physician, and Resident 2 was transferred to the acute hospital. Review of Resident 2's Observation Report dated 6/12/17 at 9:44 p.m., indicated Resident 2 was transferred to the acute hospital. Review of the acute hospital X-Ray report dated 6/13/17, indicated Resident 2 sustained a fracture to his left eighth rib. Review of Resident 2's care plan Self care deficit, initiated on 12/2/16, indicated the staff should Provide 2 person assist with Activities of daily living (ADL's) as needed. Review of Resident 2's Physical Therapist Progress Discharge Summary dated 2/23/17, indicated Resident 2 required the assistance of two or more helpers for transfer. Review of the facility's Hoyer Lift/Mechanical Lift Procedures training document for staff dated 6/14/17, indicated Mechanical lifts require at a 2-person assist. Both caregivers will steady the resident as the lift is being moved. The second caregiver will guide the resident's body while the first caregiver moves the lift. Review of the facility's Resident Transfer: Mechanical Lift policy and procedure dated 8/15/2002, revealed Mechanical lifts require at least a 2-person assist. Review of the Manual/Electric Portable Patient Lift manufacturer manual, under Transferring the Patient, indicated The use of one assistant is based on the evaluation of a healthcare professional for each individual case .before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are are not properly in place .correct this problem-otherwise, injury or damage may occur . The manual further indicated, when transferring resident to a wheelchair, one assistant will be behind the chair and the other operating the patient lift, This will maintain a good center of balance and prevent the chair from tipping forward.

Based on interviews and record review, the facility failed to start an intravenous line and give intravenous fluids when ordered and failed to evaluate the medications for one of 7 sampled residents. Resident 1 had diarrhea, became dehydrated and the doctor ordered an intravenous line to give her fluids but the facility could not start the intravenous line. Resident 1 continued to receive a diuretic medication ([MEDICATION NAME]) even though her intake was extremely low, resulting in Resident 1 being sent to the hospital on [DATE], diagnosed with [REDACTED]." Resident 1 expired on [DATE] due to septic shock, acute kidney injury. Definition: C- diff or [MEDICAL CONDITION]- The Centers for Disease Control and Prevention bulletin dated [DATE]: "[MEDICAL CONDITION] is a spore- forming bacteria that produces exotoxins (a poisonous substance excreted into the surrounding medium). The main clinical symptoms are watery diarrhea, fever, loss of appetite, nausea, and abdominal pain or tenderness. The diseases that can result from a C- diff infection include [MEDICAL CONDITION] (inflammation of the colon), perforation of the colon,[MEDICAL CONDITION] (a system- wide infection) and death. " (reference: www..cdc.gov/HAI/organisms/cdiff/Cdiff_faq-HCP.hml) Findings: On [DATE], review of the medical record showed that Resident 1 was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. The complete resident assessment, dated [DATE], showed that Resident 1 walked to the bathroom with the supervision of one staff and used a walker, was alert and communicative. Review of the Activities of Daily Living (ADL) flow sheet, documented every shift by the CNA's (certified nursing assistant), showed that Resident 1 had a total of six bowel movements on [DATE]: one on night shift, one on day shift and four on p.m. shift; on [DATE]: one stool was charted for each of the three shifts; on [DATE]: two stools on day shift and one on p.m. shift; on [DATE]: two stools on day shift and one on p.m. shift; on [DATE]: one stool on night shift, three on day shift and two on p.m. shift. . Review of the nurse practitioner's (NP) telephone orders, dated [DATE], showed: "[MEDICATION NAME] 50 mg (milligrams) orally three times per day for C- diff; Start D5NS (5% [MEDICATION NAME] and normal saline) at 75 cc. (cubic centimeters) per hour times two liters via peripheral line." A nurses' note, dated [DATE] at 11:00 p.m., signed by RN 2, showed, "Received lab results and fax'ed to NP...Received telephone order from her (NP) to start Flagy for C- diff. Start..IV...LN (licensed nurse) tried to start IV but unsuccessful so called IV nurse...they said they will call us back for ETA (estimated arrival time)." A nurses' note, dated [DATE], showed, "Phone call to the NP: "Patient complains of [MEDICAL