Every finding on record at Eden Valley Care Center

Based on interview, record review, and facility policy review, the facility failed to ensure as-needed (PRN; pro re nata) orders for psychotropic drugs were limited to 14 days without documented rationale for 1 (Resident #9) of 5 residents reviewed for unnecessary medications. Specifically, Resident #9 had an order for hydroxyzine hydrochloric acid (HCl) (an antianxiety medication) started on 12/29/2024, with no stop date or documented rationale for continued use. Findings included: A facility policy titled, Medication Monitoring Medication Management, dated 11/2017, indicated, PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #9's Admission Record indicated the facility admitted the resident on 12/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of congestive heart failure and depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #9's care plan included a focus area initiated on 12/30/2024, that indicated a mood problem related to anxiety and depression. Interventions directed staff to administer hydroxyzine as ordered and to monitor and report any mood patterns of depression or anxiety to the physician. Resident #9's Order Summary Report contained an order dated 12/29/2024 for hydroxyzine HCl oral tablet 25 milligrams (mg), with instructions to give 1 tablet by mouth every eight hours as needed for anxiety. Resident #9's Scheduling Details for hydroxyzine HCl oral tablet 25 mg 1 tablet by mouth every eight hours as needed for anxiety revealed a start date of 12/29/2024 and an end date of indefinite. Resident #9's January 2025 Medication Administration Record [MAR] revealed a transcription of an order started on 12/29/2024 for hydroxyzine HCl oral tablet 25 mg with instructions to give 1 tablet by mouth every eight hours as needed for. The MAR revealed staff documented that Resident #9 received the medication 32 times from 01/01/2025 to 01/20/2025. During an interview on 01/21/2025 at 12:52 PM, the Medical Director (MD) stated PRN antianxiety medication use should be limited to 14 days. The MD stated some patients became agitated in the hospital, and PRN antianxiety medications could be given even though there was no indication for use. The MD stated that when a resident was admitted from the hospital, a PRN antianxiety medication could carry over to the resident's consolidated orders in the facility, but the order should be discontinued. The MD stated hydroxyzine was typically used for itchiness, but if the resident's order specified the use of PRN hydroxyzine for anxiety, then the order should be discontinued. The MD stated if a resident used a PRN antianxiety medication daily then the nursing staff should notify him so he could evaluate the resident and determine if the medication should be used routinely instead of on a PRN basis. The MD stated he did not remember any indication for Resident #9 to continue the use of PRN hydroxyzine because the resident was new to him. The MD stated it was important to stop PRN antianxiety medication use because they did not want to give medications unnecessarily and polypharmacy was never good. During an interview on 01/21/2025 at 12:56 PM, the Pharmacist stated the use of PRN antianxiety medications should be evaluated within the first 14 days of use. The Pharmacist stated some physicians preferred to use PRN hydroxyzine for anxiety because it was short acting and had less side effects than benzodiazepines. The Pharmacist stated PRN hydroxyzine was typically used short term for itching instead of routine anxiety episodes. The Pharmacist stated she had not done the January 2025 medication reviews yet, so she had not reviewed Resident #9's medication list. The Pharmacist further stated it was unusual for facilities to continue the use of PRN hydroxyzine because it had more antianxiety effects in a short-acting formula, so the continued use needed to be re-evaluated. During an interview on 01/21/2025 at 3:25 PM, the Director of Nursing (DON) stated she spoke with Resident #9, who did not want hydroxyzine to be given routinely; the resident instead wanted to continue to use the medication on a PRN basis. The DON stated there was no documented rationale from the physician in Resident #9's medical record for the continued use of PRN hydroxyzine. During an interview on 01/22/2025 at 8:40 AM, the DON stated she reviewed the medication list for new admissions and saw Resident #9's PRN hydroxyzine, but the facility typically used PRN hydroxyzine for itching, so she missed the resident's indicated use for the medication. The DON stated she was aware of the 14-day stop date requirement for the use of PRN antianxiety medications. The DON stated they identified Resident #9's use of PRN hydroxyzine but the resident was scheduled to discharge the day after their last psychotropic meeting, so no changes were made. The DON stated Resident #9's stay was approved weekly by their insurance, and she initially thought Resident #9 would not be in the facility past 14 days. The DON stated she expected there to be a 14-day stop date on all PRN antianxiety medications so staff could re-evaluate the resident. The DON stated Resident #9 used their PRN hydroxyzine frequently, and when she talked to Resident #9, they wanted to keep the medication on a PRN schedule. During an interview on 01/22/2025 at 8:45 AM, the Administrator stated she was aware that stop dates were required for PRN psychotropic medications and expected there to be a stop date for PRN antianxiety medications per the regulations.

Based on interview, facility document review, and facility policy review, the facility failed to ensure a Registered Nurse (RN) provided services eight consecutive hours, seven days a week in the facility for 5 of 28 days reviewed. Findings included: A facility policy titled, Nursing Departmental Supervision, revised 08/2022, specified, 2. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A December 2024 License Staff Schedule revealed there was not an RN scheduled for 12/25/2024 or 12/26/2024. During an interview on 01/21/2025 at 2:25 PM, the Director of Nursing (DON) stated she had been having a hard time covering the RN hours. The DON stated there was not an RN at the facility on 12/25/2024. During an interview on 01/21/2025 at 2:29 PM, the Director of Staff Development (DSD) reviewed the Nursing Staffing Assignment and Sign-in Sheets and the schedule, then confirmed there was no RN on 12/25/2024. During an interview on 01/22/2025 at 10:48 AM, the DON confirmed there was no RN at the facility on 12/25/2024 or 12/26/2024. The DON stated she was aware the requirement was for eight consecutive hours a day. The DON stated an RN was required to make sure staff had supervision for resident assessments and to do the things only a RN could do, like staging pressure ulcers and administering intravenous medications. A January 2024 License Staff Schedule revealed there was not an RN scheduled for January 11th, 12th, or 18th. During an interview on 01/22/2025 at 10:48 AM, the DON stated that the January schedule was labeled 2024, but it was actually for 2025 (indicating that the dates lacking RN coverage were 01/11/2025, 01/12/2025, and 01/18/2025.) The DON stated that January 11th, 12th, and 18th were highlighted in orange on the schedule and that it indicated there was no RN coverage at the facility for eight consecutive hours on those days. During an interview on 01/22/2025 at 11:00 AM, the Administrator stated she was aware the facility did not have RN coverage on some days. The Administrator stated she expected the regulation to be followed and for an RN to be in the facility for eight consecutive hours, seven days a week.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 1 (Resident #41) of 2 residents reviewed for urinary catheters. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 08/2022, specified, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. The policy further specified, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy revealed, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: d. providing hygiene; and g. device care or use (central line, urinary catheter, feeding rube, tracheostomy/ventilator, etc. [ et cetera; and so forth]). The policy revealed, 4. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following: g. Extended Spectrum Beta-Lactamase (ESBL)- producing Enterobacterales. The policy revealed, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution or discontinuation of the indwelling medical device that places them at increased risk. The policy revealed, 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment] required. 11. PPE is available inside of the residents' rooms. 12. Residents, families, and visitors are notified of the implementation of EBPs throughout the facility. An Admission Record revealed the facility readmitted Resident #41 on 01/04/2025. According to the Admission Record, the resident had a medical history that included diagnoses of hydronephrosis with renal and ureteral calculous obstruction, sepsis due to Escherichia coli, urinary tract infection, bacteremia, other acute kidney failure, and calculus of ureter. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/07/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial to maximal assistance with toileting hygiene, had an indwelling catheter, and was frequently incontinent of bowel. The MDS indicated the resident had active diagnoses that included renal insufficiency, obstructive uropathy, septicemia, and urinary tract infection. Resident #41's care plan included a focus area initiated 01/14/2025, that indicated the resident had an alteration in urinary elimination related to neurogenic bladder, right ureteral stone with hydronephrosis status post nephrostomy tube, chronic use of Foley catheter, and history of urinary tract infections with ESBL. Interventions directed staff to monitor and perform regular catheter care for the Foley and nephrostomy tube, ensuring sterile technique during insertion or dressing changes. A hospital Discharge Summary dated 01/04/2025 indicated Resident #41 was hospitalized from 12/25/2024 through 01/04/2025 with discharge diagnoses that included septic shock secondary to complicated urinary tract infection and gram-negative rod bacteremia. An observation of Resident #41's catheter care on 01/21/2025 at 9:22 AM revealed no EBP sign or PPE outside the resident's room. Certified Nurse Assistant (CNA) #1 and CNA #2 were already in the resident's room with catheter cleaning supplies set up on the over-the-bed table next to the resident's right side of the bed, and the catheter bag was lying on top of the mattress to the left side of the resident's legs. Staff were wearing N95 masks and gloves, but neither of them were wearing gowns. While CNA #1 was performing catheter care, the front of her top was touching the resident's bed linens. CNA #2 was assisting with positioning the resident during catheter care and her top also touched the resident's bed linen. During an interview on 01/21/2025 at 9:33 AM, the Director of Nurses (DON) stated that they were currently working on the EBP policy and procedure but had not implemented or in-serviced their staff. She stated that the EBP protocol should have already been implemented. She indicated the EBP protocol should be used on residents with Foley catheters, percutaneous esophageal gastric (PEG) tubes, anyone with MDRO wounds, central lines, and peripherally inserted central catheter (PICC) lines. She stated they expected to roll out the EBP policy and procedure as soon as possible and were going over the guidelines from the Centers for Disease Control (CDC) and seeing how it would be used in their facility. During an interview on 01/21/2025 at 9:48 AM, CNA #1 stated that they performed Resident #41's catheter care three times a shift (7:00 AM - 3:00 PM), after breakfast, after or before lunch, and before the end of the shift. She stated that they changed gloves and washed their hands before and after care and if they became soiled. She stated that she had not received any other infection control instructions while providing catheter care, other than to be very careful with peri care with Resident #41 since they got a lot of urinary tract infections (UTIs). She stated that she did not remember the last UTI the resident had but thought it may have been a month prior. CNA #1 stated that she did not know what enhanced barrier precautions meant. During an interview on 01/21/2025 at 9:56 AM, CNA #2 stated that they provided catheter care three times a shift, in the morning, mid-day, and before shift change. CNA #2 stated that if the resident had a bowel movement, they cleaned them up again. She stated she had received in-service regarding catheter care and was taught to use standard precaution protocols. She stated Resident #41 had a history of UTIs. She stated she had not received any in-services or training on EBP that she could remember. During an interview on 01/21/2025 at 10:02 AM, the Director of Staff Development (DSD) stated that they were going to in-service their staff and implement the EBP protocol by the end of that day. During an interview on 01/22/2025 at 9:45 AM, the DSD stated that she had read about EBP on the CDC site and had mentioned it to the DON. The DSD stated that they were going to meet with the interdisciplinary team (IDT) regarding it but had not begun in-servicing staff regarding EBP until the previous day after it had been brought to their attention. She stated she thought it was recommended to reduce the potential spread of infections during high contact care procedures like Foley catheters. She stated that she was aware Resident #41 had frequent UTI's and was susceptible to infections and would have benefited from the EBP protocol. During an interview on 01/22/2025 at 10:07 AM, the Administrator stated that her expectation was that the facility implemented the EBP right away to protect the resident from acquiring infections.

