Every finding on record at Feather River Care Center

Based on observation and interview, the facility failed to protect two of two sampled Residents (Resident 1 and Resident 2) while performing wound care when the cleaning and sanitizing of the surgical scissors was not done between each use.This failure had the potential to cause widespread infection among the residents.Findings:A review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment dated 1/1/2026, indicated, Staff Shall follow established infection control principles for cleaning and disinfecting reusable; non-critical equipment general guidelines include.d. Multiple resident use equipment shall be cleaned and after each use.A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included difficulty walking, need for assistance with personal care, diabetes and pressure ulcer of the left heel. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included, need for assistance with personal care, diabetes and chronic ulcer (open sore or wound that fails to heal), of other part of right foot.During interview on 1/22/26 at 10:30 am, in Resident 1 & 2's room (Resident 1 and 2 were roommate), Resident 1 stated he came to the facility with right and left heel wounds. Resident 1 stated the right heel healed and the left is receiving treatment and dressing changes. Resident 1 described his morning routine as being woken up between 5-6 am. Resident 1 stated he is not offered a cloth to wash his face and hands. He stated he does not receive showers, only sponge baths twice a week, Resident 1 is unable to stand in a shower due to his heel wound.During an interview on 1/22/26 at 10:28 am, in Resident 1 & 2's room, Resident 2 stated he came to the facility with a diabetic ulcer on his right foot. Resident 2 stated he is supposed to get a shower twice a week. Resident 2 stated he must ask for his care, including wash clothes to clean his face and hands.During observation on 1/22/26 at 11:20 am, in Resident 1 & 2's room, observed Licensed Vocational Nurse (LVN A) performing wound treatment to Resident 1's left heel. LVN A gathered needed supplies to complete task. LVN A reviewed Physician order for treatment. LVN A began with soaking gauze with saline due to gauze being stuck to the left heel. After saturated by saline, removed the wet gauze and dabbed the heal dry. LVN A removed scissors from her pocket to cut special dressing Calcium Alendronate. LVN A applied the dressing to the heel, covered with 4 centimeter by 4 centimeter (cm) gauze then wrapped with gauze dressing and taped. Observed the tape indicated date and initials. LVN A then placed the uncleaned scissors in her pant pocket.During Observation on 1/22/26 at 11:40 am, in Resident 1 & 2's room, observed LVN A performing wound treatment to Resident 2's right heel. LVN A gathered needed supplies, reviewed Physician orders. LVN A began removing gauze dressing with minimal use of saline. After dressing and gauze were removed, dabbed the heel dry. LVN A then removed the scissors that was previous used on Resident 1 from her pant pocket, cut the special dressing Calcium Alendronate then applied 4 cm by 4 cm gauze to cover special dressing. Wrapped the heel with gauze dressing and taped. Observed tape indicated date and initials. LVN A disposed of trash and soiled towel. Observed LVN A place the scissors in pant pocket. Observed LVN A did not clean the scissors after resident.During interview with LVN A on 1/22/26 at 1:52 pm, when asked about the process of wound change and using personal scissors when working with multiple patients. LVN A stated she forgot to sterilize the scissors in between each resident. LVN A stated standard is to sterilize equipment between residents.During interview with Infection Control (IP) at 1:54 pm, when asked the expectation of nurses working with multiple patients using personal scissors IP stated, the expectation is to disinfect instruments between residents.

Based on observation, interview and record review, the facility failed to ensure protection from sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) when Resident 2 touched Resident 1's side of the body on 12/20/25, and touched Resident 1's chest area on 12/22/25These failures led to the compromised safety of Resident 1 and had the potential to affect Resident 1's emotional and psychosocial well-being as well as putting other residents at risk.Findings:During a record review of facility's policy titled, Abuse, Neglect, and Exploitation dated 2025, indicated Abuse means the willful infliction of injury.intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include.certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Facility policy also indicated The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and providing emotional support and counseling to the resident during and after the investigation, as needed. Facility policy further indicated sexual abuse is non-consensual sexual contact of any type with a resident.During a record review of Resident 1's admission record, indicated that Resident 1was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (a brain disorder from exposure to harmful substances like solvents, heavy metals, drugs), dementia with psychotic disturbance (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's most recent Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/2/24, at section C- Cognitive patterns, indicated that Resident 1's cognition was severe impaired with a Brief Interview for Mental Status (BIMS) score of 5. During a record review of Resident 2's admission record, he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty in walking. During a review of Resident 2's most recent MDS dated [DATE], at section C- Cognitive patterns, indicated that Resident 2's cognition was intact with a BIMS score of 14. During a record review of Resident 2's progress notes, dated 12/20/25 at 1:53 pm, Registered Nurse (RN) A documented Per staff, stated they saw this resident (Resident 2) sitting next to another female resident (Resident 1), and he was touching her side, grunting. Resident separated from another resident. During a record review of the facility's document titled, Communications Report dated 12/20/25 at 1:55 pm, RN A documented Staff member reported that this resident (Resident 2) sitting next to female resident (Resident 1) was rubbing her side, grunting. Monitor behavior.During a record review of Resident 1's Interdisciplinary Team (IDT) notes dated 12/23/25 10:00 am, indicated Resident 1 was touched in the chest area by Resident 2 on 12/22/25 at 4:45 pm. IDT note further indicated staff witnessed the incident.During an interview with Infection Preventionist (IP) on 12/23/25 at 2:02 pm, IP confirmed the incident that occurred on 12/22/25 between Resident 1 and Resident 2. IP confirmed Resident 1 was not evaluated by nursing staff after the incident on 12/22/25.During an observation and interview with Resident 1 on 12/23/25 at 2:15 pm, in Resident 1's room, Resident 1 was in her bed. Resident 1 could not recall incident from 12/20/25 or 12/22/25. Resident 1 stated Something happened that was not good, but now things are good.During an interview with Licensed Vocational Nurse (LN) B on 12/23/25 at 2:17 pm, LN B stated she was told about the incident between Resident 2 and Resident 1 that occurred on 12/22/25. LN B confirmed Resident 1 did not receive a full evaluation by nursing staff after the 12/22/25 incident. LN B confirmed facility expectation was for nursing staff to complete a full evaluation of a resident after an incident or change of condition. LN B confirmed Resident 2 ambulated throughout the entire facility in his wheelchair with no supervision, which included at the end of the hall where Resident 1 resided. LN B confirmed facility did not follow its abuse policy to protect Resident 1 and should have.During an interview with RN C on 12/23/25 at 2:20 pm, RN C confirmed he did not complete a nursing evaluation of Resident 1 after he was notified of the incident on 12/22/25. RN C stated he was not aware he should have completed a full evaluation of Resident 1 per facility policy. RN C stated he could not verify if Resident 1 sustained any physical injuries after the 12/22/25 incident. RN C confirmed facility did not follow its abuse policy to protect Resident 1 and should have.During an observation on 12/23/25 at 2:43 pm, Resident 2 was observed at the nurse's station in his wheelchair. Resident 2 ambulated in his wheelchair down the hallway to the end outside of Resident 1's room. Resident 2 was observed with no direct staff supervision.During an interview with RN A on 12/23/25 at 4:45 pm, RN A stated she texted the Director of Nursing (DON) after the incident on 12/20/25 between Resident 1 and Resident 2. RN A stated she did not remember which staff member witnessed the interaction. RN A stated she did not witness the interaction, so she did not feel compelled to report the abuse from 12/20/25. RN A confirmed she did not complete a nursing evaluation, change in condition, or report the abuse per facility policy. RN A stated, I had a hard day and should have done those things, but the DON told me just to write a progress note. RN A confirmed she only entered a progress note in Resident 2's chart, and not for Resident 1 for the 12/20/25 incident. During an interview with Administrator (Admin) on 12/23/25 at 5:08 pm, Admin stated he was unaware of what happened on 12/20/25. Admin stated it was the nursing staff that failed to notify him of the incident on 12/20/25. Admin confirmed facility did not provide interventions per facility abuse policy for the 12/20/25 incident to protect Resident 1. Admin stated facility staff were supposed to work as a team and decide amongst themselves who was going to supervise Resident 2 to ensure he stayed away from Resident 1. Admin confirmed there was no solid plan on how to keep Resident 2 away from Resident 1. Admin stated he was aware Resident 2 ambulated throughout the facility in his wheelchair without supervision. Admin confirmed the incident on 12/20/25 could have led to the escalation of Resident 2 and the incident on 12/22/25. Admin confirmed Resident 1's safety was a priority, and facility did not implement their abuse policy. Admin stated the DON no longer worked at the facility as of 12/22/25 and would be unavailable for an interview.

Based on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of 3 sample residents (Resident 1), when a staff member witnessed Resident 2 touch Resident 1's side of body on 12/20/25.This failure led to the compromised resident safety and contributed to a subsequent incident on 12/22/25, when Resident 2 was witnessed with a hand on Resident 1's chest area.During a record review of facility's policy titled Abuse, Neglect, and Exploitation dated 2025, indicated Abuse means the willful infliction of injury.intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include.certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Facility policy also indicated The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and providing emotional support and counseling to the resident during and after the investigation, as needed. Facility policy further indicated sexual abuse is non-consensual sexual contact of any type with a resident. Facility indicated Reporting of all alleged violations to the Administrator (Admin), state agency, adult protective services and to all other required agencies within specified timeframes: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.During a record review of Resident 1's admission record, indicated that Resident 1was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (a brain disorder from exposure to harmful substances like solvents, heavy metals, drugs), dementia with psychotic disturbance (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's most recent Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/2/24, at section C- Cognitive patterns, indicated that Resident 1's cognition was severe impaired with a Brief Interview for Mental Status (BIMS) score of 5. During a record review of Resident 2's admission record, he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty in walking. During a review of Resident 2's most recent MDS dated [DATE], at section C- Cognitive patterns, indicated that Resident 2's cognition was intact with a BIMS score of 14. During a record review of Resident 2's progress notes, dated 12/20/25 at 1:53 pm, Registered Nurse (RN) A documented Per staff, stated they saw this resident (Resident 2) sitting next to another female resident (Resident 1), and he was touching her side, grunting. Resident separated from another resident. During a record review of the facility's document titled, Communications Report dated 12/20/25 at 1:55 pm, RN A documented Staff member reported that this resident (Resident 2) sitting next to female resident (Resident 1) was rubbing her side, grunting. Monitor behavior.During a record review of Resident 1's Interdisciplinary Team (IDT) notes dated 12/23/25 10:00 am, indicated Resident 1 was touched in the chest area by Resident 2 on 12/22/25 at 4:45 pm. IDT note further indicated staff witnessed the incident.During an observation and interview with Resident 1 on 12/23/25 at 2:15 pm, Resident 1 was in her bed. Resident 1 could not recall incident from 12/20/25 or 12/22/25. Resident 1 stated Something happened that was not good, but now things are good.During an observation on 12/23/25 at 2:43 pm, Resident 2 was observed at the nurse's station in his wheelchair. Resident 2 ambulated in his wheelchair down the hallway to the end outside of Resident 1's room. Resident 2 was observed with no direct staff supervision.During an interview with RN A on 12/23/25 at 4:45 pm, RN A stated she texted the Director of Nursing (DON) after the incident on 12/20/25 between Resident 1 and Resident 2. RN A stated she did not remember which staff member witnessed the interaction. RN A stated the staff member told her Resident 2 touched Resident 1's chest area on her side. RN A stated because did not witness the interaction, she did not feel compelled to report the abuse from 12/20/25. RN A confirmed she did not complete a nursing evaluation, change in condition, or report the abuse per facility policy. RN A stated, I had a hard day and should have done those things, but the DON told me just to write a progress note. RN A confirmed she only entered a progress note in Resident 2's chart, and not for Resident 1 for the 12/20/25 incident. RN A confirmed she did not follow facility abuse policy and should have.During an interview with Administrator (Admin) on 12/23/25 at 5:08 pm, Admin stated he was unaware of what happened on 12/20/25. Admin stated it was the nursing staff that failed to notify him of the incident on 12/20/25. Admin confirmed this incident did not get reported per facility policy. Admin confirmed facility did not provide interventions to protect Resident 1 per facility policy. Admin stated facility staff were supposed to work as a team and decide amongst themselves who was going to supervise Resident 2 to ensure he stayed away from Resident 1. Admin confirmed there was no solid plan on how to keep Resident 2 away from Resident 1. Admin stated he was aware Resident 2 ambulated throughout the facility in his wheelchair without supervision. Admin confirmed the incident on 12/20/25 could have led to the escalation of Resident 2 and the incident on 12/22/25. Admin stated the DON no longer worked at the facility as of 12/22/25 and would be unavailable for an interview.