CONDITION]; Resident is alert and oriented to person, place and time; complains of dizziness. Received order to send to hospital for further evaluation." During phone interview on [DATE] at 9:00 a.m., the DON stated, "There is no documentation that the IV was not started on [DATE] and the physician was notified." During phone interview on [DATE] at 9:30 a.m., the NP stated, "They told me she had no urinary output. Her appetite was poor. I was not informed that the IV was not started. I gave the telephone order for IV fluids and antibiotics and to send her to the hospital." During phone interview on [DATE] at 10:00 a.m., LVN 3 stated, "When I did rounds at 7:00 a.m. on [DATE], she (Resident 1) complained of no urine output. She was on a fluid restriction but I offered her water. She only took a few sips. The RN (registered nurse) assessed her and found no problem. I didn't know about the diarrhea. She must have become dehydrated." During a phone interview on [DATE] at 3:15 p.m., RN 2 stated that she received the abnormal lab results on [DATE] and contacted the NP. When she was unable to start the IV, she called the facility's IV nurse. RN 2 stated, "The IV nurse did not arrive on my shift. I did not inform the NP. I told the next shift nurse about it." Review of the hospital's emergency department records, dated [DATE] at 10:03 a.m., showed, "Chief complaint: Patient presents with low blood pressure. Per staff at facility, alert and oriented. Bowel problem- no BM for 3 days. [MEDICAL CONDITION]- per staff at facility, no urine for 3 days. Currently being treated for [REDACTED]." Resident 1 was on [MEDICATION NAME] (one packet daily for treatment of [REDACTED]. "Upon placing a Foley (urinary) catheter in the emergency department, immediately drained 500 ml (milliliters) of dark brown urine." A CAT scan of the abdomen was performed and showed "Probable [MEDICAL CONDITION] with thickening involving the ascending colon. This is new. Some thickening of the descending colon." The diagnostic list showed "[MEDICAL CONDITION], [MEDICAL CONDITIONS], low sodium, low potassium, [MEDICAL CONDITION], acute kidney injury, and [MEDICAL CONDITION]." The hospital admission physician wrote an assessment and plan, dated [DATE], that showed, "C- diff [MEDICAL CONDITION], acute kidney injury due to dehydration likely secondary to diarrhea and medication, low sodium and low potassium likely secondary to dehydration and diarrhea, borderline hypotensive likely due to...dehydration." The hospital Death Summary, dated [DATE], written by a hospital physician, showed, "Principal Problem: Comfort measures only status, cardiopulmonary arrest for minutes, septic shock for days, C- diff for weeks, acute [MEDICAL CONDITION] for days. Active problems: dehydration, acute kidney injury, low sodium, low potassium,[MEDICAL CONDITION]"

Based on observation, interview, and record review, the facility failed to protect the funds of one of 17 sampled residents. Resident 11 had withdrawn money from his personal bank account and had it sent to the facility so that he could set up a trust fund to buy clothes and toiletries. The facility received the funds, cashed the checks and without Resident 11's knowledge used the money to pay Resident 11's medical bill. This failure resulted in Resident 11 being very angry, as evidenced by him yelling at the nurses station, because his trust fund was not set up for basic needs that included clothing and toiletries. Findings: The facility admitted [AGE] year-old Resident 11 on 3/4/14 with a [DIAGNOSES REDACTED]. Resident 11 was alert, oriented, and able to wheel himself in a wheelchair. In an interview on 7/22/14 at 12:05 p.m., Resident 11 was asked about his personal belongings. Resident 11 stated that he "Needed clothes. I had sent $1,000 to this facility and I had to wait a long time to get it. It went to the main office. It was only last week that I finally got the money." In an interview on 7/23/14 at 7:30 a.m., the Social Services Director (SSD) was asked about Resident 11's money. The SSD stated that, at the time of admission, Resident 11 asked the SSD how he could transfer his money to the facility so that he could buy things such as shampoo. The SSD stated that she "Directed him to the administrator for a trust fund (an interest bearing account that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account.) information. She told Resident 11 that when the money arrives, they would let him know. On 3/7/14, Resident 11 went to the SSD and stated that he had gone to the bank and asked