Based on interview and record review, the facility failed to develop comprehensive care plans and update these care plans for two of 51 Residents (Resident 1 and 2) in accordance with the Minimum Data Set (MDS - a resident clinical assessment tool) assessments required time frame. This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, also a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident's care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, and a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident ' s care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, and a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident's care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a lifesaving technique consisting of chest compressions and often combined with artificial ventilation used in emergencies to treat persons with ineffective heart pumping/beating and compromised breathing to improve blood perfusion throughout the circulatory system to vital organs, especially to the brain) for one of 2 sampled Residents (Resident 1) when Resident 1 was found unresponsive. This failure left Resident 1 without receiving (CPR), which was not in accordance with his choice for full treatment (to prolong life by all medically effective means), as indicated in his POLST (Physician Orders for Life-Sustaining Treatment). Findings: The clinical records of Resident 1 were reviewed. Resident 1's Face Sheet (summary of important resident information), Advance Directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity), POLST (Physician Orders for Life-Sustaining Treatment) and Order Summary Report all indicated Resident 1 had opted for Full Treatment or Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Face Sheet (summary of important resident information), dated [DATE], indicated, he was readmitted to the facility on [DATE], with diagnoses including a sacral (pertaining to the set of fused bones at the base of the spine below the lower back area of the pelvis) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of long-term pressure, or pressure in combination with shear or friction), obstructive reflux uropathy [disorder to which urinary flow is obstructed in the urinary tract (body's drainage system for removing urine)] and hypotension (lower than normal blood pressure). The Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) section of the face sheet indicated: Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated a Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 13, which meant he was cognitively intact. (,d+[DATE] points = severe cognitive impairment; ,d+[DATE] points = moderate cognitive impairment; ,d+[DATE] points = cognitively intact). Review of Resident 1's POLST Form, dated [DATE], indicated a box checked for Attempt Resuscitation/CPR and a box checked for Full Treatment. It contains dated signatures of both Physician 1 on [DATE], and Resident 1 on [DATE]. Review of Resident 1's Order Summary Report printed on [DATE] indicated, Active orders as of [DATE] . FULL CODE, Order Status: Active, Order Date [DATE]. Review of Resident 1's Record of Death received on [DATE] indicated, date of death [DATE] Hour 0500 (5:00 AM), Nurse present at time of death: name of [LVN A] (Licensed Vocational Nurse), Name of person notified: [name of Physician 1], Relationship to Patient/Resident: Physician, Attending physician notified by: [LVN A], Date and Hour: [DATE] 0545 (5:45 AM). Remarks: Resident expired peacefully in his sleep at 0500 on [DATE]. Notified [Name of Funeral Home] [Phone number of Funeral Home] . Called by [Signature of LVN A] . Mortician's Report; Received from [name of LVN D] The remains of: [Name of Resident 1] . Body released by: [Name of LVN D] at [DATE] at 0920 . Signed by [Funeral Home Staff]/Mortician, [Name of Mortuary], [Address of Mortuary]. Review of Resident 1's Nurse Notes with effective date: [DATE], at 07:31, indicated, Late Note: Nursing staff attempted to administer routine medication to resident. Resident was not responding to voice. This nurse tapped on his shoulder with no response. Nurse applied sternum stimulation (rubbing the bone in central part of the chest to test an unconscious person's responsiveness) and no response. Lungs auscultated (listened for airflow in the lungs) with no sounds heard. No heartbeat presented. Capillary refill (pressure applied to a finger to detect blood flow after releasing pressure) was not present. Complexation to the skin was pale and cold to touch. Request 2nd nurse in facility to verify and same results obtained from body. Resident expired at 0500 this morning on 3rd shift. Dr. [Name of Physician 1] primary physician, informed of resident status and aware. Administrator and DON (Director of Nursing) notified as well. Resident is his own responsible family. Friend [name of friend] number dialed but is not able to get a hold of. Orders to release body to mortuary obtained and carried out. [Name of Funeral Home] notified. Spoke to [name of staff]. Informed that mortuary will be at facility to pick up body after 0900 today. Report over to oncoming nurse . During an interview on [DATE], at 12:04 p.m., with Licensed Vocational Nurse B (LVN B), she stated she knew Resident 1 to be, alert, oriented, made his own decisions, was his own responsible party . Full Code. He died on [DATE] . On day shift on [DATE] . he was fine. Review of a document received [DATE] from Interim DON (INT-DON) regarding Resident 1 titled, Statement of [LVN A] on [DATE] at 1600 indicated, What happened? I (LVN A) was passing my meds (medications); when I arrived at the resident's room, I announced it was time for his medication. He usually responds to me; so, I went to the side of his bed and started talking to him; I called out his name and he did not respond to me. I then went to the other side of the bed and turned on the light. I touched him and he was cold to the touch. He did not wake up or respond. Then I did the sternum rub. He still did not wake up. I went to listen to his lungs and there were no sounds. I could not find his heartbeat nor his pulse rate. I noticed his capillary refill was not present. Why did you not perform CPR? I did not perform CPR because he was not breathing anymore. No life was in him. Were there any signs of declining during your shift? No, he was fine. When was the last time you interacted with the resident while he was alive? The last time I looked into his room, it was around 0400. I could see the glare from the television on his face; his eyes were open, and he had his remote in his hands - he was putting it on his table. Are you aware where the crash cart (a wheeled container carrying medicines and equipment for emergency resuscitations) is and how to call a Code Blue (used to indicate a patient requiring resuscitation or immediate medical attention)? Yes, I know where those things are, I have never had to do that here. But I know how to do it. Did you know the resident was Full Code? I did not know until after I called the doctor; I assumed he was DNR (do not resuscitate) because of his condition. Is your CPR current? Yes, it is good for 2 years; It expires [expiry date]. Is there anything you would do different next time? I will check the code status . Signed by [LVN A]; DSD and INT-DON. During an interview with the Interim Director of Nursing (INT-DON) on [DATE], at 12:12 p.m., when asked why Resident 1 was not given CPR she stated, Yes Ma'am, it was not done. When asked what should have been done, the INT-DON stated, Life saving measures should have been implemented right away . That's a patient's choice, he had the right to be Full Code . he designated that in his POLST. When asked if CPR was not done as per LVN A's statement and if there was a failure, the INT-DON stated, correct, to both questions. During an interview with LVN C on [DATE], at 1:15 p.m., when asked what she would do if a resident were Full code, LVN C stated, If I found someone unresponsive, I assess vital signs (V/S, essential body functions like heartbeat, pulse rate, temperature and blood pressure) and call a code on the Intercom so all nurses can come and help me regardless of day and time of incident. So, I will be in-charge since I was the one who found the patient unresponsive. I'll have a CNA (Certified Nursing Assistant) or myself start CPR; when code team (emergency medical response personnel) arrives, we could start oxygen (air we breathe to live), AED (automated external defibrillator, medical device to analyze a heart's rhythm, if necessary, deliver an electric shock to help the heart re-establish an effective rhythm). I would also assign a nurse to call 911 and assign a CNA or Nurse to wait by the door for EMS (emergency medical services staff) so they could come to the patient's room. We continue CPR (chest compressions, AED) until EMS tells us that we are relieved, and they will take over. When asked how to check if the patient is DNR or Full Code, LVN C stated there is a binder in every unit that has the Code Status, it has their POLST there as well . we also have our laptop on [the] Med Cart, in the EMR [name of electronic medical record] the code status is there . We notify the Provider (Physician), DON, Administrator, and family . this is taught to us usually monthly . we have nurse meetings every 2nd Tuesday of the month where they tell us what the expectations are and if the code status was updated . Station One is Post-Acute unit . every time a new patient comes, the Code Binder is updated. Station Two is Long Term Unit. Review of Facility policy titled In-Service Training, All Staff revised [DATE] indicated . 