Based on observation, interview and record review the facility failed to ensure that four out of four sampled residents (Residents 1, 2, 3, and 4) had an individualized smoking safety care plan that identified smoking-related risks, resident-specific interventions, and safety measures. Despite the facility's knowledge that these residents smoked, there was no documented care-planning process to address smoking supervision, designated smoking location, safety precautions, or ongoing evaluation and revision of the plan of care.This failure resulted in residents not receiving individualized, person-centered care related to smoking safety, with smoking-related risks remaining unrecognized and unmet, and had the potential to place residents at risk for decline in health status, including injury or other adverse outcomes.During a review of the facility's policy and procedure titled Resident Smoking - Smoke-Free Facility, revised 12/1/25, the policy stated that any resident deemed safe to smoke, with or without supervision, will be allowed to smoke only in designated smoking areas in accordance with the resident's care plan. The policy further stated that all safe smoking measures will be documented in each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking, and that supervision will be provided as indicated on the resident's care plan. The policy also stated that if a resident or family does not abide by the smoking policy, the plan of care may be revised to include additional safety measures.During record reviews on 12/19/25, Residents 1, 2, and 3's care plans and physician orders dated December 2025 were reviewed. The care plans lacked documented, individualized interventions to support safe smoking practices, including supervision requirements, designated smoking areas, or other smoking-related safety measures.A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included COPD, Tobacco use, alcohol abuse, ataxia following cerebral infarction, and other psychoactive substance dependence with intoxication delirium. Resident 1's brief interview for mental status (BIMs) score was 15, indicating Resident 1 was cognitively intact.During a review of Resident 1's Interdisciplinary (IDT) Progress Note, dated 12/17/25, the IDT note indicates, despite education the resident continues to smoke cigarettes on facility grounds. Resident has been observed smoking near hazardous areas and sneaking out multiple times during the day and night. Nicotine patch therapy was initiated but Resident refuses to use patches and continues to obtain cigarettes and lighters from outside sources. The note also indicates that the care plan is to be updated to reflect elopement risk, substance use behaviors and refusal of nicotine replacement therapy.During a review of Resident 1's care plan, dated 11/26/25, the Care Plan did not indicate elopement risk or any kind of safe smoking plan.During a review of Resident 2's medical record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that include schizoaffective disorder, muscle weakness with frontal lobe and executive function deficit. Resident 2's brief interview for mental status (BIMs) score was 15, indicating Resident 2 was cognitively intact. During a review of Resident 2's care plan, dated 12/12/25, the Care Plan did not indicate a safe smoking plan. During an interview with Resident 2 on 12/17/25 at 2:00 p.m., stated he does smoke cigarettes and he was told he must go off of property. Out of sight, out of mind. The administrator here told me I need to go off the property because they don't allow smoking here. Resident 2 stated he feels like they don't care about him or what he wants. During a review of Resident 3's medical record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that includes pleural effusion, malnutrition, nicotine dependence, difficulty walking, and kidney disease. Resident 3's BIM score is 14, indicating Resident 3 is mentally intact.During a review of Resident 3's care plan, dated 11/19/25 the Care Plan did not indicate a safe smoking plan.During an interview with Resident 3 on 12/19/25 at 10:00 a.m., Resident 3 stated he does go outside to smoke cigarettes 1-2 times a day. Resident 3 stated he goes out by himself but leaves his oxygen in the room. Resident 3 stated he was signed off by physical therapy, which means he is safe to go outside by himself. Resident 3 stated he wishes he did not have to go so far to smoke his cigarette. During a review of Resident 4's medical record indicated Resident 4 was admitted on [DATE] with diagnosis that include diabetes, chronic obstructive pulmonary disease, muscle weakness, and difficulty walking. Resident BIMs score was 15 indicating he is cognitively intact. During a concurrent interview and record review on 12/19/25 at 12:20 p.m. with Registered Nurse (RN) A, Resident 4's care plan and physician orders dated December 2025 were reviewed. The care plan addressed smoking cessation; however, there were no documented interventions or physician orders addressing safe cigarette smoking practices, including supervision requirements, designated smoking location, or other safety measures. RN A stated she was unable to locate a care plan or physician order authorizing Resident 4 to smoke cigarettes and therefore contacted the Administrator to ask whether it was acceptable for the resident to smoke cigarettes due to the absence of documented direction in the medical record. RN A further stated she was aware of the facility's non-smoking policy and routinely educates residents regarding the policy. RN A stated she believed residents who smoke cigarettes go outside around the corner of the building and clarified that she has not supervised any residents while smoking cigarettes. RN A stated she had been told that residents were not allowed to smoke cigarettes and there was no documentation in the care plan directing staff to allow or supervise cigarette smoking.During an observation on 12/19/25 at 10:20 a.m., Resident 4 exited the facility and wheeled himself in his wheelchair across uneven terrain in cold weather conditions to an area off facility property. The resident was observed smoking in that area. The location observed was not identified as a designated smoking area. No staff supervision or redirection was observed during the observation period.During an interview on 12/19/25 at 12:40 p.m. with the Administrator, the Administrator confirmed awareness that Residents 1, 2, 3, and 4 smoked cigarettes. The Administrator stated that the residents went outside to smoke cigarettes but acknowledged the facility did not have a designated smoking area at the time of the interview. The Administrator further stated that the facility was not currently following its smoke-free facility policy and indicated the facility was in the process of obtaining supplies and equipment to establish a designated smoking area and revise the smoking policy. The Administrator confirmed that Residents 1, 2, 3, and 4 did not have individualized cigarette smoking safety care plans, including documented interventions addressing cigarette smoking supervision, designated smoking location, or safety measures.

Based on observation, interview, and record review, the facility failed to implement and enforce its smoking policy when four of four residents were identified as smokers and the facility did not establish a designated smoking area as required by facility policy.This had the potential to place residents who smoke at increased risk for injury due to smoking in undesignated areas.During a review of the facility's Resident Smoking Policy, dated 12/01/25, the policy indicated that residents deemed safe to smoke, with or without supervision, are permitted to smoke only in designated smoking areas, at designated times, and in accordance with the resident's individualized care plan.During a review of the facility's Resident Smoking - Smoke-Free Facility Policy, dated 12/01/25, the policy indicated that smoking, including the use of electronic cigarettes, is prohibited in all areas except the designated smoking area, and that a designated smoking area sign will be prominently posted.During an interview on 12/17/25 at 10:30 a.m. with Registered Nurse (RN) A, RN A stated that there are four residents who smoke. RN A confirmed the facility is a non-smoking facility and stated that, per facility policy, residents who choose to smoke are instructed to leave the facility property to do so. The RN further stated that residents' cigarettes are stored in the medication cart, residents must request their cigarettes from nursing staff, and residents are required to sign a log prior to leaving the facility to smoke, documenting that they are leaving the property.During an observation on 12/19/25 at 9:00 a.m., the facility grounds and exterior areas and did not observe a designated smoking area or designated smoking area signage on or off facility property.During an observation on 12/19/25 at 10:20 a.m., Resident 4 exited the facility and wheeled himself in his wheelchair across uneven terrain in cold weather conditions to an area off facility property. The resident was observed smoking in that area. The location observed was not identified as a designated smoking area. No staff supervision or redirection was observed during the observation period.During an interview on 12/19/25 at 10:00 a.m. with Resident 3, Resident 3 stated that he smokes and obtains his cigarettes from nursing staff. The resident stated that he is instructed to leave the facility property in order to smoke. The resident further stated that he propels himself in his wheelchair out of the facility and onto the public sidewalk along the street, where he has been instructed to smoke. The resident stated that he was instructed to remain out of sight while smoking.During an interview on 12/17/25 at 1:00 p.m. with Resident 2, Resident 2 stated that he was instructed to smoke off the facility grounds. Resident 2 stated that he smokes twice per day and must propel himself in his wheelchair up a hill and off the facility property in order to smoke. Resident 2 stated that he was informed the facility is a non-smoking facility and that residents who smoke are permitted to go off the grounds to do so.During a record review of Resident 1's smoking assessment dated [DATE], the assessment indicated that Resident 1 does smoke but does not follow the non-smoking policy. Determined Resident 1 can smoke independently. Education provided to Resident 1 on facility smoking policies and risk of smoking.During an interview on 12/19/25 at 12:00 p.m., with the Administrator, the administrator revealed he was aware that four residents go outside the facility to smoke. The Administrator confirmed the facility is not following its smoke-free facility policy because the facility does not have a designated smoking area. The Administrator stated the facility is working on obtaining supplies and equipment to build a designated smoking area and stated the facility plans to revise its smoking policy once a designated smoking area is established.

Based on interview and record review, the facility failed to ensure that one of six sampled residents (Resident 1) remained free from restraint when a staff member restrained Resident 1 upright in a wheelchair. This placed Resident 1 at increased risk for injury, accident, and negative health outcomes.Findings: During a review of the facility policy titled, Restraint Free Environment, revised 2025, indicated the facility Prohibits the use of physical restraint for discipline or staff convenience and limits restraint use to circumstances in which medical symptoms warrant the use of such restraints. The policy defined Physical restraint to include the following example: Tucking in a sheet tightly so the resident cannot get out of bed . fastening fabric or clothing so that a resident's freedom of movement is restricted. The policy further clarified; Falls do not constitute . a medical symptom that warrants the use of physical restraints. During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction related to illness), pneumonia, and Chronic Obstructive Pulmonary Disease (difficulty breathing.) During a review of Resident 1's physician's order, dated 11/10/25, indicated that Resident 1 had capacity and could make his own medical decisions.During an interview on 11/25/25 at 10:40 am, with the DON (Director of Nurses,) the DON stated that the facility had confirmed that Certified Nurse Assistant (CNA) B had restrained Resident 1 on 11/16/25. DON stated CNA B had confirmed she tied Resident 1 to his chair with a sheet and asserted CNA B took this action at Resident 1's request. DON stated that CNA B had been immediately removed from patient care once the facility was notified of the accusation. The facility investigation confirmed that CNA B restrained the resident, and the facility is in the process of terminating the staff member. DON stated that no residents currently have an order for the use of restraints. DON stated that Resident 1 is no longer at the facility, Resident 1 was transferred on to the acute care hospital on [DATE].During an interview on 11/25/25 at 12:35 pm, with the CNA B, CNA B confirmed that she had been working on 11/16/25 and had used a bed sheet to tie Resident 1 upright in a chair. CNA B confirmed she secured the bed sheet with a knot at the back of the chair, and that Resident 1 could not release himself. CNA B stated she did this at Resident 1's request but now realizes she should have refused. CNA B confirmed she had received training on resident abuse and restraints from the facility and as part of her CNA training.

Based on interview and record review, this requirement was not met when the facility failed to ensure a Licensed Vocational Nurse's (LVN 1's) license was current. This resulted in a potential lapse in administrative oversight of requirements for licensure, and the potential for medical error or harm.A review of the facility's policy titled License Verification dated 2025 indicated, All personnel that require a license or certification shall be verified through the appropriate issuing agency, and, 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. The policy further stated, Any licensed/certified employee is responsible for maintaining continuing education hours as required for current licensure/certification status.A review of the Board of Vocational Nursing and Psychiatric Technicians licensure report for LVN1 indicated that LVN1's Vocational Nursing license was inactive, License is inactive, licensee may not practice in California. The record indicated that the license expires [DATE]; it has not expired, but is not active.In an interview on [DATE] at 11:25 AM, Administrator stated that LVN1's license was inactive as of late August and she was taken off of the working schedule. Administrator confirmed that LVN1's last day of working at the facility was [DATE]. In an interview on [DATE] at 11:45 AM, Director of Nursing (DON) confirmed that LVN 1's license was found to be inactive during a license lookup that was done sometime around [DATE] and that the license became inactive toward the end of August; the license was inactive, and not expired; it does not expire until [DATE]. DON stated , It was on my list, I went to review it and saw it was inactive. [NAME] stated it lapsed at the end of August since she had conducted monthly license lookups for staff. DON stated that she usually reviews licenses at the end of each month and just wasn't on top of it.