them to send money to the facility. The SSD stated that she told Resident 11, "Let's check with the front office and I asked the front desk to contact me if they received any mail for Resident 11". The SSD stated that on 3/17/14, Resident 11 came to her office and asked for his $500. She told him that this money never came. Resident 11 stated that it should have been at the facility by now. The SSD asked him to call and check with the bank and said that he became upset. He went to the administrator and asked about the money and was showed a piece of paper from the bank that showed that the check was cashed. She said, "On March 21, 2014, the resident (Resident 11) became very upset and was yelling at the nurses' station and asking where his money was. We called the police 5150." In an interview on 7/23/14 at 7:55 a.m., the SSD stated that, on 5/14/14, Resident 11 told her that he had another $500 check transferred from the bank to the facility. The SSD stated that, "No one ever knew what happened to the first check. I told the administrator, who was no longer working at the facility, about the second check. The administrator said that the facility had not received the first or second check." In an interview on 7/23/14 at 8:25 a.m., Resident 11's emergency contact, Family 1, was asked about the missing money. Family 1 stated that the facility had told her that they had "Not received the money. I told them that they had to get to the bottom of this. It had been 4-5 weeks since Resident 11 had written the first check. After he wrote the second check, I called the facility and asked them to look out for the second check. This went on for several months. I told the Social Service Director that if this continued, we may have to prosecute. I told her that someone or somehow the facility had cashed the checks. Approximately one month ago (6/23/14) the facility said that they found the money and it had gone into the corporate office. I asked them why it went there since it was for the resident's personal use. He (Resident 11) told me that he needed clothes and he was angry." In an interview on 7/23/14 at 8:55 a.m., the Accounts Receivable Supervisor (ARS) for the facility was asked about the missing money. The ARS stated, "In the beginning, the first check was cashed and it went towards Resident 11's care. He had a balance and no secondary insurance. It wasn't until the second check was cashed in April that I was asked by the SSD if we could give him a refund. I reminded her that we still had a balance due. I then gave the file to our Medical Representative and she expedited Resident 11's application process for secondary insurance. The resident's money then went into his personal trust on 7/10/14 (4 months after the first check had been sent). In an interview on 7/24/14 at 10:00 a.m., the facility's Director of Patient Advocacy (DPA), was asked about the incident of the missing money. The DPA stated that he had spoken with Resident 11 in May, 2014 and said "I checked his account with the facility. Sure enough, the facility had cashed the checks and processed them as a share of cost. We realized this was wrong. The former administrator said that there were no checks made out to the facility. I then went through the ledger with him and showed him that yes, there were checks that had come in and were cashed. Once he saw this he reversed the whole process and we apologized to Resident 11. I was brought into this case in May. I am not sure why it took so long to reverse this". In a concurrent observation and interview on 7/24/14 at 8:45 a.m., Resident 11 was asked how he felt regarding the delay in finding his personal funds. Resident 11 stated that he felt as if he were "Running up against a brick wall. They were telling me that it did not exist. The Social Service Director and the Administrator told me that there was no money. It was rough. They were totally disinterested. I even showed them the bank statements. At the time they called the police on me, I wanted someone to pay attention to me. The administrator and the Social Service Director told me to make the second check out to the facility. They never told me to make it out to myself. I had absolutely no clothes whatsoever. I finally bought sweat pants and shirts yesterday (7/23/14). It is very important for me to have clothes. It was rough and they never even tried to get me clothes. I asked repeatedly for basic toiletries." Resident 11 was then observed lifting up a new, unopened toothbrush and stated, "I just bought this last night."