1) All staff are required to participate in regular in-service education. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. 5. Training methods and teaching materials are appropriate to the level of education and expected roles of those attending. During an interview with Physician 1 on [DATE], at 1:30 p.m., he stated, . if patient was doing okay at 4:00 a.m. and at around 5:00 a.m. was found unresponsive, the nurse should have initiated a Code Blue (code blue or code, used to indicate a patient requiring CPR or to indicate a patient requiring resuscitation or immediate medical attention) . The reality of the situation, even say patient died say 4 hours ago, she should have initiated a code and called 911. She is not a licensed person that can pronounce death. It's not her place to declare death . I did not pronounce the patient dead at 5:00 a.m. when she called. I wasn't aware it was an issue until . later I found out no code was done, and the patient was a full code. During an interview with the Director of Staff Development (DSD) on [DATE], at 2:07 p.m., she stated all the facility's LVN staff should know how to do CPR and should know whether their assigned residents are full code, or not. Review of Facility's Job Description for Position Title: Licensed Vocational Nurse (LVN), with Date written: [DATE] indicated, . Purpose: LVNs provide medical support to physicians, registered nurses and patients. They provide routine care, take vital information from patients, provide information about treatments and prescriptions and observe patient health.Responsibilities: . Observe patients under treatment to identify progress, side effects of medications etc. Monitor patients' condition .Requirements: Familiarity with skilled Nursing, safety and sanitation standards and procedures, .Current BLS (Basic Life Support - medical care used for patients with life-threatening illnesses or injuries, covers CPR but includes additional life-saving techniques that can help those experiencing cardiac arrest, respiratory distress, or an obstructed airway) Certification Required. According to the California Code of Regulations: Title 16 CCR S 2518.5. Scope of Vocational Nursing Practice. The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan and treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. Title 16 CCR S 2518.6. Performance Standards. (b) A licensed vocational nurse shall adhere to standards of the profession and shall incorporate ethical and behavioral standards of professional practice which include but are not limited to the following: (1) Maintaining current knowledge and skills for safe and competent practice . During an interview on [DATE], at 2:23 p.m. with LVN A, she stated, I was in the hallway passing meds, usually when I go in there, he (meant Resident 1) is alert and he responds. I went in there the TV was on. I called out his name, Mr. [Resident 1 name] here's your meds, usually he would respond, but he did not. I bumped the bed with my hip, my hands were full with meds and drink, no response . I went around the other side of the bed to pull the light, I noticed he was very pale, eyes wide open. So, I touched him, and he was cold. I was feeling the pulse, no pulse. I listened to his lungs with the stethoscope (medical instrument used to listen to sounds produced within the body), there was nothing then I did the sternum rub. LVN A was asked if she knew the code status and she stated, No, not at that time and that was my mistake, I should have checked that because he was going downhill, he was already weak, he had bedsores. There were times he wouldn't want his drink or care and would say 'leave, me alone, no I don't want that,' I didn't want him to be riled. LVN A was asked if she thought about doing CPR, LVN A stated, no because he had no more life, he was cold. LVN A was asked if she knew that, as an LVN, she could not pronounce death, LVN A stated, Now I am aware, I was a home health nurse . I guess it's different than what I thought. When LVN A was asked if she knew there is a Code Binder in the unit, LVN A stated, Yeah, no I did not look at that time . after the sternum rub, I called the CNA 'hey he passed away,' I let the Doctor (Physician 1) know . I texted him; he got the message, he said okay . I let the Administrator (ADMIN) know, I texted them all and the DON . The ADMIN said/texted, 'Was it expected?' I texted everything was fine during the shift until he was found unresponsive. When asked if the ADMIN asked her if they did CPR, LVN A stated, No. LVN A further stated, I called the Mortuary on his chart, informed the mortuary that he died . they did not pick up right away. LVN A was asked who pronounced Resident 1 dead, LVN A stated It was me I guess, the doctor (Physician 1) said okay on text . At this time the CNAs cleaned him up and prepared him for the mortuary . The body was in the room ready for pick-up for mortuary. I endorsed to the next shift nurse . I left the facility at 8:00 a.m. came back at 2:00 p.m. they (Facility) were telling me I need to redo my statement to make it clearer on my notes to reword it to make it understandable, I reworded it, but it is the same thing, why I didn't do CPR. When LVN A was asked if Physician 1 gave an order to release the body, LVN A stated, No, he said okay, so I wrote it as an order to send him out to mortuary. When he asked if she assumed it was an order, LVN A stated, Yes. LVN A confirmed there was no mention of CPR done and 911 was not called in her note. She stated, I feel bad that I didn't. I didn't focus that night . it takes a toll . I take the blame, I'm sorry. Record review of the Emergency Medical Record Progress Notes, dated [DATE], at 1500, indicated, Note/Text: Discharge/Death Summary, Dx (Diagnoses): CVA (cerebrovascular accident, STROKE, interruption of blood flow to the brain), BPH (Benign Prostatic Hyperplasia, enlarged prostate glands in men), HTN (Hypertension, high blood pressure), RA (Rheumatoid Arthritis, swollen painful joints), Hx CAUTI (history of catheter - associated urinary tract infection) and pneumonia (inflammation of the lungs) . Hospital Course . The patient was treated again with abx (antibiotics) and then sent back to [the skilled nursing facility's name] and admitted on ,d+[DATE]. The patient was last seen on ,d+[DATE] at which time RN reported dysuria (painful or difficult urination) symptoms. UA (urinalysis, laboratory examination of a person's urine) ordered. On the morning of ,d+[DATE], I was informed by RN that the patient had passed away peacefully at 5 AM. Author: [Physician 1]. Review of Facility policy Emergency Procedure - Cardiopulmonary Resuscitation, Revised February 2018, indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS, type of care that first responders, healthcare providers and public safety professionals provide to anyone experiencing cardiac arrest, respiratory distress, or obstructed airway), including defibrillation, for victims of sudden cardiac arrest . If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a do not resuscitate (DNR) that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis, stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days) . If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR (do not resuscitate) or a physician's order not to administer CPR . if the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instruction until a CPR-certified staff member arrives.

Based on interview and record review, the facility failed to safely discharge one of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. The resident is currently residing in the facility with coverage provided by Medi-Cal. These failures resulted in an inappropriate discharge for Resident 1 and caused harm to the resident's mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn ' s disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain .A/P [assessment/plan]: 1. Debility - cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control .dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on 4/11/23, Resident 1 was having a breakdown. During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge ' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. Based on interview and record review, the facility failed to safely discharge one of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. The resident is currently residing in the facility with coverage provided by Medi-Cal. These failures resulted in an inappropriate discharge for Resident 1 and caused harm to the resident's mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain . A/P [assessment/plan]: 1. Debility - cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control . dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on 4/11/23, Resident 1 was having a breakdown. During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork.

Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past .Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): .The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Resident 1's social services progress note, dated 4/12/23 after she returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal [California's health care program which covers most medically necessary care], she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs .Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's PASSR Level I Screening, dated 5/30/23, indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the responses were, Yes and anxiety disorder, adhd. There was no documentation that indicated Resident 1 had a PASRR Level I assessment prior to admission or within 30 days of admission. There was no documentation that indicated Resident 1 had a PASRR Level II evaluation. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI (gastrointestinal) appointment and a psych appointment. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD (a mental health condition with similar symptoms as PTSD, but may include problems controlling emotions and feelings of worthlessness, shame and guilt) due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but stated she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 1:50 p.m., Resident 1 stated she has not had a psych referral yet and expressed the need for it. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m. with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on 4/11/23, Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on 4/11/23. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1's 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the staff should stay with the resident and ask if they have an active plan. The staff should let the SSD, DON, and MD know, and monitor the resident for emotional distress. The ADON stated the nurse should document a change of condition assessment and monitor the resident for 72 hours or past 72 hours. She stated it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm. The ADON confirmed there was no documentation that indicated staff attempted to request for psych services for Resident 1. The ADON also confirmed there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility, she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later on. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. The ADON stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician's office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A 'facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. Review of the facility's undated position description for Director of Social Services indicated the essential functions included to develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident and Participate in discharge planning, development and implementation of social care plans. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR .All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) and treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past . Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): . The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Resident 1's social services progress note, dated 4/12/23 after she returned to the facility [TRUNCATED]

Based on interview and record review, the facility failed to provide a discharge notice 30 days prior to discharge for one of three residents (Resident 1) when: 1. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a shelter. 2. The Office of the State Long-Term Care Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) did not receive a discharge notice 30 days prior to the resident ' s discharge. This failure resulted in Resident 1 not receiving sufficient notice prior to her discharge to prepare her post discharge care. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): .The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she did not send the notice of Resident 1's discharge to the office of the State Long-Term Care Ombudsman. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated, The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. It also indicated, A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Based on interview and record review, the facility failed to provide a discharge notice 30 days prior to discharge for one of three residents (Resident 1) when: 1. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a shelter. 2. The Office of the State Long-Term Care Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) did not receive a discharge notice 30 days prior to the resident's discharge. This failure resulted in Resident 1 not receiving sufficient notice prior to her discharge to prepare her post discharge care. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): . The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she did not send the notice of Resident 1's discharge to the office of the State Long-Term Care Ombudsman. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated, The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. It also indicated, A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1) prior to discharge when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm were not evaluated prior to her discharge. 4. Resident 1's ordered referrals (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) for gastrointestinal (GI) services related to Crohn's disease (a type of inflammatory bowel disease) and psychological (psych) services for her diagnoses of post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder were not initiated or followed up. These failures had the potential to result in missed opportunities for the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) to evaluate the resident's continuing care needs. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn ' s disease, ADHD, and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self-harm. States she does not have a plan but has self harmed in the past .Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's social services notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] .dispo [disposition]: cont rehab. Review of Resident 1's physician orders, dated 3/21/23, indicated, Per MD [medicine doctor] start GI [gastrointestinal] Referral r/t [related to] Crohn's disease. Review of Resident 1's physician orders, dated 3/29/23, indicated, Per MD start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t Anxiety Disorder, ADHD, and PTSD. Review of Resident 1's progress notes, indicated there was no documentation Resident 1's GI and psych referrals were initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs .Res states she knows she reacted horrible to the leaving but it is related to her PTSD. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI appointment and a psych appointment. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places)as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on 4/11/23, Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on 4/11/23. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the nurse should document a change of condition assessment and it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm, there was no documentation that indicated staff attempted to request for psych services for Resident 1, and there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician ' s office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. Based on interview and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1) prior to discharge when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm were not evaluated prior to her discharge. 4. Resident 1's ordered referrals (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) for gastrointestinal (GI) services related to Crohn's disease (a type of inflammatory bowel disease) and psychological (psych) services for her diagnoses of post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder were not initiated or followed up. These failures had the potential to result in missed opportunities for the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) to evaluate the resident's continuing care needs. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease, ADHD, and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self-harm. States she does not have a plan but has self harmed in the past . Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's social services notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's physician orders, dated 3/21/23, indicated, Per MD [medicine doctor] start GI [gastrointestinal] Referral r/t [related to] Crohn's disease. Review of Resident 1's physician orders, dated 3/29/23, indicated, Per MD start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t Anxiety Disorder, ADHD, and PTSD. Review of Resident 1's progress notes, indicated there was no documentation Resident 1's GI and psych referrals were initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI appointment and a psych appointment. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places)as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on 4/11/23, Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on 4/11/23. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the nurse should document a change of condition assessment and it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm, there was no documentation that indicated staff attempted to request for psych services for Resident 1, and there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care . Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician's office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments.

Based on interview and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASRR, a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care; Level I Screening is a tool to identify individuals who are diagnosed or suspected to have MI, DD, or ID; based on the Level II Evaluation, as performed by the State-Designated Authority [SDA] when Level I screening showed the individual is positive for MI, the Department of Health Services would issue a determination of the treatment and placement recommended for the individual) assessments for one of three residents (Resident 1) when: 1. Resident 1's PASSR was not completed prior to admission or within 30 days of admission; and, 2. Resident 1's Level II evaluation was not completed when the resident's PASSR Level I screening was positive. These failures had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance), dated 7/12/23 indicated, she was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's PASSR Level I Screening, dated 5/30/23 indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the response was, Yes and anxiety disorder, adhd. During a telephone interview on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1 ' s 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR . All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. Based on interview and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASRR, a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care; Level I Screening is a tool to identify individuals who are diagnosed or suspected to have MI, DD, or ID; based on the Level II Evaluation, as performed by the State-Designated Authority [SDA] when Level I screening showed the individual is positive for MI, the Department of Health Services would issue a determination of the treatment and placement recommended for the individual) assessments for one of three residents (Resident 1) when: 1. Resident 1's PASSR was not completed prior to admission or within 30 days of admission; and, 2. Resident 1's Level II evaluation was not completed when the resident's PASSR Level I screening was positive. These failures had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance), dated 7/12/23 indicated, she was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Review of Resident 1's PASSR Level I Screening, dated 5/30/23 indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the response was, Yes and anxiety disorder, adhd. During a telephone interview on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1's 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR . All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation.

Based on interview, record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 1) when the Attending Physician (AP) and Responsible Party (RP, person designated to make decisions on behalf of a resident) were not notified after Resident 1 got out of the facility unassisted. This failure resulted in Resident 1's RP and Attending Physician being left unaware of the resident's elopment status. Findings: Review of Resident 1's Face sheet (a document that indicated a resident's basic information, including contact details and a brief medical history) indicated she was admitted on [DATE] and had the diagnosis of dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 1's Wandering Risk Assessment, dated 2/5/22, indicated Resident 1 was forgetful/with short attention span, independent with aide (cane/walker) with mobility, a moderate risk for wandering, and was diagnosed with early dementia. Review of Resident 1's Progress Notes, dated 5/22/22 at 11:07 p.m., indicated a staff found Resident 1 outside of the facility's front door. Review of Resident 1's clinical record lacked evidence the facility notified the AP and the resident's RP. There was also no documented evidence that a Wandering Risk Assessment and a Change in Condition Assessment were completed after the incident. During an interview on 9/19/23 at 11:15 a.m. with the administrator (ADM), she stated after a resident eloped, nursing staff should notify the physician and the resident's RP, complete a Change in Condition Assessment, monitor and document about the resident every shift for 72 hours after the incident, and complete a new Wandering Risk Assessment. Review of the facility's Policy and Procedure (P&P) titled, Wandering and Elopements , revised March 2019, indicated, When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall . b. Contact the Attending Physician and report findings and conditions of the resident . c. Notify the resident's legal representative (sponsor) . e. Complete and file an incident report . f. Document relevant information in the resident's medical record.