Based on observation, interview and record review, the facility failed to update the care plan for three of three residents when:Resident 1's care plan was not updated with a 24 hour 1:1 monitor (where one staff member is assigned to continuously monitor a single resident for behaviors, needs, etc.) and visual checks every 15 minutes at night.Resident 2's care plan did not state an intervention of a 1:1 monitor.Resident 3's care plan did not state an intervention of a 1:1 monitor.This failure had the potential to result in physical and/or psychosocial harm to other residents and staff.During a record review of facility policy titled Care Plan Revisions Upon Status Change dated August 2024, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Facility policy further indicated the care plan will be updated with the new or modified interventions. Facility policy also indicated care plans will be modified as needed by the MDS coordinator or other designated staff member.A record review of Resident 1's admission record indicated she was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, including both high and low periods), schizoaffective disorder (a mental health condition characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like depression or mania), adjustment disorder with mixed anxiety and depressed mood (a mental health condition where an individual experiences an excessive emotional or behavioral reaction to a stressful life event or change), and parkinsonism (symptoms can include tremor, bradykinesia (slowed movement), rigidity (stiffness), and postural instability).During a record review of Progress Notes Situation-Background-Assessment-Recommendation (SBAR - a communication technique used to structure and improve communication, especially in high-[NAME] situations like healthcare) Note for Providers dated 4/22/25 4:40 pm, indicated provider was notified of incident between Resident 1 and another resident. Provider recommended a 1:1 until further notice.During a record review of Interdisciplinary Team (IDT - a group of healthcare professionals who collaborate to develop and implement care plans for residents) Interdisciplinary Post Event Note dated 4/23/25 11:50 am, indicated IDT met and discussed the incident between Resident 1 and another resident on 4/22/25. IDT note further indicated a 1:1 will be in place until behaviors are decreased.During a record review of Resident 1's progress notes 7/31/25 2:29 pm, indicated IDT met to discuss resident. Progress note further indicated Resident 1 placed on visual checks every 15 minutes overnight when she was asleep by staff.During a record review Resident 1's care plan dated 6/25/25, indicated Resident 1 was placed on a 1:1 supervision until behaviors decreased. Care plan further indicated Resident 1's behaviors fluctuated. Care plan also indicated when Resident 1 was not having active behaviors, frequent checks were acceptable. Care plan indicated when Resident 1's behaviors increased, a 1:1 was to be provided. Care plan also indicated 1:1 supervision would continue to be reviewed by the IDT team for the need of a 1:1 vs frequent supervision to avoid distress to the resident and avoid further antagonizing her frustration and behaviors. Care plan did not indicate a 24 hour 1:1 monitor as an intervention for Resident 1. Care plan did not indicate visual checks every 15 minutes as an intervention for Resident 1.A record review of Resident 2's admission record indicated he was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury (a disruption of normal brain function caused by an external force, like a bump, blow, or jolt to the head, or a penetrating head injury), traumatic subdural hemorrhage (a collection of blood between the brain's outer covering (dura mater) and the brain itself, caused by head trauma), and aphasia (a language disorder that affects a person's ability to communicate). During a record review of Resident 2's progress notes dated 7/12/25 11:40 pm, indicated Resident 2 noted with multiple episodes of threatening to kill 1:1 staff. Resident on 1:1 watch due to being a high fall risk.During a record review of Resident 2's progress notes dated 8/4/25 6:52 am, indicated Resident on 1:1 due to increased behaviors; banging head on wall.During a record review of Resident 2's IDT notes dated 7/31/25 9:40 am, indicated Resident has impulsive behaviors related to traumatic brain injury. Resident has behaviors of striking out, becoming easily agitated, and exit seeking. IDT determines that resident remain on 1:1 for this time.During a record review of Resident 2's care plan, there was no documentation of a 1:1 monitor intervention.A record review of Resident 3's admission record indicated he was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels, alternating between periods of mania (or hypomania) and depression), depression (a serious mood disorder that affects how a person feels, thinks, and behaves), and chronic obstructive pulmonary disorder (a group of lung diseases that block airflow and make it difficult to breathe).During a record review of Resident 3's progress notes dated 7/26/25 2:47 pm, indicated Resident 3 was verbally aggressive towards roommate. Resident 3 to be a 1:1 until further notice.During a record review of Resident 3's care plan, there was no documentation of a 1:1 monitor intervention.During an interview with Administrator (Admin) on 8/5/25 at 11:11 am, Admin confirmed all three care plans for Resident 1, Resident 2, and Resident 3 were not updated with appropriate 1:1 monitor interventions per facility policy.During an interview with Director of Nursing (DON) on 8/5/25 at 11:11 am, DON confirmed Resident 1, Resident 2, and Resident 3 all required 1:1 monitoring interventions. DON stated Resident 1 was a 24-hour 1:1 during the day shift and evening shift and needs visual checks every 15 minutes overnight. DON confirmed this was not in Resident 1's care plan. DON stated Resident 2 required a 1:1 sitter. DON confirmed a 1:1 intervention was not in Resident 2's care plan. DON stated Resident 3 required a 1:1 sitter. DON confirmed a 1:1 intervention was not in Resident 3's care plan. DON verified all three residents did not have accurate or updated care plans. DON confirmed their care plans did not follow facility policy and should have.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 2) was protected from physical abuse when Resident 3 hit Resident 2 with a closed fist which resulted in a bruised right eye. This failure caused Resident 2 to feel anger and discomfort, and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: A review of the facility's policy revised 2025, titled, Abuse, Neglect, and Exploitation, indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse included, but is not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. This facility's policy also indicated the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. During a review of Resident 2's medical record, the admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis (MS, a progressive debilitating disease of the nervous system), dehydration (absence of enough water needed in the body), diabetes (too much sugar in the blood), dementia (progressive loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), depression (prolonged feelings of sadness, hopelessness and loss of interests), high blood pressure, heart disease, dysphagia (difficulty swallowing), and the need for personal care and dependence on wheelchair. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 8/4/25, indicated that Resident 2 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). During a review of Resident 2's medical record, a document dated 6/14/25, titled, Progress Note, from a local hospital indicated chief complaint right eye swelling status post assault. Resident stated he was punched once in the eye by a resident at his care facility. During a review of Resident 3's medical record, the admission Record, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular and fast heart beat), heart disease, diabetes (too much sugar in the blood), Bi-polar disorder (mental health condition with severe mood swings), severe protein malnutrition (poor nutrition), chronic gout (a type of inflammatory arthritis caused by too many wastes particle of uric acid), chronic obstructive pulmonary disease (COPD, a chronic and progressive lung disease), depression (prolonged feelings of sadness, hopelessness and loss of interests), high blood pressure, history of venous thrombosis and embolism (a blood clot that travels to the lungs) and osteoarthritis (joint pain and stiffness). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 6/12/25, indicated that Resident 3 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). During an interview on 7/10/25 at 3:20 pm, Resident 2 stated, I was sitting at my doorway, and I asked [Resident 3] to stop talking so loud and to leave the room, he just hit me in the eye. I admit, I probably yelled at him before he hit me because I am hard of hearing (HOH). It just all happened so fast. I did feel discomfort for a few days. During an interview on 7/10/25 at 3:50 pm, Resident 3 stated, Listen, I know it was wrong, I just have a lot of stress on me, it just happened. I never planned to hit [Resident 2]. I just had a reaction to his yelling. I was just trying to talk with my friend that also lives in that room. I told him I was sorry; I never meant to hurt him. During an interview on 7/10/25 at 4:25 pm, Registered Nurse (RN) B stated, I was in another room, and we heard a lot of yelling. I along with other staff went into the room but [Resident 3] had already hit [Resident 2] in the eye. Two men fighting is what happened. We then called 911 and sent [Resident 2] to the hospital to make sure he was okay. During an interview on 7/10/25 at 5:45 pm, the Director of Nursing (DON) confirmed Resident 2 was physically abused by Resident 3. DON stated, [Resident 2] did have a Right black eye for a few days, and I do confirm he stated he was having discomfort. During a phone interview on 7/17/25 at 12:30 pm, the administrator confirmed Resident 3 physically abused Resident 2 when he was hit in the right eye.

Based on interview, and record review, the facility's nursing staff failed to recognize and report a change in condition for one of eight sampled residents (Resident 7). This failure caused Resident 7 to have a delay in acute care treatment required, and the need for new placement after a hospitalization related to the lack of communication when Resident 7 had a change in condition.A review of the facility's policy revised 8/2024, titled, Notification of Changes, indicated the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. During a review of Resident 7's medical record, the admission Record, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular and fast heart beat), aortic valve disorder (a major heart valve that narrows, decreases blood circulation), bilateral pneumonia (infection of both lungs), Bi-polar disorder (mental health condition with severe mood changes), Chronic Obstructive Pulmonary Disease (COPD, a chronic and progressive lung disease), Major depressive disorder (prolonged feelings of sadness, hopelessness and loss of interests), history of sepsis (a severe reaction to an infection), benign prostatic hyperplasia (BPH, enlarged prostate), hyponatremia (low level of sodium in the blood), history of venous thrombosis and embolism (a blood clot that travels to the lungs) and schizophrenia (a condition that has severe effects on your physical and mental well-being. It disrupts how your brain works, interfering with things like your thoughts, memory, senses and behaviors). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 6/17/25, indicated that Resident 7 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). During a review of Resident 7's medical record, a document dated 7/2/25, titled, Blood Pressure Summary, the blood pressure (B/P, measured by two numbers, the top number systolic when your heart beats, and the bottom number diastolic is when your heart rests by Millimeters of Mercury, (mmHg, a unit of measure) normal range for B/P adults are 120/80. Resident 7's B/P was documented at 82/64 mmHg with a note that indicated the following: Systolic low of 90 exceeded. During a review of Resident 7's medical record, a document dated 7/2/25 at 8:07 pm, titled, Progress Note, indicated Resident 7's blood pressure was 82/64 mmHg, and this note did not indicate more than one measurement, or which position Resident 7 was in when taking the B/P. MD orders to push fluids, but no noted documentation to send Resident 7 for an evaluation. This progress note indicated resident was own Responsible Party (RP). During a review of Resident 7's medical record, a document dated 7/2/25 at 11:32 pm, titled, Progress Note, indicated the following: At about 22:25 the cops arrived at facility. The cops went in to see resident. Resident was talking on the phone with daughter at the time the cops arrived. Per resident and daughter's request, resident agreed with his daughter to be sent out to the hospital due to daughter's concern of resident's possible allergic reaction to Buspirone. Resident has NKA and did not show any signs of allergic reactions prior to being discharged . Resident is his own RP. MD notified and aware. During a review of Resident 7's medical record, a document dated 7/2/25 at 11:57 pm, titled, Progress Note, indicated the following: Police officers spoke with resident, and after a half hour, officers inform nurse that resident would like to be sent out to the hospital, per his request (resident full code). Notified MD at 22:51, given okay. Called EMS at 22:51 to request transfer. 2300 EMS arrives to take resident via gurney to hospital. Resident brought along his Continuous Positive Airway Pressure (CPAP, machine), a suitcase, wallet, and a black bag. Resident was on phone with daughter on speaker phone, having EMS repeat conversation having in room. Daughter stated she is recording conversation. Resident stated that he did not want to come back and was informed that a family member may return to pick up the rest of his belongings. EMS left the facility with resident at 23:25. During a concurrent interview and record review on 7/10/25 at 5:25 pm, the Director of Nursing (DON) confirmed the Family Member (FM) should be updated with any change of condition even if they are their own RP by the nursing staff. DON confirmed their facility policy for change of condition was not followed for Resident 7. The DON agreed the FM and Resident 7 were upset and this was avoidable if their policy had been followed. During a follow-up interview on 7/10/25 at 5:40 pm, the DON confirmed Resident 7 had a change of condition with an extremely low blood pressure and should have been sent to the local hospital for an evaluation without the police being called for help on 7/2/25. DON stated, I confirm Resident 7 had a delay in care and should have been sent out to the local hospital earlier. I do confirm Resident 7 was admitted to a local hospital for an extended period, and they were not happy with the care at this facility.