During an interview and concurrent record review on 9/16/14 at 4 p.m., the (ADMIN) Administrator and (DON) Director of Nursing acknowledged and agreed that the law requires that the facility should have had written authorization from Resident 2 and/or Resident 2's responsible party. The Admin stated, " It is still work in progress". The Admin stated that he will continue to try and reach Resident 2's responsible party to obtain written authorization to manage Resident 2's trust account. Based on observation, interview, and record review, the facility failed for one of ten sampled residents (Resident 2), to obtain written authorization for managing personal funds and inform Resident 2's responsible party that funds in the trust account were close to the Medicaid asset limit. These failure had the potential to result in mismanagement or misuse of the funds, and the potential for Resident 2 to lose Medicaid benefits. Findings: Review of Admission Intake Form date of 6/15/10, indicated Resident 2 had a history of disorganized thinking. Review of The Minimum Data Set (a resident assessment tool), dated 8/22/14, indicated Resident 2 mental ability was moderately impaired. Review of the physician's orders [REDACTED]. Review of the clinical record for Resident 2, a notarized document date 4/27/05, indicated Resident 2 appointed her responsible party an attorney-in-fact, with the power to open or close bank accounts on her behalf. Review of the Resident Fund Management Service dated, 9/16/14 indicated the account of Resident 2 was opened 7/8/10. Review of facility letter titled, "Resident Fund Balance Notification," dated 8/26/14, addressed to (Resident 2), indicated, "This letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next 7 days to discuss ways to assure continuance of Medicaid benefits." There were no signatures by Resident 2 or Resident 2's responsible party. During an observation and interview on 9/16/14 at 2 p.m., Resident 2 stated that she had no need to use her money. Resident 2 stated, "It's fine in the safe place". Resident 2 was sitting in bed with the head of the bed elevated, a completed lunch plate on the table over her lap. She stated, "I get three meals a day...I don't need anything else". Resident 2 stated she had money in the facility trust, and she was going to use it to go to a different facility. During an interview with the Administrator (Admin) and the Director of Nursing (DON), on 9/16/14, at 4:40 p.m., they stated they were unable to find a signed Resident Fund Management Service Authorization and Agreement to Handle Resident Funds for Resident 2. The Admin stated he attempted to call Resident 2's responsible party today, in order to get authorization, but had not yet established contact. The Admin stated he did not have written authorization to manage Resident 2's money. During a telephone interview with the responsible party for Resident 2 on 9/18/14, at 10:38 a.m., she stated she was the only person with power of attorney for Resident 2. She stated she received bills from the facility on a monthly basis, but didn't know how often she received statements about the resident fund. She stated she asked the facility to send her a current statement on 9/17/14, but had not received it yet, and wasn't sure how much money was in the fund. She stated she wanted to maintain the fund for burial expenses for Resident 2, and wasn't aware Medicaid had limits for personal resources. She had not been told that Resident 2's fund was within two hundred dollars of the limit. The responsible party did not remember if she had signed an authorization. The facility policy and procedure titled, "Resident Trust Accounts," received 9/18/14, indicated, "When a resident chooses to set up a trust account the resident or responsible party must sign an authorization form...Trust statements for residents who have been properly declared incompetent to make healthcare/financial decisions should be sent to the legal representative...The resident or legal representative must be provided with an individual accounting of all transactions on a quarterly basis , or upon request...When the Resident's account approaches the State limit (a balance within $200 under the limit), the facility's Social Services Department or designee must notify the resident and/or responsible party.