Based on interview and record review, the facility failed to provide necessary treatment when there was no registered nurse available on 2/4/23, 2/5/23, and 2/9/23 to administer intravenous (IV, to deliver a medication into a vein) antibiotic (medication used to treat bacterial infections) medication for Resident 1. This failure resulted in three missed IV antibiotic doses for Resident 1. This failure had the potential to compromise the resident's health and result in ineffective antibiotic therapy. Findings: Review of Resident 1's face sheet, indicated he was admitted on [DATE] with a primary diagnosis of sepsis (complication of an infection that can lead to tissue damage, organ failure, and death). Review of Resident 1's medication administration record (MAR), dated 2/1/23 - 2/28/23, indicated the following: Resident 1 had a physician order for Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM IV (IV antibiotic) one time a day for sepsis, start date 1/31/23, until 2/7/23; Resident 1 had a physician order for Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM IV one time a day for sepsis, start date 2/7/23, until 3/3/23; Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM was On Hold by Physician on 2/4/23 and 2/5/23 and was not signed as administered on 2/9/23. Review of Resident 1's nursing note, dated 2/4/23 indicated, MD notified of unavailable RN coverage. Hold IV ATB [antibiotic] for 2 days. During a telephone interview on 7/10/23 at 10:41 a.m., the director of staff development (DSD) confirmed that Resident 1's IV antibiotic was not given on 2/4/23 and 2/5/23 because there was no RN to administer the medication. The DSD confirmed that Resident 1's IV antibiotic was not signed on 2/9/23. The DSD stated if it was not signed, then it was not given. During a telephone interview on 7/11/23 at 11:34 a.m., the human resources administrator (HRA) stated there was no RN that worked on 2/9/23. Review of the facility's policy, Administering Medications, dated 4/2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medication administration times are determined by resident need and benefit, not staff convenience.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) signed and certified that Minimum Data Set (MDS, an assessment tool) assessments were completed when: 1. The MDS Coordinator (MDSC), a licensed vocational nurse, falsified the dates and signatures for three MDS assessments for Residents 2, 3, and 4. 2. The Medical Director signed Resident 1's MDS assessment when there was no RN available. These failures had a potential to result in inaccurate assessments that could affect the plan of care and delivery of necessary care and services for residents. Findings: Review of Resident 2's Admission MDS assessment, dated 2/27/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI, damage to the brain caused by an external force) and seizure disorder or epilepsy (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity); For Section Z0400 (Signature of Persons Completing the Assessment), the MDSC completed Sections A, F, G, GG, H, I, J, K , L , M, N, O, P, and S on 3/23/23; For Section Z0500A (Signature of RN Assessment Coordinator Verifying Assessment Completion), the interim Director of Nursing (IDON) signed the assessment; and For Section Z0500B (Date RN Assessment Coordinator signed assessment as complete), the IDON signed the assessment as complete on 3/1/23. Review of Resident 3's Annual MDS assessment, dated 2/15/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and atrial fibrillation (extremely fast, irregular, abnormal heartbeat); For Section Z0400, the MDSC completed Sections A to P on 3/24/23; For Section Z0500A, the IDON signed the assessment; and For Section Z0500B, the IDON signed the assessment as complete on 3/1/23. Review of Resident 4's Quarterly MDS assessment, dated 2/20/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including renal insufficiency, renal failure, or end stage renal disease (the loss of the kidney's ability to remove waste and balance fluid) and seizure disorder or epilepsy; For Section Z0400, the MDSC completed Sections A, G, GG, H, I, J, K, L, M, N, O, P, and S on 3/24/22; For Section Z0500A, the IDON signed the assessment; and For Section Z0500B, the IDON signed the assessment as complete on 3/5/23. Review of Resident 1's MDS assessment, dated 2/5/23 indicated for Section Z0500A, the Medical Director signed under Signature of RN Assessment Coordinator Verifying Assessment Completion. During a concurrent interview and record review of Residents 2, 3, and 4's MDS assessments on 7/5/23 at 12:55 p.m., the MDSC stated MDS assessments should be signed as completed within 14 days of the assessment reference date (ARD). The MDSC stated the MDS ARD is date of the MDS. When asked how the assessments were signed as completed prior to the MDSC's completion date, the MDSC stated, I don't have an answer. During concurrent interview and record review of Residents 2, 3, and 4's MDS assessments on 7/5/23 at 1:09 p.m., IDON confirmed she was hired on 3/10/23. When asked how she could have signed the MDS assessments prior to the date she was hired, the IDON stated, I don't know how it makes sense. I wasn't here on 3/1/23 and 3/5/23. During a telephone interview on 7/10/23 at 3:55 p.m., the administrator (ADM) stated she looked into Resident 2, 3, and 4's MDS assessments and audit reports of the facility's electronic health record. The ADM stated the IDON did not sign Resident 2, 3, and 4's MDS assessments on 3/1/23 and 3/5/23. She stated the MDSC falsified dates and created a different username to make it appear as if the IDON signed the MDS assessments. Review of the ADM's letter to CDPH, Re: Falsification of Records (MDS), dated [DATE] indicated, The Facility concluded that [the MDSC] altered the dates on the MDS once signed in . It was discovered the [the MDSC] had Admin access at the time which would allow him the ability to manage other usernames and passwords. During an interview on 7/12/23 at 11:27 a.m., the ADM stated there was no RN to sign Resident 1's MDS assessment, so the MD signed. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the following: Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete. Registered Nurse Assessment Coordinator (RNAC) is defined as an individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and is responsible for coordinating and certifying completion of the resident assessment instrument. For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date must be equal to the latest date at Z0400 or later than the date(s) at Z0400, which documents when portions of the assessment information were completed by assessment team members.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS, an assessment tool) assessments timely for five residents (Residents 2, 3, 4, 5, and 6). This failure had the potential to result in inadequate care based on delayed assessments and care planning. Findings: Review of Resident 2's Admission MDS assessment, dated 2/27/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI, damage to the brain caused by an external force) and seizure disorder or epilepsy (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity); For Section Z0400 (Signature of Persons Completing the Assessment), the Minimum Data Set Coordinator (MDSC) completed Sections A, F, G, GG, H, I, J, K , L , M, N, O, P, and S on 3/23/23; Review of Resident 3's Annual MDS assessment, dated 2/15/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) and atrial fibrillation (extremely fast, irregular, abnormal heartbeat); For Section Z0400, the MDSC completed Sections A to P on 3/24/23. Review of Resident 4's Quarterly MDS assessment, dated 2/20/23 indicated the following: The resident was admitted to the facility on [DATE] with diagnoses including renal insufficiency, renal failure, or end stage renal disease (the loss of the kidney's ability to remove waste and balance fluid) and seizure disorder or epilepsy; For Section Z0400, the MDSC completed Sections A, G, GG, H, I, J, K, L, M, N, O, P, and S on 3/24/22. Review of Resident 5's list of MDS assessments indicated the resident's last annual assessment was on 2/11/22 and the resident's last quarterly assessment was on 11/11/22. There was no annual assessment completed on 2/2023. Review of Resident 6's list of MDS assessments indicated the resident's last annual assessment was on 2/15/22 and the resident's last quarterly assessment was on 11/17/22. There was no annual assessment completed on 2/2023. During a concurrent interview and record review of Residents 2, 3, 4, 5, 6's MDS assessments on 7/5/23 at 12:55 p.m., the MDSC stated MDS assessments should be signed as completed within 14 days of the assessment reference date (ARD). The MDSC stated the MDS ARD is date of the MDS. The MDSC confirmed the Residents 2, 3, and 4's MDS assessments were completed more than 14 days after the ARD. The MDSC stated they were late. The MDSC also confirmed Residents 5 and 6 should have had annual MDS assessments done on 2/2023. The MDSC stated, It does not look like they were done. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). For an Admission assessment, the MDS completion date should be no later than the 14th calendar day of the resident's admission (admitted + 13 calendar days). For a Quarterly assessment, the MDS completion date should be no later than the ARD + 14 calendar days.

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) monitored the residents' weights, identified the residents who had unplanned weight loss, assessed and discussed the cause of unplanned weight loss, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain acceptable weights of the residents, for three of three sampled residents (Residents 1, 2, and 3). 1. For Resident 1, in 12/2022, the resident had a 7.6 pounds (lbs) weight loss (4.9% in 30 days) and the IDT recommended weekly weights to monitor. Resident 1's weekly weight was not monitored as the IDT recommended and there was no documented evidence the IDT had followed up the resident's weight loss. In 2/2023, the resident had a significant weight loss, 16.2 lbs in 90 days, at 137.8 lbs, the registered dietitian (RD) recommended weekly weights, but the weekly weight was not repeatedly monitored. Resident 1's attending physician had inaccurate monthly weights of Resident 1 and when the RD identified Resident 1's significant weight loss, there was no evidence the IDT discussed and assessed the cause of Resident 1's significant weight loss and care planned regarding the resident's weight loss. The care plan regarding the resident's weight loss was not updated and developed with a measurable goal and actual interventions to prevent further weight loss or specify the acceptable weight range. These failures resulted in Resident 1's significant weight loss and continuous weight loss; 2. For Resident 2, there was no follow up by the IDT for four months after the resident's weight loss in January 2023. 3. The weekly weights of Residents 1, 2, and 3 were not monitored per care plan, IDT recommendations, and/or a physician order. This failure had the potential to result in being unable to identify the residents' weight loss, timely evaluate Residents 1, 2, and 3's complete nutritional status, and provide necessary interventions. Findings: 1. Review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions) and Type 2 diabetes (a condition which affects the way the body processes blood sugar). Resident 1's admission weight was 151.6 pounds (lbs). Review of Resident 1's Food and Nutrition Services Assessment, dated 8/24/22 indicated Resident 1's weight was 156 lbs, her usual weight was 150's, and the desired/goal body weight was stable weight. Review of Resident 1's Weight Change Note, dated 12/2/22 indicated, IDT met for monthly weight meeting .IDT recommends to cont. [continue] weekly weight, monitoring PO [by mouth] intake and follow up as needed. Review of Resident 1's short term: IDT monthly meeting care plan, dated 12/3/22 indicated current weight of 146.4 lbs. and weight loss of 7.6 lbs/4.9% in 30 days. A care plan intervention indicated, Weekly weights, date initiated 12/3/22. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weights were taken weekly after 12/3/22. Review of Resident 1's Food and Nutrition Services Quarterly Assessment (Registered Dietitian [RD] Assessment), dated 2/27/23, indicated Resident 1's current weight was 137.8 lbs and the rate of unplanned weight loss was greater than 5 percent (%) in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. The assessment indicated, Unintended Weight Loss related to Psychological causes 2/2 [secondary to] depression as evidenced by weight loss of -16.2# [lbs] over last 90 days and -18.2# [lbs] over the last 180 days (significant weight loss). It also indicated, Please re-weigh, weigh weekly for 4 weeks. Will monitor nutrition intake and tolerance, and weight. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weight was re-weighed. There was no documented evidence Resident 1's weights were taken weekly after 2/27/23. Review of Resident 1's potential nutritional problem care plan, dated 8/30/21, indicated, 2/27/23: 30 days: no data, 90 days: -16.2# [lbs] (-11.8%), 180 days: -18.2# (-13.2%). Significant weight changes . The nutritional problem care plan was revised on 2/27/23. The care plan's goal, also indicated, The resident will maintain adequate nutritional status as evidenced by maintaining weight within, no s/sx [signs and symptoms] of malnutrition, and consuming at least 50% of meals daily through review date. The care plan's Goal did not specify the range Resident 1's weight should be maintained within. There was no update or revision to the care plan's goal. The latest revision to the goal was 9/20/22. There was no update or revision to the care plan's Interventions. The latest care plan intervention was initiated on 12/3/22. Review of Resident 1's clinical record indicated there was no documentation that indicated the IDT discussed the RD's recommendation and Resident 1's significant weight loss identified in the 2/27/23 RD assessment. There was no documentation that indicated the IDT followed up on Resident 1's continued weight loss, addressed Resident 1's depression, identified the possible cause of Resident 1's weight loss, or discussed interventions or plan regarding Resident 1's weight. Review of Resident 1's Weights and Vitals Summary, dated 5/11/23, indicated the resident's most recent weights were 146.8 lbs on 12/8/22, 143.6 lbs on 12/29/22, and 137.8 lbs on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 12/27/22 indicated, Wt [weight] 146.8 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 1/30/23 indicated, Wt 143.6 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 2/13/23 indicated, Wt 137.8 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 3/20/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. During an interview on 4/11/23 at 2:04 p.m., the registered dietitian eligible (RDE) stated if he had a recommendation to add a resident to be weighed weekly, he would inform the administrator, charge nurse, and director of nursing. The RDE stated nursing staff is responsible for weekly weights and documenting the weekly weights. During an interview on 5/11/23 at 1:08 p.m., the MDS coordinator (MDSC) confirmed there was no weight input in Resident 1's electronic medical record after 2/2/23. The MDSC stated weights are documented on paper and then the previous director of nursing would enter the weights into the electronic medical record. During concurrent interview and record review, on 5/11/23 at 1:30 p.m., the MDSC stated Resident 1's weights were taken monthly and provided paper documentation of Resident 1's weights. The documentation indicated Resident 1's weight was decreasing at 137.6 lbs in March 2023, 133.8 lbs in April 2023, and 133.2 in May 2023. The MDSC confirmed there was no documentation Resident 1's weights were taken weekly after the RD's 2/27/23 assessment. During an interview on 5/23/23 at 11:45 a.m., the MDSC confirmed there were no new interventions added to Resident 1's potential nutritional problem care plan after 12/3/22. The MDSC stated any intervention could have been added at any time to address Resident 1's weight loss. During an interview on 5/23/23 at 11 a.m., the director of nursing (DON) stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 11:43 a.m., the DON stated in the past, IDT weight meetings were held by the dietary supervisor and involved all department heads, including the dietitian, DON, assistant DON, MDSC, and restorative nursing assistant. The DON stated she did not know how often IDT weight meetings were held. During an interview on 5/23/23 at 11:45 a.m., the MDSC stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 1:08 p.m., the dietary supervisor (DS) stated there was no IDT meeting that addressed resident weights since March 2023. During a telephone interview on 5/23/23 at 12:42 p.m., Resident 1's physician (MD) stated she was aware Resident 1 had gradual weight loss in February 2023 but was not sure Resident 1 was continuing to lose weight. During an interview with the registered dietitian (RD) on 5/25/23 at 12:50 p.m., the RD stated he would expect Resident 1 weekly weights to be done if it was a care plan intervention or an RD recommendation. The RD stated adding a resident on a list to be weighed weekly does not require an MD order. He stated it is within an RD's scope to add a resident to weekly weights. The RD stated that it falls under nursing to make sure the weights are being taken. He stated an RD not having the most updated weight would affect an RD's assessment. The RD also stated that it was important to work with the IDT. He stated there should have been documentation of an IDT discussion regarding Resident 1's weight. The RD confirmed Resident 1's care plan did not specify what Resident 1's weight should be maintained within. He stated the care plan should have a specific goal that is measurable, typically a target body mass index (BMI, a measure of body fat based on height and weight) range or a target weight range. The RD stated in the 2/27/23 RD assessment, after Resident 1's weight loss, there was no specific calculations for calorie, protein, or fluid needs and there was no target weight range indicated. During an interview on 6/6/23 at 1:18 p.m., the administrator (ADM) confirmed Resident 1 did not have weekly weights taken because there was no physician's order for weekly weights. During an interview and concurrent record review on 6/6/23 at 4 p.m., the ADM confirmed there was no documentation that the IDT discussed Resident 1's weight loss after 12/2/22. The ADM confirmed the last IDT note was on 12/2/22 and the note indicated the IDT would follow up as needed. The ADM stated if the RD were to review information and identify issues, then the IDT should follow up at that time. The ADM stated there were no nursing notes or IDT documentation regarding Resident 1's weight loss identified in the 2/27/23 RD assessment. The ADM also stated there was no documentation by the IDT regarding Resident 1's depression. The ADM confirmed there should have been some type of discussion and documentation by the IDT regarding Resident 1's weight loss after the 2/27/23 RD assessment identified significant weight loss. 2. Review of Resident 2's face sheet indicated he was admitted to the facility with diagnoses including severe sepsis with septic shock (serious infection that can cause organ failure and low blood pressure). Review of Resident 2's Weights and Vitals Summary indicated his weights were 189 lbs on 12/29/23, 184.8 lbs on 1/5/23, 178.4 lbs on 1/12/23, 175 lbs on 1/19/23, and 172 lbs on 2/2/23. Review of Resident 2's Weight Change Note, dated 1/13/23, indicated the resident had a 6.4 lbs weight loss in one week and the IDT will continue to monitor and follow up as needed. Review of Resident 2's Weight Change Note, dated 1/23/23, indicated the resident had a 3.4 lbs weight loss in one week and the IDT would continue to monitor and follow up as needed. Review of Resident 2's Food and Nutrition Services Quarterly Assessment, dated 3/21/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated the weight history was No updated weight, unable to calculate weight changes. The assessment indicated, Documented by [RDE] and was signed by the MDSC, who is a licensed vocational nurse (LVN). Review of Resident 2's Food and Nutrition Services Assessment, dated 4/4/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated, Documented by [RDE] and was signed by the MDSC, an LVN. Review of Resident 2's physician orders indicated an order, dated 4/8/23, for weekly weight one time a day every Monday. There was no documented evidence Resident 2's weights were taken weekly after 4/8/23. Review of Resident 2's Medication Administration Record for April 2023 and May 2023, indicated the order weekly weight one time a day every Monday was not signed as administered on 4/17/23, 4/24/23, 5/1/23, and 5/8/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC confirmed there was no documentation Resident 2's weights were monitored weekly in April and May. Review of the facility weights for May 2023 indicated Resident 2's weight was 162. There was no documentation that the IDT discussed Resident 2's weight from February 2023 to May 2023. During concurrent interview and record review, on 7/7/23 at 10:30 a.m., the RD confirmed the 3/21/23 and 4/4/23 Food and Nutrition Services assessments utilized Resident 2's weight on 2/2/23. The RD stated the assessments would not be accurate and Resident 2's weight should have been taken. The RD also confirmed the assessments were documented by the RDE and signed by an LVN (MDSC). The RD stated if an assessment was documented by an RDE, the assessment should be monitored and signed by an official registered dietitian. During an interview, on 7/10/23 at 10:25 a.m., the RD confirmed there was no IDT discussion regarding Resident 2's weight between February 2023 and May 2023. 3. Review of Resident 3's face sheet indicated she was admitted to the facility with diagnoses including Type 2 diabetes and hypertension (high blood pressure). Review of Resident 3's Weights and Vitals Summary, dated 4/11/23 indicated her last recorded weight was 121 lbs on 2/2/23. Review of Resident 3's Food and Nutrition Services Assessment, dated 2/13/23, indicated Resident 3 had a change in condition and had a slight decrease in intake by mouth. The assessments indicated the nutritional monitoring and evaluation was Will monitor weekly weight, dietary intake and tolerance. Review of Resident 3's clinical record indicated there was no documented evidence Resident 3's weights were taken weekly after 2/13/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC stated Resident 3's weights were taken monthly. The MDSC confirmed there was no documentation Resident 3's weights were taken weekly. Review of the facility's policy, Weight Assessment and Intervention, revised 3/2022 indicated the following: - Residents are weighed upon admission and at intervals established by the interdisciplinary team . - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe c. 6 month - 10% weight loss is significant; greater than 10% is severe - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight chance has been met. The evaluation includes the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. - The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss. - Individualized care plans shall address the identified causes of weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes and the interdisciplinary team reviews and updates the care plan when the desired outcome is not met. Review of the facility's policy, Care Planning - Interdisciplinary Team, revised 3/2022, indicated the interdisciplinary team is responsible for the development of resident care plans and the IDT includes but is not limited to the resident ' s attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, the resident and/or the resident's representative and other staff as appropriate or necessary to meet the needs of the resident.