Based on observation, interview, and record review, this facility failed to accommodate the need to communicate with of one (Resident 1) of four sampled residents when the facility failed to provide any means of translation to a Hmong only speaking resident. This failure resulted in Resident 1 not being properly assessed and Resident 1's pain was not treated. Findings: A record review of Resident 1's face sheet indicated an admission date of 4/24/25 for hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (tissue death caused by a lack of blood supply to the affected area) affecting right dominant side, and dysphagia (difficulty swallowing). Resident 1 was her own representative. The only language Resident 1 speaks was Hmong. During an interview on 5/9/25 at 11:10 am of Director of Nursing (DON), DON stated that the facility does not have any way of translating for their non-English speaking residents. By a record review of the Minimum Data Set (MDS) assessment completed on 4/27/25, the Section C - Cognitive Patterns indicated Resident 1 to have a code of 0 (resident is rarely/never understood). By a record review of Care Plans (Undated), indicated Resident 1 had a communication deficit related to language barrier primary language is Hmong Social Services (SS) provided a picture binder for communication. The facility indicated it would provide resident with a communication board. On an interview with family member (FM) 1 on 5/8/25 at 1:10 pm by phone, FM 1 stated the facility has no way of translating and Resident 1 only speaks Hmong. On an interview of family member FM 2 on 5/9/25 at 4:00 pm by phone, FM 2 stated Resident 1 only speaks Hmong and the only way the facility has translated is to ask family members. There was no other means of translation by the facility to Resident 1. During an interview on 5/9/25 at 1:23 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated there is no way to translate or to communicate with Resident 1. The facility does not provide any means of translation or communication. By concurrent observation and interview on 5/9/25 at 1:43 pm with CNA 2, went to Resident 1's room (12-2). CNA 2 confirmed the facility does not have a way to communicate with the resident. CNA 2 confirmed there were no communication boards in drawers and no pictures provided by the facility. Observed no communication boards or pictures in Resident 1's room. During an interview of LN 2 on 6/11/25 at 1:40 pm, asked if LN 2 how she communicated with Hmong only speaking Resident 1? LN 2 stated the facility has no way to translate with Resident 1.

Based on observation, interview, and record review, this facility failed to address and treat the pain of one (Resident 1) of four sampled residents when Resident 1 had an accident in the shower chair, sustained an injury, and complained of pain. This resulted in a complete omission of pain treatment and management and Resident 1 suffering without any pain relief. Findings: A policy titled Pain Management (Undated), indicated that the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan . This policy defines acute pain as pain that is usually sudden onset and time-limited with a duration of less than one month and often is caused by injury . The facility will: 1. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated and evaluate the resident for pain, during ongoing scheduled assessments, and when a significant change in condition occurs. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include facial expressions . A record review of Resident 1's face sheet indicated an admission date of 4/24/25 for hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (tissue death caused by a lack of blood supply to the affected area) affecting right dominant side, and dysphagia (difficulty swallowing). Resident 1 was her own representative. The only language Resident 1 speaks was Hmong. An interview on 5/9/25 at 1:23 pm of Certified Nursing Assistant (CNA) 1, asked what happened with Resident 1 while in the shower chair on 5/6/25? CNA 1 stated Resident 1 is very tiny, and resident was in the shower chair and she slipped down with her rear-end that fell into the hole in the shower chair. Resident 1's right leg got caught in the opening and it cut the top of her right leg at the thigh. CNA 1 stated she went to get Resident 1 out of the hole in the shower chair. CNA 1 stated the Director of Nursing (DON), and Licensed Vocational Nurse (LN) 1 came running into shower room. CNA 1 stated patient said, pain and pointed to the middle of her right thigh. CNA 1 stated Resident 1 had a grimace on her face. By concurrent observation and interview on 5/9/25 at 1:43 pm with CNA 2, went to Resident 1's room (12-2). Observed a long circular scab on Resident 1's right middle thigh (going perpendicular to the leg, going around the front part of leg, mid-thigh) and on the inner thigh, Resident 1 had a scab that went down the leg, parallel to it. CNA 2 stated, Resident 1 did have pain. By concurrent interview and record review of shower sheet dated 5/6/25 at 1:23 pm by CNA 1 did not chart any evidence of the incident. There are no records that indicate an accident on 5/6/25 that occurred with Resident 1 in the electronic medical record. There are no social worker notes, no notes on consulting with the physician, no psycho-social follow up, no care plans, no charting in the system indicating and accident had occurred, or pain was addressed. A record review of the Medication Administration Record (MAR) for 5/1/25 - 5/9/25 indicated Resident 1 was not administered any new pain medication from the incident on 5/6/25, and the MAR indicated Resident 1's pain score was 0 every day. Prior to the accident, Resident 1 had Tylenol ordered, but it was not given to the resident on or after injury. A record review of all active orders for Order Summary Report as of 5/6/25 to 5/9/25 indicated no orders for any physician evaluation of Resident 1 after the accident and sustained injury on 5/6/25. An interview of family member (FM) 1 on 5/8/25 at 1:10 pm by phone call stated Resident 1 did have an accident while in the shower room on 5/6/25. She was told about the incident. FM 1 stated the accident did have something to do with shower chair not fitting Resident 1 and Resident 1 fell in it. FM 1 stated she did hear Resident 1 say the words, pain, pain to staff. FM 1 stated another family member FM 2 was at the facility that day of the accident in the shower chair on 5/6/25. An interview on 5/9/25 at 4:00 pm, called FM 2. FM 2 stated she was in Resident 1's room when the CNA 1 brought Resident 1 back from the shower. CNA 1 reported that Resident 1 had an accident in the shower because her bottom and legs went down into the hole of the shower chair. CNA 1 reported Resident 1 got stuck inside of the hole and the gap in the front of the shower chair. FM 2 stated Resident 1 was complaining about having pain. An interview of Licensed Nurse (LN) 1 on 6/10/25 at 12:20 pm asked if LN 1 remembered the shower chair accident with Resident 1? LN 1 stated LN 1 did come to the shower room on 5/6/25 to assist with Resident 1. LN 1 confirmed there was an accident where the resident was stuck inside the shower chair. Her rear-end went down into the chair and she was twisted and her right leg was sandwiched in the opening in the front of shower chair. LN 1 stated this resident was not her assigned resident that day so she did not chart on it. LN 1 stated she saw an injury to the right middle thigh where resident was stuck in shower chair. LN 1 stated the shower chair had cut the front of Resident 1's right thigh. LN 1 stated Director of Nursing (DON) was aware of incident. An interview of LN 2 on 6/11/25 at 1:40 pm and asked if LN 2 remembered the shower chair accident with Resident 1 on 5/6/25? LN 2 stated LN 2 was the nurse for Resident 1 on this day of 5/6/25. Stated Resident 1 sunk into the shower chair. LN 2 stated staff pulled her out and moved resident onto a different shower chair. LN 2 stated Resident 1's leg was red. LN 2 could not recall any other information. When asked if Resident 1's right middle thigh was bleeding? LN 2 stated, I cannot recall. When asked if LN 2 reported this incident to the physician? LN 2 stated, I cannot recall. When asked if Resident 1's pain was addressed or treated? LN 2 stated, I cannot recall. An interview on 6/11/25 at 2:15 pm with Infection Preventionist (IP), stated he was aware of the accident concerning Resident 1 on 5/6/25. IP stated that this accident and injury was not addressed at all by nursing staff or facility.

Based on observation, interview, and record review, this facility failed to ensure licensed staff the competencies and skill set necessary to provide nursing care for one (Resident 1) of four sampled residents when: Nursing staff did not assess and document when Resident 1 had an accident and sustained an injury. Nursing staff did not complete a change in condition or alert the physician. There was no care plans completed to address the accident and injury Resident 1 had. This resulted in Resident 1 not receiving the treatment and pain relief needed for Resident 1's injury. Findings: A record review of Resident 1's face sheet indicated an admission date of 4/24/25 for hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (tissue death caused by a lack of blood supply to the affected area) affecting right dominant side, and dysphagia (difficulty swallowing). Resident 1 was her own representative. The only language Resident 1 speaks was Hmong. A review of a policy titled, Nursing Assessment Policy (Undated) indicated, Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. A review of a policy titled, Notification of Changes (Undated) indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances that required notification included: accidents resulting in injury. An interview on 5/9/25 at 1:23 pm of Certified Nursing Assistant (CNA) 1, asked what happened with Resident 1 while in the shower chair on 5/6/25? CNA 1 stated Resident 1 is very tiny, and resident was in the shower chair and she slipped down with her rear-end that fell into the hole in the shower chair. Resident 1's right leg got caught in the opening and it cut the top of her right leg at the thigh. CNA 1 stated she went to get Resident 1 out of the hole in the shower chair. CNA 1 stated the Director of Nursing (DON), and Licensed Vocational Nurse (LN) 1 came running in. CNA 1 stated patient said, pain and pointed to the middle of her right thigh. CNA 1 stated Resident 1 had a grimace on her face. A review of a PubMed study cited nonverbal ways to assess pain, Ghayem H, [NAME] MR, Aghaei B, Norouzadeh R. The Effect of Training the Nonverbal Pain Scale (NVPS) on the Ability of Nurses to Monitor the Pain of Patients in the Intensive Care Unit. Indian J Crit Care Med. 2023 Mar;27(3):195-200. doi: 10.5005/jp-journals-10071-24425. PMID: 36960117; PMCID: PMC10028721. The study indicated, Nonverbal pain scale is a combination of behavioral and physiological measurements and provides a more reliable assessment of pain. The study also indicated an example of facial expressions nurses could assess are the following: grimacing, frowning, or other expressions that might indicate pain. A record review of the Medication Administration Record from 5/1/25 through 5/9/25 indicated Resident 1 was not administered any pain medication from the incident on 5/6/25, and indicated Resident 1's pain score was 0 every day. By concurrent interview and record review of shower sheet dated 5/6/25 at 1:23 pm by CNA 1 did not chart any evidence of the incident. By concurrent observation and interview on 5/9/25 at 1:43 pm with CNA 2, went to Resident 1's room (12-2). Observed a long circular scab on Resident 1's right middle thigh (going perpendicular to the leg, going around the front part of leg, mid-thigh) and on the inner thigh, Resident 1 had a scab that went down the leg, parallel to it. CNA 2 stated, Resident 1 did have pain. An interview on 5/9/25 at 11:10 am of the DON, DON stated she was unaware of the accident and the injury of Resident 1 in the shower chair that occurred on 5/6/25. An interview of family member (FM) 1 on 5/8/25 at 1:10 pm by phone call stated Resident 1 did have an accident while in the shower room on 5/6/25. She was told about the incident. FM 1 stated the accident did have something to do with shower chair not fitting Resident 1 and Resident 1 fell in it. FM 1 stated she did hear Resident 1 say the words, pain, pain to staff. FM 1 stated another family member FM 2 was at the facility that day of the accident in the shower chair on 5/6/25. An interview on 5/9/25 at 4:00 pm, called FM 2. FM 2 stated she was in Resident 1's room when the CNA 1 brought Resident 1 back from the shower. CNA 1 reported that Resident 1 had an accident in the shower because her bottom and legs went down into the hole of the shower chair. CNA 1 reported Resident 1 got stuck inside of the hole and the gap in the front of the shower chair. FM 2 stated Resident 1 was complaining about having pain. An interview of Licensed Nurse (LN) 1 on 6/10/25 at 12:20 pm asked if LN 1 remembered the shower chair accident with Resident 1? LN 1 stated LN 1 did come to the shower room on 5/6/25 to assist with Resident 1. LN 1 confirmed there was an accident where the resident was stuck inside the shower chair. Her rear-end went down into the chair and she was twisted and her right leg was sandwiched in the opening in the front of shower chair. LN 1 stated this resident was not her assigned resident that day, so she did not chart on it. LN 1 stated she saw an injury to the right middle thigh where resident was stuck in shower chair. LN 1 stated the shower chair had cut the front of Resident 1's right thigh. LN 1 stated Director of Nursing (DON) was aware of the incident. An interview of LN 2 on 6/11/25 at 1:40 pm and asked if LN 2 remembered the shower chair accident with Resident 1 on 5/6/25? LN 2 stated LN 2 was the nurse for Resident 1 on this day of 5/6/25. Stated Resident 1 sunk into the shower chair. LN 2 stated staff pulled her out and moved resident onto a different shower chair. LN 2 stated Resident 1's leg was red. LN 2 could not recall any other information. When asked if Resident 1's right middle thigh was bleeding? LN 2 stated, I cannot recall. When asked if LN 2 reported this incident to the physician? LN 2 stated, I cannot recall. When asked if Resident 1's pain was addressed or treated? LN 2 stated, I cannot recall. A record review of the Nursing Progress Notes and Alert Charting from 5/5/25-5/8/25, there were no notes or assessments on Resident 1's accident or injury. A record review of the Care Plans (all undated) from admission on [DATE] through day of injury on 5/9/25 for Resident 1, there was no care plan for the accident and injury indicated. A record review of the Minimum Data Set (MDS) assessment completed on 4/27/25, the Section C - Cognitive Patterns indicated Resident 1 to have a code of 0 (resident is rarely/never understood). An interview on 6/11/25 at 2:15 pm with Infection Preventionist (IP), stated he was aware of the accident concerning Resident 1 on 5/6/25. IP stated that this accident and injury was not addressed at all by nursing staff or facility.