Based on observation, interview, and record review, the facility failed to protect one (Resident 1) of 3 sampled residents from a second assault by another resident (Resident 2) resulting in Resident 1 sustaining nose and mouth bleeding, a bruise on his forehead and on the bridge of his nose. Staff found Resident 2 holding down Resident 1's arm on 6/4/14 and separated them. Resident 2 left the room and returned shortly after and again attacked Resident 2 causing bruises on forehead and nose bridge, and bleeding near his nose and mouth. Findings: On 6/4/14, the facility reported to the Department that on 6/4/14 at 8:30 a.m., CNA 1 observed Resident 2 yelling at his roommate (Resident 1) and holding his hand down in their room. Residents were separated and Resident 2 left the room. However Resident 2 returned in a few minutes to his room and when CNA 1 returned to check on the residents, she observed Resident 2 holding one hand near the face of Resident 1. Resident 1 had a blood near his nose and mouth. On 6/11/14, Record review showed Resident 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]..www.mayoclinic.org).. In an interview on 6/11/14 at 10:05 a.m., Registered Nurse 1, (RN 1), was asked to describe the incident between Resident 1 and 2 which took place in their room on 6/4/14. RN 1 stated she was called by CNA 1 (Certified Nursing Assistant), at 8:30 a.m. on 6/4/14 and informed that Resident 2 was holding down Resident 1's arm. RN 1 stated she, "Went to the room and separated the residents (Residents 1 and 2). Resident 2 went out of the room and she went to talk to the supervisor about changing their rooms. After 5 minutes, CNA 1 came to me and said that Resident 2 was again holding Resident 1's arm down." RN 1 stated that she again went to the resident's room and talked with Resident 2 about not touching Resident 1 and the need to move him out of that room. RN 1 was asked why Resident 1 was left alone with Resident 2 following the first incident of holding his arm down. RN 1 stated that Resident 2 had, "Gone out for a smoke. No one saw him go back into the room. CNA 1 walked in and saw the second incident and reported it to me. It would have been better if the CNA had been instructed to stay in the room to ensure Resident 1's safety." RN 1 was asked to describe Resident 1's condition following the second incident. RN 1 stated that there was, "Swelling on Resident 1's forehead and bleeding coming from his nose and mouth. There was discoloration on his right arm". In an interview on 6/12/14 at 11:25 a.m., RN 1 was asked to confirm that the bruising and bleeding occurred after the second incident and not the first. RN 1 stated, "Yes, that is correct." In an interview on 6/12/14 at 11:50 a.m., CNA 1 was asked to describe the incident on 6/4/14 between Resident 1 and 2. CNA 1 stated that she saw, "Resident 2 holding down Resident 1's arm. I called the charge nurse. We both intervened and separated them. Then Resident 2 went out of the room. I then left the room and finished seeing the rest of my residents. I circled back and again found Resident 2 holding down the right arm of Resident 1 with one arm and his other hand near Resident 1's face. I asked Resident 2 to stop and took him out of the room." CNA 1 stated that Resident 1 had, "Nose and mouth bleeding. He had a bruise on his forehead and on the bridge of his nose. I did not see this following the first incident." In an interview on 6/12/14 at 12:15 p.m., the Director of Nursing, (DON), was asked why Resident 1 had been left alone following the first assault from Resident 2. The DON stated that Resident 1, "Should not have been left alone." In an interview and concurrent observation on 6/12/14 at 10:50 a.m., Resident 1 was asked if, following the first assault from Resident 2, did he feel staff did all that they could to keep him safe. Resident 1 stated, "No." Resident 1 was observed to have bruising in the middle of his forehead and on his arms. Record review of the facility's policy and procedure entitled, Abuse and Neglect Prohibition, and dated 10/2004, showed that each resident has the right to be free from mistreatment, neglect, and abuse. Physical abuse includes hitting, slapping, pinching, and kicking.