Based on observation, interview, and record review, the facility failed to implement infection control practices to help prevent the spread of infection and COVID-19 (Coronavirus disease is an infectious disease, spread from person to person via respiratory droplets) when: 1. Two facility staff (OFS 1 and OFS 2) did not wear their face masks while in the open safe in the front desk. 2. One staff did not perform hand hygiene after touching possibly contaminated surfaces during medication administration. These failures could spread the infection to residents, staff and visitors. Findings: 1. During an observation on 10/4/22 at 2:51 p.m., the office staff 1 (OFS 1) and OFS 2 who worked in the front office accessible to staff, visitors and residents were not wearing any masks while working in their cubicle. Both staff were not eating or drinking and validated the observation. During the concurrent interview, the OFS 1 ans OFS 2 both stated, they should wear their facemasks at all times except when eating or drinking. During an interview on 10/4/22 at 3:50 p.m., the assistant director of nursing (ADON) and infection preventionist (IP) both stated staff should wear surgical (procedure) masks outside resident care area and use of appropriate mask as source control measures for COVID-19. The California Department of Public Health (CDPH) Guidance for the Use of Face Masks dated 9/20/22 indicated, Long-term care indoor settings, masks are required for all individuals regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended. The AFL 22-07.1 dated 10.6.22 indicate SNF residents and health care personnel (HCP) must continue to follow current CDPH Masking Guidance to protect themselves and others, including wearing a mask, avoiding crowds and poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following guidance for personal protective equipment use and [CONDITION(S)]-CoV-2 testing. 2. During medication administration observation for Resident 5 on 10/3/22 at 9:15 a.m., LVN H was observed donning on a pair of gloves, then turning off the G-tube feeding by touching the feeding pump. LVN H touched the bed remote control to raise the bed and disconnected the G-tube. Then LVN H flushed the G-tube with water and proceeded with the medication administration without changing gloves and washing hands after touched potentially contaminated surfaces. During an interview with LVN H on 1/3/22 at 10:15 a.m., the LVN H stated, I should remove gloves, wash my hands, and apply new pair of gloves after I touched the bed remote control, G-Tube, and pump. I should do hand hygiene before I started flushing water and medications via GT. During an interview with ADON on 10/3/22 at 11:00 a.m., the ADON said, Nurses should wash hands after touching possible contaminated surfaces before start giving medications via G-tube. A review of the Center for Disease Control and Prevention (CDC) website titled, Guidelines for Hand Hygiene in Healthcare Settings dated October 2002, indicated, Failure to remove gloves between 'dirty' and 'clean' body site care on the same patient must be regarded as non-adherence to hand-hygiene recommendations, and, Change gloves and perform hand hygiene during patient care, if . moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Based on observation, interview and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions when: 1. six aluminum baking pans were rusty; and 2. food trays were stored underneath the dishwashing sink beside chemicals. These failures had the potential for foodborne illness (caused by food or water contaminated with bacteria, viruses, parasites or toxins) for the 33 residents receiving food from the kitchen. Findings: 1. Observation and interview during the initial kitchen tour with the dietary supervisor (DS), on 10/3/22 at 9:14 a.m., yielded the following: a.) six rusty aluminum baking pans were on the storage rack. DS verified that these six aluminum baking pans were rusty and should not be used or placed in the storage rack. According to the Food and Drug Administration (FDA, responsible for protecting public health) Food Code 2017, Section 4-601.11, indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Review of the facility's Food Service Procedures Manual: Safety, Equipment Care and Cleaning, dated 2019, indicated, Staff will be oriented and trained on the care and cleaning of equipment. Equipment will be cleaned according to the frequency outlined on the facility's cleaning schedule list. 2. During the dishwashing observation on 10/6/22 at 9:18 a.m., clean and air-dried food trays were placed underneath the dishwashing sink beside the detergent, bleach and drying agent additive. During an interview with DS on 10/6/22 at 9:20 a.m., she verified that these clean and air-dried food trays should not be placed underneath the dishwashing sink beside the chemicals. DS further stated that they will transfer them right away to another storage area. During an interview on 10/6/22 at 2:45 p.m., with the registered dietician (RD), she verified that baking pans should be clean, sanitary and without rust. RD also verified that clean food trays should not be placed underneath the sink beside the dishwashing detergent, bleach and drying agent additive. Review of the facility's Food Service Policies and Procedures Manual: Safety, dated 2019, indicated, Chemicals will be stored separately. All soaps, detergents, cleaning compounds or similar substances will be stored in an area separate from food supplies and/or eating utensils.

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for 10 of 12 sampled residents when: 1. For Resident 9 and 21 pacemakers were not monitored; 2. For Resident 230, her oxygen inhalation order was not followed; 3. For Resident 14, the nursing staff did not carry out the physician's order for labs; 4. For Residents 14, 15, 26, 128, 12, 22, 25 and also 230, staff did not document the systolic blood pressure (amount of pressure in the arteries during the contraction of the heart muscle) between lying and/or standing/siting positions when completing the Fall Risk Evaluation. Accuracy of assessments is important in identifying the resident-centered needs and appropriate interventions of each resident. Resident Assessments are the bases of resident's plan of care. These failures had the potential to compromise the residents' health and well-being. Findings: 1a. Review of Resident 9's clinical record indicated he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order dated 6/24/21 indicated to monitor Medtronic transmitter at bedside every shift related to loop recorder, *transmit information per cardiologist office request. During an interview with licensed vocational nurse A (LVN A) on 10/6/22 at 8:35 a.m., he stated Resident 9 had a pacemaker (device implanted into the chest to control abnormal heart rhythms) and nursing was monitoring the Medtronic transmitter (remote heart monitoring device) at bedside every shift. LVN A stated his role was to check that the device was plugged in and the green light was on. During a concurrent record review with LVN A he stated there was no monitoring for signs and symptoms of pacemaker failure for Resident 9. Review of Resident 9's face sheet (summary of important information about a patient including identification, insurance coverage, contacts, and diagnoses) did not include the presence of a cardiac pacemaker. Review of Resident 9's clinical record did not contain any information regarding the pacemaker's manufacturer, model number, the paced rate, type of leads, date of implant, or the cardiologists address and telephone number. There were no physician orders to monitor the pacemaker or observe for signs and symptoms of pacemaker failure. There was no documentation to indicate nursing was following the facility's policy for monitoring residents with pacemakers. 1b. Review of Resident 21's clinical record indicated he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation in Resident 21's room on 10/6/22 at 10:00 a.m., with LVN A, there was a Medtronic transmitter on Resident 21's dresser. During a concurrent interview with LVN A, he acknowledged that Resident 21 had a transmitter used by residents who have pacemakers. LVN A stated he was unaware that Resident 21 had a pacemaker. During a concurrent record review of Resident 21's medical record and interview with LVN A, there was no documentation indicating nursing staff monitor Resident 21's pacemaker. LVN A confirmed there was no monitoring of the transmitter by facility staff and there was no monitoring for signs and symptoms of pacemaker malfunction. Review of Resident 21's clinical record did not contain any information regarding the pacemaker's manufacturer, model number, the paced rate, type of leads, date of implant, or the cardiologists address and telephone number. There were no physician orders to monitor the pacemaker or observe for signs and symptoms of pacemaker failure. There was no documentation to indicate nursing was following the facility's policy for monitoring residents with pacemakers. During an interview with the director of nursing (DON) on 10/6/22 at 10:40 a.m., she confirmed that Resident 9 and Resident 21 have implanted cardiac pacemakers. She reviewed Resident 9 and 21's clinical records and confirmed there was no documentation of the pacemaker information for Resident 9 and 21. The DON stated the medical record should contain the pacemaker information including the model number and manufacturer, the type of leads, date of insertion, the set rate, and the cardiologist's information. The DON further stated nursing staff should monitor residents every shift for signs and symptoms of pacemaker malfunction. She confirmed there was no monitoring for signs and symptoms of pacemaker failure in Resident 9 and Resident 21's medical record. A review of the facility's policy Care of a Resident with Pacemaker, revised December 2015, indicated to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmias (slow heart rate) which include [CONDITION(S)] ([CONDITION(S)]), shortness of breath, dizziness, fatigue and confusion. The policy further indicated for each resident with a pacemaker, to document the following in the medical record: the name, address and telephone number of the cardiologist; type of pacemaker; type of leads; manufacturer and model; serial number; date of implant; and paced rate. A review of the U.S. Department of Health & Human Services' National Heart, Lung, and Blood Institute website, www.nhlbi.nih.gov, indicated a pacemaker can stop working properly over time because the wires get dislodged or broken, the battery gets weak or fails, the heart disease progresses, and other devices have disrupted its electrical signaling. 