Based on interview and record review the facility failed to protect one of two sampled residents (Resident 2) from abuse when Resident 2 was pushed out of her wheelchair to the floor by Resident 1. This failure had the potential to cause physical and psychosocial harm to Resident 2. Findings: A review of the undated facility policy titled Abuse, Neglect and Exploitation indicated It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing, and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility policy indicated, III. Prevention of Abuse, Neglect and Exploitation, D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse practitioner note dated 3/17/25 at 1:33 pm, indicated he had Bipolar II disorder (cycle of mood swings from high to low) continue sertraline (medication for depression). Social Service Assistant notes indicated Resident 1 had four appointments with psychology on 03/17/25, 3/20/25, 3/24/25, and 3/27/25 before transfer to another skilled nursing facility. A review of a Minimum Data Set (MDS, resident assessment) dated 03/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 9 determining moderate cognitive impairment. The Patient Health Questionnaire (PHQ-9, used to screen level of depression indicated Resident 1 was experiencing mild depression. Resident 1 was wheelchair dependent and moderately dependent for support from caregivers to navigate daily activities. A review of Resident 1's progress notes dated 5/20/25 at 1:52 pm, indicated Resident 1 exhibited one episode of aggression toward staff. Resident 1 threatened to kill staff after being wheeled out of the dining room and after choking from eating too fast. A review of Resident 1's progress notes dated 5/20/25 at 3:00 pm, a indicated a change in condition (agitation, psychosis). During morning report, nurse noted that Resident 1 threatened to kill the nurse during medication administration. Resident 1 was uncooperative with increased agitation and behaviors. At approximately 2:40 pm, Resident 1 threw an empty urinal at the Certified Nursing Assistant (CNA) while the CNA was performing resident care. Shortly after at 2:50 pm, Resident 1's nurse was made aware by CNA that Resident 1 was wheeling self-outside hallway naked. A review of Resident 1's progress notes dated 5/21/25 at 3:31 pm, indicated CNA was made aware that resident had one episode of hitting himself with palm of hand on shift. Resident was redirected with small conversation successfully. Resident 1 monitored during shift. A review of Resident 1's progress notes 5/21/25 at 11:15 pm, indicated Resident 1 began making statements of wanting to take his life or wanted his life to end. One statement was hoping that one of his wounds would start bleeding out so much to the point that he would die. Another statement was he was going to bash his head onto the railing in the hallway by the nurse's station until he was no longer alive. He also sat and make motions of slicing his throat open multiple times along with stating he was going to kill himself one way or another once he figured it out. Resident 1 didn't relax or calm down until midnight. The physician was notified at 12:09 am, it was advised a staff member was to ensure their safety and wellbeing, be assigned to closely always watch and stay with Resident 1 (1:1, staff always assigned to monitor). A review of Resident 1's progress notes dated 5/22/25 at 5:22 pm, indicated at 3:20 pm, Resident 1 was in hallway in his wheelchair near the breakroom/hallway. Resident 2 was in vicinity of Resident 1. Resident 1 approached Resident 2 yelled get out of my way then shoved her out of her wheelchair and on to the floor. While under continuous 1:1 monitoring, Resident 1 was still able to initiate an altercation with Resident 2. A review of Resident 2's record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke, manic depression and Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). A review of a MDS dated 03/2025, indicated Resident 2 had a (BIMS) score of 3 (severe cognitive impairment). Resident 2 was wheelchair dependent and significantly dependent for support from caregivers to navigate daily activities. A review of Interdisciplinary Team (IDT, is a group of professionals from different specialties who work together to plan and provide coordinated care for a resident) records dated 5/28/25 at 9:32 am, indicated they did not meet to discuss the resident-to-resident altercation until six days after the event. The IDT note indicated Resident will remain on 1:1 monitoring and will be reevaluated in one week. During a concurrent interview and record review on 6/4/265 at 1:05 pm, the Director of Nursing (DON) confirmed the admission team did not identify that Resident 1 had Bipolar II disorder or that he was participating in psychology visits at the other facility. DON was not aware that his MDS PHQ-9 indicated Resident 1 was mildly depressed upon admission. DON confirmed there were no behavioral health care plans in his record, nor were there any mental health appointments provided to Resident 1 at the facility since admission.

Based on interview and record review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR, evaluation for serious mental illness and intellectual disability,) for one of two sampled residents (Resident 1) during an admission from another Skilled Nursing Facility. This failure had the potential for Resident 1 not to receive a plan of care to meet his behavioral and mental health needs. Findings: An undated copy of the facility policy titled, Resident Assessment – Coordination with PASRR Program indicated, This facility coordinates assessments with the readmission screening and resident review (P ASARR) program under Medicaid to ensure that individuals with a mental disorder intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Recommendations, such as any specialized services, from a P ASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse practitioner note dated 3/17/25 at 1:33 pm, indicated he had Bipolar II disorder (cycle of mood swings from high to low) continue sertraline (medication for depression). Social Service Assistant notes indicated Resident 1 had four appointments with psychology on 03/17/25, 3/20/25, 3/24/25, and 3/27/25 before transfer to another Skilled Nursing Facility (SNF). A review of a Minimum Data Set (MDS, resident assessment) dated 03/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 9 determining moderate cognitive impairment. The Patient Health Questionnaire (PHQ-9, used to screen level of depression indicated Resident 1 was experiencing mild depression. Resident 1 was wheelchair dependent and moderately dependent for support from caregivers to navigate daily activities. A review of Resident 1's PASRR dated 11/4/24 done at the previous SNF admission, indicated under Section Ill - Serious Mental Illness, question number 9 Diagnosed Serious Mental Illness, was answered no, question number 10 Suspected Mental Illness was answered no, and question number 11 Psychotropic Medication was answered no. A review of Resident 1's record indicated when he was transferred/admitted to the current SNF on 3/31/25, the facility staff did not validate or reassess his PASRR done on 11/4/24. During a concurrent interview and record review on 6/4/265 at 1:05 pm, with the Director of Nursing (DON) confirmed the admission team did not reassess Resident 1's PASRR upon admission to this facility. DON confirmed the PASRR dated 11/4/24 was not accurate related to Resident 1's depression, Bipolar II, and use of sertraline (psychotropic medication for depression) and no behavioral health care plan in his record. During a phone interview 6/5/25 at 11:00 am with Social [NAME] Director (SSD) who was involved in the PASRR screenings for new admits stated We were told we did not have to repeat it. SSD stated they did not validate the accuracy of the PASRR dated 11/11/24, that was received from prior SNF.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had a comprehensive care plan that was person-centered to meet his mental health needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation. Findings: A review of the undated facility policy titled Comprehensive Care Plans indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse practitioner note dated 3/17/25 at 1:33 pm, indicated he had Bipolar II disorder (cycle of mood swings from high to low) continue sertraline (medication for depression). Social Service Assistant notes indicated Resident 1 had four appointments with psychology on 03/17/25, 3/20/25, 3/24/25, and 3/27/25 before transfer to another skilled nursing facility. A review of a Minimum Data Set (MDS, resident assessment) dated 03/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 9 determining moderate cognitive impairment. The Patient Health Questionnaire (PHQ-9, used to screen level of depression indicated Resident 1 was experiencing mild depression. Resident 1 was wheelchair dependent and moderately dependent for support from caregivers to navigate daily activities. A review of Resident 1's progress notes dated 5/20/25 at 1:52 pm, indicated Resident 1 exhibited one episode of aggression toward staff. Resident 1 threatened to kill staff after being wheeled out of the dining room and after choking from eating too fast. A review of Resident 1's progress notes dated 5/20/25 at 3:00 pm, a indicated a change in condition (agitation, psychosis). During morning report, nurse noted that Resident 1 threatened to kill the nurse during medication administration. Resident 1 was uncooperative with increased agitation and behaviors. At approximately 2:40 pm, Resident 1 threw an empty urinal at the Certified Nursing Assistant (CNA) while the CNA was performing resident care. Shortly after at 2:50 pm, Resident 1's nurse was made aware by CNA that Resident 1 was wheeling self-outside hallway naked. A review of Resident 1's progress notes dated 5/21/25 at 3:31 pm, indicated CNA was made aware that resident had one episode of hitting himself with palm of hand on shift. Resident was redirected with small conversation successfully. Resident 1 monitored during shift. A review of Resident 1's progress notes 5/21/25 at 11:15 pm, indicated Resident 1 began making statements of wanting to take his life or wanted his life to end. One statement was hoping that one of his wounds would start bleeding out so much to the point that he would die. Another statement was he was going to bash his head onto the railing in the hallway by the nurse's station until he was no longer alive. He also sat and make motions of slicing his throat open multiple times along with stating he was going to kill himself one way or another once he figured it out. Resident 1 didn't relax or calm down until midnight. The physician was notified at 12:09 am, it was advised a staff member was to ensure their safety and wellbeing, be assigned to closely always watch and stay with Resident 1 (1:1, staff always assigned to monitor). A review of Resident 1's progress notes dated 5/22/25 at 5:22 pm, indicated at 3:20 pm, Resident 1 was in hallway in his wheelchair near the breakroom/hallway. Resident 2 was in vicinity of Resident 1. Resident 1 approached Resident 2 yelled get out of my way then shoved her out of her wheelchair and on to the floor. While under continuous 1:1 monitoring, Resident 1 was still able to initiate an altercation with Resident 2. A review of Social Services note dated 5/21/25 at 8:29 am, indicated Social Services Director (SSD), met with Resident 1 who was resting in bed, calm and social. SSD asked Resident 1 if he wanted to talk about incident and resident replied no not at this time. Resident 1 was placed on 1:1 intervention for 72 hours. A review of Resident 1's progress notes dated 5/22/25 at 5:22 pm, indicated at 3:20 pm, Resident 1 was in hallway in his wheelchair near the breakroom/hallway. Resident 2 was in vicinity of Resident 1. Resident 1 approached Resident 2 yelled get out of my way then shoved her out of her wheelchair and on to the floor. While under continuous 1:1 monitoring, Resident 1 was still able to initiate an altercation with Resident 2. During a phone interview 6/25/25 at 11:00 am, SSD explained she participates in creating care plans for residents along with nursing and Interdisciplinary Team (multiple disciplines who evaluate and develop care plans for residents). SSD confirmed she uses all progress notes in the record and was behind on developing resident plan of care. SSD confirmed Resident 1 did not have a care plan that addressed his behavioral health needs. During a concurrent interview and record review and interview on 6/4/265 at 1:05 pm, the Director of Nursing (DON) confirmed the admission team did not identify that Resident 1 had Bipolar II disorder or that he was participating in psychology visits at the other facility. DON was not aware that his MDS PHQ-9 indicated Resident 1 was mildly depressed upon admission. DON confirmed there were no behavioral health care plans in his record, nor were there any mental health appointments provided to Resident 1 at the facility since admission.