Based on observation, interview and record review the facility failed to supervise one of one sampled residents(1), resulting in the resident leaving the building on the evening shift and being hit by a car and expiring. Resident 1 had dementia and a history of trying to leave the facility. A wander guard (device that triggers alarms on doors) was placed on the resident however there were no wanderguard alarms on the two doors leading to the front patio. The facility did not have alarms on three back gates and did not have a working alarm on the front patio to alert staff when the gate was opened. Resident 1 exited the building on the evening shift, and while crossing the street in front of the building, was hit by a car and died . Findings: According to a facility report, Resident 1 was last seen by the nurses at 6:45 p.m. on [DATE]. At 7:05 p.m. she was nowhere to be found in the building and all staff immediately searched all parts of the facility. Shortly thereafter, the staff heard the paramedic' s siren and saw flashing lights a few meters away from the facility. Staff discovered that Resident 1 was involved in a vehicular accident. She was brought to the emergency room and later expired. On [DATE] record review showed Resident 1 was an [AGE] year old female, admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment revealed that the resident was rarely or never able to make herself understood and others were rarely or never able to understand her and she had both short and long term memory problems. The "Elopement Risk Review" dated [DATE] revealed that the resident was ambulatory with behaviors of wandering with no purpose and wanting to go home, or to work, or somewhere else. She was considered at risk for elopement and a care plan was developed. The care plan dated [DATE] for the risk of elopement and wandering out of the facility had a goal to minimize the risk for elopement and wandering by providing activities that will divert resident's attention from wandering, and checking resident's whereabouts, then gently redirecting the resident back to supervised areas. The interventions also included wearing a "Wander-guard" bracelet at all times to alert staff that the resident was leaving the facility. Certified Nursing Assistant 1 (CNA 1) stated in an interview on [DATE] at 3 p.m., that she was assigned to Resident 1 on [DATE]. She had worked with Resident 1 since her admission earlier in February 2013. CNA 1 said that Resident 1 was confused, and could only say a few words in English like, " me go home, " and " want to eat. " CNA 1 stated that Resident 1 wandered around the facility and just the evening before had tried to get out through the door on the station 4 hallway. She said that the resident could become combative with staff if they were trying to get her away from the doors, and that she was strong. She said the resident in the past had tried all the different doors in the building, e.g. staffing office, station 3 door, and even the evening before was found in the front lobby trying to go out. The staff depended on the alarms to let them know when she was attempting to leave. She went on to say that on [DATE] she had to sit with another resident who was on a one to one observation because of her wandering, from 5 p.m. to 6:35 p.m. She then had an admission in room 35 A across the hall from Resident 1. She went in the room to help the ambulance drivers and settle the admitted resident into his room. She was in the room about 25 minutes until 7:30 p.m. and when she came out she didn't see Resident 1 in her room or in the bathroom. She then told the charge nurse (RN 2) and they started looking right away. They looked all over the building in every room and could not find her. CNA 1 went to the smoking patio and saw a flashing light from the street. She went to the street and saw the resident lying on the ground with the ambulance drivers. In an interview on [DATE] at 10:45 a.m. s RN 2 stated that when she came on duty that evening, [DATE] she did her rounds and Resident 1 was sleeping which was unusual for her. By 6 p.m. the resident was up and getting juice at the nursing station. She stated that the last time she saw Resident 1 was around 6:45 to 6:50 p.m. At 7:05 she heard from CNA 1 that the resident was not in her room. RN 2 went to the front lobby but the receptionist said she did not see anyone leave the facility. Then CNA 1 told her she saw the lights of an ambulance in the street and she went out there and saw Resident 1 lying in the street. She stated that the resident had a history of [REDACTED]. She also said that the resident understood a little bit of English, but would get frustrated when nurses couldn't understand her. A tour of the perimeter of the building, on [DATE] at 1:15 pm revealed that there was short metal fencing (35 inches per the maintenance director) around rooms that had patio sliding glass doors. The patios opened up to the back parking lot by gates