2. During a concurrent observation and interview on 10/4/22 at 10:40 a.m. with Resident 230, her oxygen inhalation was at 4 liters per minute via nasal cannula continuous and Resident 230 verified that she's currently receiving 4 liters per minute of oxygen inhalation. Review of Resident 230's resident information admission record indicated, Resident 230 was a [AGE] year old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 230's order summary report on 10/4/22 at 11:25 a.m., indicated, she's on oxygen inhalation at 3 liters per minute via nasal cannula continuous. During an interview on 10/4/22 at 12:00 p.m., with the assistant director of nursing (ADON), she verified that they had not followed Resident 230's oxygen inhalation order. ADON further verified that Resident 230 was currently receiving oxygen inhalation at 4 liters per minute via nasal cannula continuous and since her order was oxygen inhalation at 3 liters per minute via nasal cannula continuous, they should have called the physician first to change the current oxygen inhalation order which is 3 liters per minute, into 4 liters per minute via nasal cannula continuous, before administering it to Resident 230. Review of the facility's, Nursing Services Policy and Procedure Manual for Long-Term Care: Medication and Treatment Orders, revised February 2014, indicated, Orders for treatments will be consistent with principles of safe and effective order writing and shall be administered only upon the written order of a person duly licensed and authorized to prescribe in this state. Treatment will be administered by nursing service personnel as soon as the order had been received. All orders must be charted and made a part of the resident's medical record and care plan. 3. Resident 14 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 14's physician order, dated 6/29/2021, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 14's medical record indicated there were no laboratory results for the above in June 2022. During a concurrent interview and record review with License Vocational Nurse A (LVN A) on 10/5/22, at 11:58 a.m., LVN A verified Resident 14's clinical record did not contain above laboratory results for June 2022 During concurrent interview and record review with the assistant director of nursing (ADON) on 10/6/22, at 10:48 a.m., the ADON stated, Lab work was not done in June 2022, but lab work should have done. She verified the physician's order was not carried out. 4.a A review of Resident 14 clinical record indicated she was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Fall Risk Evaluation done on 8/19/22. indicated she was high risk for fall. 4.b A review of Resident 15 clinical record indicated admission on 4/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Fall Risk Evaluation done on 2/5/22 and 8/9/22 indicated she was high risk for fall. 4.c A review of Resident 26 clinical record indicated admission on 8/30/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Fall Risk Evaluation done on 3/2/22, 5/31/22 and 8/30/22 indicated she was high risk for fall. 4.d A review of Resident 128's clinical record indicated admission on 9/29/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Fall Risk assessment done on 9/29/22 indicated she was high risk for fall. During an interview with the licensed vocational nurse G(LVN G) on 10/5/2022 at 3:34 p.m., LVN G stated licensed nurse completed the Fall Risk Evalualion upon admission and should document the vital signs specific to sitting and lying positions in the resident's vital signs record. During an interview with registered nurse F (RN F) on 10/5/22 at 3:49 p.m. RN F stated she also completed Fall Risk Evaluation upon resident's admission and had taken the resident's blood pressure once unless the resident had problems with elevated blood pressure and documented the vital signs in the resident's record. During an interview and concurrent record review with the assistant director of nursing (ADON) on 10/5/2022 at 4:51 p.m., confirmed the Fall Risk Evaluation, Section F requiring to take the systolic blood pressure in lying and standing/or sitting positions were not done. The ADON validated upon review of Residents 14,15, 26 and 128's vital signs records there were no documented evidences that the SBP were taken in different positions). The ADON admitted this concern was systemic (involved the whole facility) and she would conduct in-services to her staff during their next staff meeting 4. e. Review of Residents 12, 22, 25 and 230's fall risk evaluation records indicated that they should be monitored for any drops in their systolic blood pressures between lying and standing positions. Resident 12 had an admission fall risk evaluation on 8/3/22, Resident 25 had his admission fall risk evaluation on 8/28/22, Resident 230 had her admission fall risk evaluation on 9/19/22 and Resident 22 had his quarterly fall risk evaluation on 9/7/22. Review of Residents 12, 22, 25 and 230's vitals summary records indicated that they were not monitored for any drops of their systolic blood pressures during their fall risk evaluations on 8/3/22, 9/7/22, 8/28/22 and 9/19/22, respectively.

Based on interview and record review, the facility failed to ensure the Fall Care Plan was implemented for one of two residents (Resident 1) when staff did not keep the resident within their view after dinner or did not assign available staff until assigned staff was ready to assist the resident back to bed and as a result, the resident fell and sustained a fracture of her left hip. Findings: Resident 1's clinical record was reviewed. Resident 1 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/1/16 indicated a Brief Interview for Mental Status (BIMS) score of 6, which means her cognition is severely impaired (a score of 0 to 7 is severe impairment). The MDS' dated 9/1/17 and 12/1/17 indicated she had short and long term memory problems. Resident 1's MDS' dated 9/1/17 and 12/1/17, indicated Resident 1 was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, and moving surface-to-surface transfer. Resident 1 required one-person physical assist in ambulation, and extensive assistance (staff provide weight-bearing support) in transfer. Resident 1's Fall Risk Assessments dated 10/30/17 indicated a score of 18 and 12/6/17 a score of 20, which means she had a high risk fall level. A score of 10 and above is high risk for falls. Review of the physician's orders [REDACTED]. Review of a nurse's notes for Resident 1's first unwitnessed fall, dated 12/9/17 at 2:43 p.m., indicated the staff and charge nurse responded to pressure pad alarm and upon entering the room noticed Resident 1 on the floor in a sitting position. Upon assessment there was no noted skin injury, no ill effect from the fall and Resident 1's neurological status was normal. Review of another nurse's notes of Resident 1's second unwitnessed fall, dated 12/9/17, indicated on the same day at 6:30 p.m., Resident 1 had a second fall in another resident's room. Resident 1 was found lying down on the floor and leaning on her left side. The notes also indicated while transferring the resident to her room she was guarding her left hip. A bump was found on her left hip. Resident 1's left hip became unsymmetrical to the right hip. Her left hip was swollen and her left lower extremity was shorter than the right lower extremity. An ice bag was placed in the meantime to her left hip's swollen area. Resident 1 was transferred to an acute care hospital. Resident 1's two falls occurred within less than 4 hours and both were unwitnessed. During a telephone interview with the licensed vocational nurse C (LVN C) on 12/18/17 at 1:43 p.m., she stated she was on break when the second unwitnessed fall incident happened. LVN C further stated both certified nursing assistants (CNAs) should have kept an eye on Resident 1 because Resident 1 already fell earlier and they do not want another fall. During a telephone interview on 12/18/17 at 1:55 p.m. with CNA A regarding Resident 1's second unwitnessed fall episode, she stated she and CNA B were watching Resident 1 who was in her wheelchair in front of the nurses station. She saw another resident (Resident 2) across the nurses station inside his room sliding off his wheelchair. Both CNAs ran to help Resident 2. While assisting Resident 2, CNA A stated no staff observed Resident 1 at that time in front of the nurses station. While they were assisting Resident 2 to put him in bed, she heard the pressure pad alarm, and immediately ran and found Resident 1 on the floor in another resident's room. During an interview with CNA B on 12/18/17 at 2:58 p.m. regarding Resident 1's second unwitnessed fall episode, she stated she was watching Resident 1 in front of the nurses station. She saw Resident 2 across the nurses station sliding off his wheelchair. She and CNA A ran to prevent the resident from sliding off from his wheelchair. CNA B did not call other staff to watch Resident 1. No staff watched Resident 1 while they were assisting to put Resident 2 in his bed, then she heard the pressure pad alarm and CNA A ran to where the alarm was heard and found Resident 1 in another resident's room lying down on the floor. Review of the Fall Care Plan (interventions or tasks to prevent fall) dated 12/6/17, indicated staff to keep Resident 1 within view, after dinner or will assign available staff until an assigned CNA is ready to assist Resident 1 back to bed. During an interview with the director of staff development (DSD) on 12/18/17 at 3:20 p.m., stated all CNAs were given in-service training in nursing interventions to prevent falls for Resident 1. Review of Resident 1's acute hospital radiology report dated 12/9/17, revealed a [MEDICAL CONDITION] hip. Further review of Resident 1's acute hospital discharge summary dated 12/12/17, indicated she was admitted on [DATE] with a left [MEDICAL CONDITION]. She was evaluated by an Orthopedic doctor who decided that comfort care required surgical repair. Her left [MEDICAL CONDITION] was repaired by open reduction and internal fixation (ORIF, a surgical procedure to fix and align the fractured bone) surgery. Review of the facility's undated Fall Management Policy, indicated Residents will be assessed for fall risk and intervention will be implemented to reduce the risk of falls. It further indicated that new or existing residents scoring as high risk will have interventions implemented to reduce the potential for falls outlined in their plan of care.