Based on interview and record review the facility failed to ensure Resident 1 had a behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation. Findings: A review of Resident 1's record indicated he was transferred from a skilled nursing facility and admitted to the new facility on 3/31/25 with diagnoses which included stroke affecting right dominant side and depression unspecified. A review of Resident 1's transfer record included a nurse practitioner note dated 3/17/25 at 1:33 pm, indicated he had Bipolar II disorder (cycle of mood swings from high to low) continue sertraline (medication for depression). Social Service Assistant notes indicated Resident 1 had four appointments with psychology on 03/17/25, 3/20/25, 3/24/25, and 3/27/25 before transfer to another skilled nursing facility. A review of Resident 1's PASRR dated 11/4/24 done at the previous SNF admission, indicated under Section Ill - Serious Mental Illness, question number 9 Diagnosed Serious Mental Illness, was answered no, question number 10 Suspected Mental Illness was answered no, and question number 11 Psychotropic Medication was answered no. A review of Resident 1's record indicated when he was transferred/admitted to the current SNF on 3/31/25, the facility staff did not validate or reassess his PASRR done on 11/4/24. A review of a Minimum Data Set (MDS, resident assessment) dated 03/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, cognitive screening tool) and scored 9 determining moderate cognitive impairment. The Patient Health Questionnaire (PHQ-9, used to screen level of depression indicated Resident 1 was experiencing mild depression. Resident 1 was wheelchair dependent and moderately dependent for support from caregivers to navigate daily activities. A review of Resident 1's progress notes indicated 5/20/25 at 1:52 pm, Resident 1 exhibited one episode of aggression toward staff. Resident 1 threatened to kill staff after being wheeled out of the dining room and after choking from eating too fast. A review of Resident 1's progress notes dated 5/20/25 at 3:00 pm, a indicated a change in condition (agitation, psychosis). During morning report, nurse noted that Resident 1 threatened to kill the nurse during medication administration. Resident 1 was uncooperative with increased agitation and behaviors. At approximately 2:40 pm, Resident 1 threw an empty urinal at the Certified Nursing Assistant (CNA) while the CNA was performing resident care. Shortly after at 2:50 pm, Resident 1's nurse was made aware by CNA that Resident 1 was wheeling self-outside hallway naked. A review of Resident 1's progress notes dated 5/21/25 at 3:31 pm, indicated CNA was made aware that resident had one episode of hitting himself with palm of hand on shift. Resident 1 was redirected with small conversation successfully. Resident 1 monitored during shift. A review of Resident 1's progress notes 5/21/25 at 11:15 pm, indicated Resident 1 began making statements of wanting to take his life or wanted his life to end. One statement was hoping that one of his wounds would start bleeding out so much to the point that he would die. Another statement was he was going to bash his head onto the railing in the hallway by the nurse's station until he was no longer alive. He also sat and make motions of slicing his throat open multiple times along with stating he was going to kill himself one way or another once he figured it out. Resident 1 didn't relax or calm down until midnight. The physician was notified at 12:09 am, it was advised a staff member was to ensure their safety and wellbeing, be assigned to closely always watch and stay with Resident 1 (1:1, staff always assigned to monitor). A review of Resident 1's progress notes dated 5/22/25 at 5:22 pm, indicated at 3:20 pm, Resident 1 was in hallway in his wheelchair near the breakroom/hallway. Resident 2 was in vicinity of Resident 1. Resident 1 approached Resident 2 yelled get out of my way then shoved her out of her wheelchair and on to the floor. While under continuous 1:1 monitoring, Resident 1 was still able to initiate an altercation with Resident 2. A review of Social Services note dated 5/21/25 at 08:29 am indicated, Social Services Director (SSD) met with resident who was resting in bed, calm and social. SSD asked Resident if he wanted to talk about incident and resident replied no not at this time. Resident 1 was placed on 1 to 1 intervention for 72 hours. A review of Resident 1's progress notes indicated 5/22/25 at 5:22 pm, approximately 3:20 pm, resident was in hallway in wheelchair near breakroom/laundry room. Resident 2 was in vicinity of Resident 1. Resident 1 approached Resident 2, he yelled get out of my way then proceeded to shoved her out of her wheelchair and on to the floor. Residents were immediately separated by staff. Resident 1 then wheeled himself over to the handrail and began to repeatedly bang his head against it. Resident 1 was pulled away from the railing and Resident 1 stated call the police, I don't care. The nurse stayed with Resident 1 and took him to the end of the hallway to attempt to deescalate the situation. The nurse got on the phone with the physician who gave the order to send Resident 1 to the hospital for psychiatric evaluation. The nurse called 911. Resident 1 again wheeled up to the handrail and started banging his head repeatedly. Emergency Medical Team (EMT) and policy arrived at the facility. The Police advised EMT to place Resident 1 on a 72-hour hold at the hospital. During a concurrent interview and record review and interview on 6/4/265 at 1:05 pm, the Director of Nursing (DON) confirmed the admission team did not identify that Resident 1 had Bipolar II disorder or that he was participating in psychology visits at the other facility. DON was not aware that his MDS PHQ-9 indicated Resident 1 was mildly depressed upon admission. DON confirmed there were no behavioral health care plans in his record, nor were there any mental health appointments provided to Resident 1 at the facility since admission. During a phone interview 6/5/25 at 11:00 am with Social [NAME] Director (SSD) who was involved in the PASRR screenings for new admits stated We were told we did not have to repeat it. SSD stated they did not validate the accuracy of the PASRR dated 11/11/24, that was received from prior SNF. When asked if Resident 1 had seen psychology since he has been there? SSD stated, he was offered a psych appointment but can't find date.

Based on interview and record review, the facility failed to inform the conservator (an individual appointed by a court to oversee the mental health care of an individual with a serious mental illness who is unable to make decisions themselves) of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers in advance of a medication change for one of two sampled residents (Resident 1). Resident 1 was receiving Clozapine (medication used to treat severely ill patients with Schizophrenia who have used other medicines that did not work well) for her diagnosed Schizophrenia (a chronic mental health disorder characterized by a disconnection from reality) prior to her admission to the facility and upon admission to the facility on 7/22/2024, and it was placed on hold for an unknown reason from 8/3/2024 until discharge from facility on 10/25/2024, without conservator knowledge. This deficient practice caused a decline in Resident 1's mental health status and resulted in a hospital readmission for treatment of her Schizophrenia. Findings: A review of a facility policy titled, Resident Representative, with a revised date of February 2021, indicated, The facility treats the decisions of the resident representative as the decisions of the resident . to the extent required by the court . If the resident is determined to be incompetent . the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident ' s behalf. This document indicated that a resident representative can be defined as a court-appointed guardian or conservator of the resident. The facility will treat the decisions of a resident representative as the decisions of the resident . A review of a facility policy titled, Use of Psychotropic Medication(s), with no revised date, indicated, The indications for initiating, maintaining, or discontinuing medication(s) . will be determined by evaluating the resident . including the assessment of relative benefits and risks, and the preferences and goals for treatment. This document further indicated, The resident ' s medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication . Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication . in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care . and the preferred option to accept or decline . A review of the facility ' s records indicated Resident 1 was admitted to the facility on [DATE] and discharged to the acute care hospital on [DATE]. Resident 1 had diagnoses that included Schizophrenia, dysphagia (difficulty swallowing) and sepsis (life threatening medical emergency when a body ' s response to an infection harms its own tissues and organs). Resident 1 had a conservator contact on file indicated as their Responsible Party to make decisions. A review of a document titled, Informed consent, indicated that Resident 1 had signed an informed consent form on 9/3/2024 for Paliperidone 1.5 mg daily (an antipsychotic medication used to help treat schizophrenia). This form was signed by a licensed staff member and the Medical Physician; however, it was not signed by the resident ' s responsible party. A review of the facility ' s progress note dated 10/18/2024 at 1:01 PM by Licensed Vocational Nurse (LVN1), indicated, Nursing observations, evaluation, and recommendation are: on 10/18/24. After reviewing medications, it was determined that resident should be taking Clozapine, MD (Medical Physician) made aware due to unable to be prescribed by MD he gave new order to transfer to acute. RP aware. A review of the facility ' s Medication Administration Record (MAR), indicated that Clozapine Oral Tablet 100 mg for Schizophrenia had a start date at the facility for 7/22/2024, a hold date on 8/3/2024 and an eventual discontinuation date on 10/4/2024. Paliperidone Extended Release Oral Tablet 1.5 mg for Schizophrenia had a start date on 7/23/2024 until Resident 1 discharged from the facility. During an interview on 5/14/2025 at 4:50 PM with Behavioral Health (BH1), stated, Resident 1 had to get hospitalized due to psychiatric medications being changed without her conservator ' s permission, causing deterioration in her health. BH1 further stated that Resident 1 was on a [NAME]-Petris-Short (LPS) Conservatorship (a legal arrangement where a court appoints a conservator to be responsible for the comprehensive medical treatment of an adult who has a serious mental illness and is deemed gravely disabled. The appointed conservator has the legal authority to make decisions regarding the resident ' s mental health treatment, including consenting to medication. The conservator has the authority to ensure they receive mandatory medication). During an interview on 5/28/2025 at 9:24 AM with LVN1, stated Resident 1 did need the medication Clozapine and since the medical physician was unable to prescribe it, Resident 1 was transferred to acute care. LVN1 stated he was unsure of why the physician could not prescribe the medication. During an interview on 5/28/2025 at 9:40 AM with BH2, stated Resident 1 was LPS conserved which meant that medication can be forced if need be in an appropriate manner. BH2 stated that the facility changed Resident 1 ' s medication without consent from the conservator and discontinued her medication without the conservator ' s knowledge, and they should have been contacted. They didn ' t notify us they changed her medication. We don ' t know why they put the medication on hold, you can ' t just stop that medication they completely decompensate. She just got worse and worse. BH2 stated the conservator was never consulted until Resident 1 was already decompensated, and she had been on these medications for a long period of time given that she had been under a conservatorship for about 20 years. I think they didn ' t follow protocol. Maybe they felt they got consent from her, but they needed it from the conservator who should have been called and informed each time Resident 1 had refused medications. BH2 stated the conservator must consent to medication changes; however, no consent was given to the doctor to pull Resident 1 off of her medications or change her medications. They need to have a consequence for doing this, so they don ' t do it again. During an interview on 5/28/2025 at 10:37 AM with Administrator, stated, there is only an informed consent form for Paliperidone and not one for Clozapine for Resident 1. During an interview on 6/4/2025 at 3:57 PM with Administrator, confirmed that there was no further documentation that would have indicated why Resident 1 ' s Clozapine was held by the Medical Physician.