that opened freely with no alarms. The back parking lot could be entered from either side of the building from the street. The Facility was on the corner of a four lane street, with a meridian separating the four lanes, two lanes for each direction. There was a street light that controlled the traffic at the corner of the facility which was directly across the street from a city park. In an interview with the Nursing Supervisor RN 1, in the presence of the Administrator at 1:25 p.m. on [DATE] she demonstrated that Resident 1's room had a patio door that opened to another fenced area with a gate that led to the side of the building adjacent to the smoking patio and kitchen. She stated that there was no alarm on that gate until after the incident with Resident 1. During a tour of the inside of the facility , by the Maintenance Director, on [DATE] at 1:45 pm the door alarms were all working except the gate alarm from the front patio. The lobby door and the door next to the copy machine which opened to the front patio did not have a wander guard alarms (an alarm placed on a door that will signal when a resident wearing a wander guard bracelet passes through). Those were the only two doors which residents could enter the front outdoor patio. The maintenance director stated that he checked the alarm that morning and had just purchased a new alarm for the gate and couldn t understand why it was not working. He was also unaware that the two fenced patios along the rooms, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, had gates that opened to the back parking lot and were not alarmed. He stated that the fences replaced the old wooden fences about a year ago. On [DATE] at 10:45 a.m. the front patio gate alarm did not sound when opened. There were two different alarms, and neither was working. The maintenance director stated that he had just checked it that morning and did not know why it wasn t working. The administrator stated that it was working but sometimes it was not working. He told the maintenance director to buy a better alarm. The paramedics "Patient Care Report" dated [DATE] at 7:18 p.m. revealed that they arrived to find Resident 1 lying down face up in the intersection with the Firemen performing cardio-pulmonary resuscitation (CPR) . Resident 1 was walking across the intersection when she was struck by an SUV (sports utility vehicle) at approximately 30 miles per hour. The SUV had moderate front end damage. Resident 1 had a laceration to her left forehead, bleeding from her right ear, and unstable jaw with a 3 inch hematoma (bruise) around her liver. The emergency department " Comprehensive Trauma History and Physical " dated [DATE] at 8:28 p.m. reflected " This is an 80 yo (year old) female who is a resident of a nursing home ...who wandered out of the facility and into traffic. She was struck by an auto at unknown speed. By report, Fire-rescue was the first on the scene and CPR begun at that time ... " The document also revealed that the resident continued to receive life saving measures but was pronounced dead at 9:45 p.m. of a traumatic brain injury.

Based on interviews and record review, the facility failed to protect one (1) of one sampled resident from neglect, when staff refused to allow Resident 1 to re-enter the facility after he left without a pass. The resident returned one hour later. He told the charge nurse that he left to buy some food. When the resident returned, staff informed him that when he left without a pass, he had discharged himself against medical advice. When Resident 1 tried to re-enter the facility, the staff called the sheriff to escort Resident 1 off the grounds, and told Resident 1 to go to the emergency room if he needed help. This failure resulted in Resident 1 sitting outside the facility for 22 hours without food, water, blood sugar checks for diabetes, medications including insulin, pain medications, and an antibiotic for a bladder infection, or wound care to his four pressure sores. Findings: Record review on 8/20/12 showed that Resident 1 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS - resident assessment) dated 7/3/12, reflected that Resident 1 depended on a staff member for bathing and toilet use. He was often incontinent of bowel and had an indwelling urinary catheter. The MDS reflected that there was no active discharge planning being done as of 7/3/12. The MDS reflected that Resident 1 had frequent behaviors of threatening and cursing at others. A nurse's note, dated 6/26/12, reflected a report to the Nurse Practitioner (NP) that staff found alcohol at Resident 1's bedside. This was the second time that the resident left the facility and bought alcohol. NP told the nurse that due to the risk of harm from ingesting alcohol with medications, Resident 1 would not be allowed to go out on pass by himself. The NP told the nurse that if Resident 1 went out without a doctor's order, that the resident would be discharging himself, "AMA" (against