Based on observation, interview and record review, the facility failed to update the care plan with a 1:1 monitor (where one staff member is assigned to continuously monitor a single resident for behaviors, needs, etc) for one of four residents (Resident 1) when Resident 1 walked past Resident 2 and hit him in the back of his head. This failure had the potential to result in physical and/or psychosocial harm to other residents. Findings: A record review of facility policy titled Care Plan Revisions Upon Status Change copyright 2024 indicated the care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Facility policy further indicated the Interdisciplinary Team (IDT - a group of facility healthcare professionals who collaborate to provide comprehensive care to residents) will discuss the resident condition and collaborate on intervention options and the care plan will be updated with the new or modified interventions. A record review of Resident 1's Admission Record indicated she was readmitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, including both high and low periods), schizoaffective disorder (a mental health condition characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like depression or mania), adjustment disorder with mixed anxiety and depressed mood (a mental health condition where an individual experiences an excessive emotional or behavioral reaction to a stressful life event or change), and parkinsonism (symptoms can include tremor, bradykinesia (slowed movement), rigidity (stiffness), and postural instability). During a record review of Progress Notes SBAR Note for Providers dated 4/22/25 4:40 pm, indicated provider was notified of incident between Resident 1 and Resident 2. Provider recommended a 1:1 until further notice. During a record review of IDT - Interdisciplinary Post Event Note dated 4/23/25 11:50 am, indicated IDT team met and discussed the incident between Resident 1 and Resident 2 on 4/22/25. IDT note further indicated a 1:1 will be in place until behaviors are decreased. A record review of Resident 1's Care Plan dated 1/31/25 indicated Resident 1 had a history of being the aggressor in resident-to-resident altercations. Care plan further indicated interventions included allow Resident 1 to express concerns, approach Resident 1 in a calm manner, do not argue with Resident 1, attempt to de-escalate, and psychiatry consultation as needed. Care plan did not indicate a 1:1 monitor as an intervention for Resident 1. During a concurrent observation and interview with Certified Nursing Assistant (CNA) A on 4/23/25 at 11:07 am, CNA A stated she was designated to sit outside of Resident 1's room as her 1:1 monitor after incident between Resident 1 and Resident 2 on 4/22/25. CNA A stated Resident 1 had a history of aggressive behaviors towards other residents. Observed Resident 1 resting on her side in her bed. CNA A stated she did not read or verify interventions in Resident 1's care plan. During an interview with Director of Nursing (DON) on 4/23/25 at 11:36 am, DON stated Resident 1's 1:1 monitor should have been updated in her care plan during the IDT meeting that occurred on 4/23/25 in the morning. DON stated the 1:1 monitor intervention should have been in Resident 1's care plans each time Resident 1 had an aggressive event with another resident. DON confirmed facility should have updated Resident 1's care plan to reflect 1:1 monitor intervention as current plan of care. DON confirmed facility did not update Resident 1's care plan per facility policy and expectation.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1a. Certified Nurse Assistant (CNA) I wore the same isolation gown (worn over clothing and used to prevent the spread of infection) while providing care to Resident 24 (who was diagnosed with Clostridium difficile, C-diff, a bacterium that caused diarrhea, was spread from person to person by direct contact, could cause serious illness, hospitalization , or even death) and Resident 23 (who was not diagnosed with C-diff); and 1b. There was no dedicated cleaning equipment for Resident 24's bathroom; and 2. The nurse's station counter was chipped and not able to be disinfected. These failures had the potential to spread infection. Findings: 1a. A review of the facility's undated policy and procedure (P&P) titled, Management of C. Difficile Infection, indicated, the use of isolation gowns would be used as a method to prevent the spread of C-diff. A review of the Admission Record, dated 7/9/24, indicated, Resident 23 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (a disease that affected the lungs and caused breathing problems). A review of the Admission Record, dated, 8/23/21, indicated, Resident 24 was admitted to the facility on [DATE] with the diagnoses of difficulty in walking and need for assistance with personal care. A review of the Client Report, dated 2/23/25, indicated, Resident 24 tested positive for C-Diff. During a concurrent observation and interview on 3/18/25 at 12:33 pm, CNA I was observed putting on an isolation gown at the doorway of room [ROOM NUMBER]. CNA I took Resident 24 his lunch tray and was observed leaning against Resident 24's bed and the isolation gown was touching the bed. CNA I walked to the door, changed her gloves and was provided Resident 23's lunch tray. CNA I was observed leaning against Resident 23's bed wearing the same isolation gown. CNA I confirmed the observation and stated, [Resident 24] has C-diff and Resident 23 did not have C-diff. I leaned against [Resident 23 and 24's] bed, didn't change gowns (in-between resident care), and should have. During a concurrent interview and record review on 3/20/25 8:26 am, with the Infection Preventionist (IP), the line listing (list of residents with infections) dated March 2025, was reviewed. IP stated, the line listing indicated, [Resident 24] was diagnosed with C-diff and placed on contact isolation and Resident 23 did not have a diagnosis of C-Diff. IP stated, when facility staff provided care to Residents 23 and 24, they were expected to change their isolation gowns in-between resident care. During an interview on 3/21/25 at 10:19 am, Director of Staff Development (DSD) was described the observation made and confirmed, CNA I should have changed the isolation gown in-between care that was provided to Resident 23 and 24 and stated, there was a potential for cross contamination. 1b. A review of the facility's undated policy and procedure (P&P) titled, Management of C. Difficile Infection, indicated, Use disposable equipment whenever possible. During a concurrent observation and interview on 3/19/25 at 2:28 pm, Maintenance Director (MTD) observed Resident 24's bathroom and stated, when a resident was diagnosed with C-diff, a toilet bowl scrubber and plunger would be dedicated to that bathroom only. MTD confirmed there was not a toilet bowl scrubber present in Resident 24's bathroom and stated, there should be. MTD confirmed, the purpose of using a dedicated toilet bowl scrubber was to reduce the potential for spread of infection. During an interview on 3/20/25 at 11:47 am, Housekeeping (HSK) E and H stated, they were unaware C-diff bathrooms required its own toilet bowl scrubber, and confirmed, the toilet bowl scrubber stored on the housekeeping cart was utilized to clean all resident toilets. 43755 2. A review of the facility's policy titled Routine Cleaning and Disinfection (undated), indicated It is the policy of this facility to ensure the provision of routine cleaning and disinfection (the process of cleaning something, especially with a chemical, in order to destroy bacteria [microorganisms, germs]) in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. During an observation on 3/19/25 at 9:07 am, one of one nursing station was observed. The countertop had many areas of chipped plastic laminate (a countertop covering used to create a durable surface that is moisture resistant and able to be cleaned and disinfected). The 16 feet of countertop edge was missing 13.5 feet of plastic laminate trim which caused porous (something that is full of tiny holes or openings which has a great ability to hold fluid i.e. [for example] sponges, wood, rubber . where microorganisms can grow) wood to be exposed. The top of the counter also had many chips in the plastic laminate. During a concurrent observation and interview with Housekeeper (HSK) on 3/19/25 at 9:15 am, the nursing station countertop was observed. HSK stated I did not know it was that bad, (it is) not able to(be) disinfected. HSK indicated the chipped areas should be fixed. During a concurrent observation and interview with the Infection Preventionist (IP) on 3/19/25 at 9:43 am, the nursing station countertop was observed. IP indicated that the chipped areas of the countertop could not be disinfected, and they should be able to be disinfected.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a system was implemented to alert staff when residents exited the building onto the outside resident patio area. This affected 1 (Resident #26) of 3 sampled residents reviewed for accident hazards. On 09/20/2023 at approximately 3:00 AM, Resident #26 exited the facility without staff's knowledge and sustained a fall. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J. The IJ began on 09/20/2023 at approximately 3:00 AM when Resident #26 exited the facility without staff's knowledge and sustained a fall. The Administrator and Clinical Resource Nurse were notified of the IJ and provided a copy of the IJ template on 01/08/2024 at 1:40 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/09/2024 at 12:24 PM. The IJ was removed on 01/10/2024 at 12:01 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings included: A review of Resident #26's Admission Record revealed the facility originally admitted the resident on 05/19/2023 and readmitted the resident on 10/30/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left dominate side, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, bipolar disorder, end stage renal disease, and history of falling. A review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. According to the MDS, Resident #26 required supervision and one-person physical assistance with walking in their room or corridor and was independent with set-up help only for locomotion on and off the unit. The MDS indicated the resident was not steady but able to stabilize without staff assistance when walking and used mobility devices, including a walker and wheelchair. A review of Resident #26's comprehensive care plan revealed a Focus area, initiated on 05/20/2023, that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to a recent stroke with resulting left sided weakness, chronic kidney disease requiring hemodialysis, a history of falls, and side effects from medications. Interventions dated 07/21/2023 indicated the resident was not steady during transitions/walking, required limited assistance with one-person physical assistance for locomotion on and off the unit, and used a wheelchair and walker. Another Focus area, initiated on 05/20/2023, indicated the resident was at risk for falls related to gait/balance problems, dizziness, and cannabis use. A Focus area, initiated on 07/21/2023, indicated the resident had an inability to achieve restful sleep. A review of Resident #26's Progress Notes revealed an Alert Note, dated 09/20/2023 at 3:00 AM, that indicated the resident was found sitting on a brick wall in front of the facility. The resident reported they had gone for a walk, got too far, and fell , hitting their left knee on the ground. The resident complained of pain to their left knee and said they did not realize what time it was. Nursing staff assisted the resident back to their room and performed a skin assessment that revealed the resident had sustained an abrasion to their left kneecap that was approximately 1 inch by 1 and 1/2 inch with a small amount of blood. A review of an IDT [interdisciplinary team] - Interdisciplinary Post Event Note, dated 09/20/2023, revealed the resident reported they were having trouble sleeping and went outside for fresh air. The resident further stated they were wearing slippers and tripped and landed on their left knee. The Factors Relating to Recent Event were listed as unstable gait, disturbed sleep pattern, improper footwear/devices, and poor safety awareness. A review of Resident #26's comprehensive care plan revealed a Focus area was initiated on 09/20/2023 related to an unwitnessed fall in which the resident sustained an abrasion to the left knee and complained of pain. However, the resident's comprehensive care plan did not address the resident exiting the facility without staff's knowledge. During an interview on 01/06/2024 at 2:37 PM, Resident #26 stated on 09/20/2023 they were in the parking lot approximately 10-15 minutes before staff came outside and found the resident. Resident #26 stated the resident walked around from the back of the facility to the front of the building and fell on the curb. Resident #26 stated the resident did not think to tell anyone before going outside. During a follow-up interview on 01/07/2024 at 9:21 AM, Resident #26 stated on 09/20/2023 when they fell outside, the resident went out the back door without using their wheelchair. During another follow-up interview on 01/10/2024 at 4:30 PM, Resident #26 stated on 09/20/2023, the resident went out the back gate and walked around to the front of the building, where they tripped over the curb. On 01/10/2024 at 7:55 AM, the surveyor walked the path the resident described taking. The surveyor took approximately 250 steps and estimated approximately one-tenth of a mile. On 01/10/2024 at 4:31 PM, the Maintenance Supervisor measured off the approximate distance the resident traveled. It was estimated the resident traveled approximately one-tenth of a mile from the back of the facility to the front of the facility where staff found the resident. During an interview on 01/06/2024 at 7:13 PM, Certified Nursing Assistant (CNA) #14 stated she got off work at 3:00 AM on 09/20/2023, and as one of her coworkers was walking her out to the car, they saw Resident #26 in the parking lot sitting on the concrete blocks or the curb in front of the facility. She stated the resident had a tendency of taking walks, and for this incident, no one knew the resident had gone outside. CNA #14 stated there were no alarms on the doors to alert staff when one was opened. During an interview on 01/06/2024 at 9:12 PM, CNA #16 stated on 09/20/2023 staff found Resident #26 sitting outside on a little brick wall in front of the parking lot. She stated the resident was out of breath, very tired, and had scraped their knee by the time staff found them. CNA #16 said the resident reported they exited out the back of the facility and ended up in the front of the facility. CNA #16 said she did not know the resident had gone outside. CNA #16 further stated there were no alarms on the doors exiting the facility that would alert staff if one was opened, and some of the doors were sliding doors that were easy to unlock and open, allowing residents to go outside at any time. During an interview on 01/07/2024 at 1:22 AM, Licensed Vocational Nurse (LVN) #6 stated on 09/20/2023, no one knew Resident #26 had gone outside. She stated the staff had not seen or heard any of the doors open or close in the hallway. She further stated at one time the doors were equipped with alarms to alert staff when they were opened, but they were not anymore. LVN #6 was unsure at what point the doors were no longer equipped with alarms. During an interview on 01/07/2024 at 8:59 AM, the Interim Director of Nursing (IDON) stated the facility's main doors had not been equipped with alarms in years; a previous administrator took them off. During a follow-up interview on 01/10/2024 at 10:36 AM, the IDON said it was not safe for Resident #26 to be outside at 3:00 AM without staff's knowledge. During an interview on 01/10/2024 at 11:45 AM, the Administrator stated it was unsafe when Resident #26 was outside at 3:00 AM without staff's knowledge. The Administrator said staff should have known the resident was outside, either by way of the resident informing them or by knowing where the residents were in general. During an interview on 01/06/2024 at 5:15 PM, the Administrator stated the facility did not have a policy related to residents going outside. The Administrator said staff knew which residents liked to go outside, and if staff were unable to locate a resident, staff checked the outside resident patio and walkways, because residents could go out the side doors that lead to the gated resident patio area. On 01/09/2024 at 12:24 PM, a Removal Plan was submitted by the facility and accepted by the State Survey Agency. It read as follows: Immediate Action: 1. The facility immediately assigned a dedicated staff member on January 8th, 2024 at approximately 1:45 PM to complete facility rounds every 30 minutes for all shifts to ensure residents were not outside unknowingly until door alarms were placed. This process was documented on the form Q [every] 30 Minute Monitor Sheet - Resident Safety Log, signed by the facility staff responsible for the checks and Administrator review and attestation of information being correct and accurate. The documentation will be retained for facility accessibility in the shared OneDrive > Clinical file by month, at the end of every month. 