medical advice). A social Service note, dated 7/9/12, reflected that Resident 1 became agitated, and was screaming and cursing at staff. He stated that he was leaving. The IDT told Resident 1 that if he attempted to leave the facility without his doctor's ok, that he would be discharged AMA/AFA (against medical/facility advice). A care plan titled, "Community Discharge Potential, dated 7/9/12, directed staff to, "Coordinate discharge plans with the resident and responsible party". The plan also directed staff to, "Assist in community referral for continued care." There was no documented evidence that the Interdisciplinary Team (IDT) assessed the placement needs of Resident 1 or made referrals. During an interview at approximately 3 p.m. on 9/18/12, the Director of Nursing Services stated that the IDT did not assess the post discharge care needs of Resident 1 with the participation of the resident and the RP as required. The facility did not have a policy and procedure for planning post discharge care. The 12/18/02 facility policy entitled, "Transfer and Discharge", contained the following: Procedure: " 4. At least 30 days prior to transfer or discharge, notify the resident and if known, the family member ... of the transfer and the reasons for the move. " a. Provide the information in writing ... " b. Explain the resident ' s right to appeal the transfer/discharge. " c. Provide the name, address, and phone number of: -the State long term care ombudsman, -the agency responsible for advocating for individuals (with special needs) " 5. Provide preparation and orientation to the resident to ensure safe and orderly transfer/discharge from the facility ... -Informing the resident where (s/he) is going; -taking steps to assure safe transportation; -involving the resident and family in selecting the new residence ... " physician's orders [REDACTED]. He received insulin four times a day, in varying doses, depending upon the results of the finger stick tests. physician's orders [REDACTED]. A lab test result dated 8/7/12, showed that Resident 1 had a urinary tract infection. The physician's orders [REDACTED]. In an interview at 1:30 p.m., on 8/20/12, Resident 1 stated that he was absent without leave from the facility for approximately one hour, from 9 p.m., until 10 p.m., on 8/15/12. When he returned to the facility, he was informed that he was being discharged . Resident 1 told the staff that he did not want to go. Resident 1 also stated that he was escorted from the building at 10:35 p.m., by the Sheriff's department, and was left on the street by the facility's sign. He stated that he remained there overnight, until the following evening because he didn't know where to go. Review of the physician's orders [REDACTED]. In an interview with RN 2 at 4:11 p.m., on 9/21/12, she stated Resident 1 was escorted to the street at 10:35 p.m., on 8/15/12 without a destination for shelter or a meal plan, transportation, medication (antibiotics for an infection, insulin to reduce blood sugars, [MEDICATION NAME] for severe pain) or treatment supplies, or a means of contacting anyone for help. RN 2 stated that if Resident 1 did not have a cell phone, the resident could go to a phone booth to make calls. There was also no documentation that staff checked to be sure that the phone booth telephone was working, or that Resident 1 had change to make a call. There was no documentation to show that the facility checked the status of the wheelchair battery charge before discharging Resident 1 to the street. In a written declaration, dated 8/23/12, the RP stated that she found Resident 1 at around 5 p.m., on 8/16/12, slumped over in his wheelchair beside the facility's sign. Resident 1 was drowsy and his catheter bag was very full. Resident 1 told her he was in severe pain. The RP called 911, and paramedics arrived at 8:38 p.m., on 8/16/12. They transported him to an emergency room . In an interview with the RP on 8/23/12, at 1 p.m., she stated that Resident 1 was on the street for nearly 23 hours before being transported to the hospital by the paramedics. She was extremely upset to see Resident 1 slumped over and in severe pain outside of the facility. During an interview at 3:55 p.m., on 8/21/12 the family member/Responsible Party (RP) denied receiving notice that the facility was making plans to discharge Resident 1 to the community at any time after the readmission on 4/26/12. Review of the emergency room record, on 9/18/12, showed that upon admission to the hospital at 1:37 a.m. on 8/17/12, Resident 1 had a temperature on 99.4?F, abdominal pain, rated as 10 on a scale of 10 (10 being worst level), nausea, blood in the urine, a white blood cell count of 17 (normal 4.5-11), and his indwelling catheter bag was leaking urine at the insertion site. The urine in his bag was foul-smelling, and cloudy. His blood glucose level was 392 mg/UL.(normal is 70-120) The wounds on Resident 1's hip, and thigh were graded as stage 2 to three.