2. An inservice to one RN, two LVNs, twelve CNAs was immediately initiated and documented on the Feather River All Staff Inservice sheet by MDS/LVN on January 8, 2024, to properly educate them on the process put in place to have Q-30 minute facility rounds completed for all shifts until door alarms have been received, installed and in functioning order. When the alarms were confirmed to be installed and in working order on all doors, the Q-30 minute checks were discontinued. If door alarms are never [sic, ever not] in working order the Q-30 minute checks will be reimplemented until the facility can reinstall all alarms for all doors out of the facility. The inservice also included educating the staff on alerting to the sounding alarms when placed. This process of inservice will continue by MDS LVN and/or designee to be completed for all shifts to ensure that all staff have been educated by January 9, 2024. Staff that are on call and unavailable to come in, or on leave will be inserviced by DSD [Director of Staff Development] or designee upon return to the facility prior their first shift. Administrator and/or designee will be responsible to ensure this process continues to be in place and properly documented while in place. 3. Door alarms were immediately purchased on January 8, 2024, by the Maintenance Director and confirmed at 3:56 PM to be installed and in proper functioning order by clinical resource RN, CDM [Certified Dietary Manager], AD [Activities Director], and DES [Director of Environmental Services]. Facility rounds discontinued due to alarms in place after 4:00 PM Q-30 check was completed to ensure resident safety. 4. Angel Rounds will be completed by Department Managers no less than 3x [times] a week to ensure that all door alarms are in place and in proper functioning order and doors are locked as necessary and/or required. IDT members during Angel Rounds will also conduct a staff response to alarm sounds and provide tracking for review at QAPI [Quality Assurance Performance Improvement] committee meeting to identify and track any issues with alarms or response to doors opening. Any issues identified will be immediately brought forth and resolved to ensure continued resident safety. 6. [sic, no 5. included] Elopement Risk Assessment for Resident #26 was completed by LVN on 10/30/2023 with a score of 0.0. Social Service Director completed a new Elopement Risk Assessment for Resident #26 on January 8, 2024, with a score of 10 which places [him/her] into a High Risk in the elopement risk category. 7. Resident #26 has a Care Plan that was initiated on 05/23/2023 to indicate that resident enjoys strolling out of [his/her] slider door to get fresh air and leisure strolls around the outside of the facility. Care Plan was updated on 01/08/2024 @ [at] 6:40 PM that indicates resident has been provided with education regarding the expectations to inform staff when [he/she] has a desire to go outdoors, the alarms placed at exit doors including the resident's slider to alert staff when resident opens the sliding door, increase supervision, allow resident to be as independent as possible with the walker/wheelchair as much as possible with staff assistance as indicated, notify MD [medical doctor] of any changes, and a social services referral to allow resident to express feelings or concerns related to expectations of informing staff when [he/she] desires to go outside. 8. Post fall Rehab [rehabilitation] Evaluation was initiated on 09/20/2023 with a recommendation for resident to utilize [his/her] walker while ambulating. A fall risk care plan for Resident #26 was updated on 09/20/2023 with new interventions for resident [sic, staff] to remind resident to utilize [his/her] walker while ambulating. How to identify other residents having the potential to be affected by the same practice: 9. All other residents who trigger as a high elopement risk may be affected by the same deficient practice. A list of residents who are at high risk of elopement will be kept at the nursing station. All facility staff will be given an in-service on how to access the list of residents identified as a high elopement risk by January 9, 2024. This list will also be used during the inter-shift reporting for staff to focus on and supervise the high-risk residents during their shift. Measures/Systemic changes to ensure that practice does not recur: 10. The Clinical Resource Consultant and the Interim Director of Staff Development conducted an in-service training on 01/08/2024 to one RN, two LVNs, twelve CNAs, on 01/09/2024 to three LVNs and two CNAs regarding the following: * Individualized Resident-Centered Plan of Care - development and updating as it relates to the root-cause(s) of the safety issues * Door alarms - ensure door alarm link is activated and in proper functioning order * Monitoring of all residents and increased supervision of residents who are deemed High Risk for elopement * Development and updating of resident care plan for every incident / accident / falls - with new interventions that focus on the root-cause(s) of each event. * List of residents with a high risk for elopement - kept in the nursing station and will be used during inter-shift reporting for continued monitoring of resident safety and functionality of each device. Staff that have not received the education and/or are on leave, will be educated to this inservice's topics prior to the start of their first shift. 11. Department Managers will monitor the functioning door alarms during their 3x a week Guardian Angel rounds to ensure that all door alarms are in place and in functioning order. Any non-functioning door alarms shall be replaced immediately. Fully charged door alarms will be kept in the medication room at all times. 12. An ad hoc QAPI meeting was held on January 8, 2024 at 5:03 PM involving the Medical Director, Administrator, Interim DON, Rehab Director, Maintenance Director, Activities Director, Social Services Director, Admissions Coordinator, Dietary Manager, MDS/Interim Staff Development Director and clinical resource RN. The meeting identified the root cause, set goals, implemented a measurable plan to track and trend findings of angel rounds, or as needed fixes. A Performance Improvement Project (PIP) will be initiated on January 8, 2024. The Maintenance Director and/or designee will conduct point of care competencies checking the functionality of door alarms, at least three (3) times per week in the next three months and validate the monitoring performance of activation of alarms and door alarms. Medical Records and/or Designee shall monitor that Actual elopement risk and wandering events plan of care are developed as they occur, risk for elopement and/or wandering care plan modified or updated as it applies to the actual root-cause(s) of the events. Medical Records and/or Designee shall report compliance audits to the Interdisciplinary Team (IDT) and/or the PIP Coordinator (Administrator) on a weekly basis for continued compliance and resident safety outcomes. Monitoring: 13. The Administrator will monitor and coordinate all the Performance Improvement Project (PIP) activities at least three (3) times per week in the next three (3) months. Tracking and trending of the PIP data will be discussed by the Administrator with the facility Safety Committee at least once every week and with QAA/QAPI Committee every month for continued compliance and modification if needed. The facility's removal plan was signed by the Administrator and specified, *All corrections were completed by January 9, 2024 *The immediacy of the IJ (immediate jeopardy) was removed on January 9, 2024. Onsite Verification: The IJ was removed on 01/10/2024 at 12:01 PM after the survey team verified the implementation of the facility's Removal Plan as follows: 1. The survey team reviewed the Q30 Minute Monitor Sheet Resident Safety Log and interviewed the Clinical Resources Nurse to verify every 30-minute facility rounds were conducted on 01/08/2024 until all alarms were installed and in proper working order. 2. Inservice documentation was reviewed, and the survey team interviewed staff to ensure they received education and retained the information. 3. The survey team reviewed the receipts for the purchase of the door alarms, and interviewed the Maintenance Supervisor and Clinical Resource Nurse to ensure alarms were installed and in proper working order. Observations were conducted on 01/09/2024 and 01/10/2024 and revealed the alarms were installed and in proper working order. 4. The survey team reviewed an Angel Round Assignments sheet and verified a check for Door Alerts are in place an in proper functioning order was included on the Angel Round checklist. On 01/10/2024, the survey team interviewed the Social Services Director and Admissions Coordinator, who confirmed Angel Rounds would include verification the door alarms were functioning. 5. [sic, no 5. included] 6. Resident #26's Elopement Risk Assessment was reviewed. The assessment was conducted on 01/08/2024, and the resident scored a 10, placing the resident into the High Risk category. 7. Resident #26's comprehensive care plan was reviewed, and a Focus area addressing elopement risk was initiated on 01/08/2024. Interventions indicated the resident was educated on the expectation to inform staff when they had the desire to go outside on 01/08/2024, and alarms were placed on exit doors on 01/09/2024. 8. Resident #26's Rehab - Post Fall Evaluation, dated 09/20/2023, and the resident's fall risk care plan were reviewed. 9. On 01/10/2024, staff were interviewed to ensure that they were educated on newly identified elopement residents, where staff could find which residents were at risk for elopement, and supervision of high-risk residents during their shift. The elopement book was observed at the nurses' station. 10. The survey team reviewed in-service records to ensure staff were educated on resident centered care plans, door alarms, monitoring high risk residents who were deemed high risk, and where to find the list of residents who were at risk of elopement. 11. The survey team reviewed an Angel Round Assignments sheet and verified a check for Door Alerts are in place and in proper functioning order was included on the Angel Round checklist. On 01/10/2024, the survey team interviewed the Social Services Director and Admissions Coordinator, who confirmed Angel Rounds would include verification the door alarms were functioning. 12. The survey team reviewed the Quality Assurance / Performance Improvement Committee sign-in sheet, dated 01/08/2024. According to the sign-in sheet, department managers attended the ad hoc meeting, and the Medical Director attended by way of the telephone. On 01/10/2024 at 12:57 PM, the Medical Director was contacted to verify their involvement in the ad hoc meeting and the development of the facility's removal plan. 13. The survey team reviewed the Performance Improvement Project (PIP) Worksheet, dated 01/09/2024. According to the worksheet, the facility started a PIP on 01/08/2024 addressing that the facility's exit doors did not have an indication system that alerted staff to residents leaving the building. In addition, the worksheet indicated the PIP would be completed by March 2024.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1, and 2) were treated respectfully and in a dignified manner, when their needs for pain medications were not addressed by Licensed Nurse (LN, a Registered Nurse) J and he referred to them as drug addicts. This resulted in two residents experiencing unnecessary distress and discomfort. Findings: During a review of LN J's personnel file, the facility's Resident Rights, dated 1/2014, were reviewed and showed he understood and acknowledged them on 2/12/18. The Resident Rights showed the facility must care for its residents in a manner that promotes maintenance or enhancement of each resident's quality of life and promotes care for the residents in a manner that enhances each resident's dignity. The facility's Resident Rights showed residents would be treated with consideration, respect and full recognition of dignity and individuality . 1. Resident 1's record was reviewed and showed he was transferred to the facility on [DATE], from another long-term care facility, with [DIAGNOSES REDACTED]. Resident 1's Durable Power of Attorney for Health Care, a legal document with instruction for end of life requests, dated 12/3/15, also specified he wanted comfort care only and read, I want Hospice and no pain, comfort care only . Resident 1's Physicians Order for Life-Sustaining Treatment (POLST, a physician's orders [REDACTED]. This was included, Relieve pain and suffering with medication by any route as needed . Resident 1's Pain Care Plan, dated 3/28/18, showed complaints of pain would be treated and maintained at a level no greater than 4 of 10. It showed the physician would be notified for modifications of medications if not effective. Resident 1's Skilled Daily Nurses Note, dated 3/31/18 at 11 pm, read, Agitation during shift. Resident using tripod positioning (position used by [MEDICAL CONDITION] patients to get air when difficulty breathing) in chair. [MEDICAL CONDITION] +3 (swelling) BLE (both lower extremities) noted. Decreased alertness .put on C[NAME] (change of condition) for decline in condition. It showed his physician was notified. Resident 1's Skilled Daily Nurses Note, dated 4/1/18 at 12 midnight showed LN J charted he had a temperature of 100.7 and observed generalized pain .tachypnic rate 24 (breaths per minute, normal 12 to 20). Another entry at 2 am showed Resident 1 was nauseous and vomited. LN J charted again at 6:20 am that Resident 1 was tachypnic (rapid breathing) throughout the night. There was no intervention listed for his tachypnic breathing. Resident 1's record contained a physician's orders [REDACTED]. Tylenol, 650 mg milligrams suppository every 4 hours, as needed for pain level 4-6. Resident 1's Medication Administration Records showed he only had Tylenol for pain (4-6 on a 1-10 scale) and was treated with 650 milligrams at midnight and again at 4:30 am on 4/1/18 by LN J. According to the American Family Physician, 3/15/2017, opiates ([MEDICATION NAME]) are the medication of choice for treating and managing end of life pain and difficulty breathing. Resident 1's Interfacility Transfer Report, dated 4/1/18, showed, Resident had change overnight of respiratory distress (inability to breathe, frightening). Not able to keep comfortable here. No meds available. Resident 1's emergency room Physician Note, dated 4/1/18, showed he arrived from the facility by ambulance and was last seen normal at midnight last night .Staff states they felt they were not able to comfort him appropriately with the medications available to him . It listed Chronic Pain as part of his past medical history. The report showed his heart rate and breathing were faster than normal and he had poor airway movement and appeared uncomfortable. He was assessed to be in [MEDICAL CONDITION] with very low blood sugar before he passed away at 9:45 am. On 4/26/18 at 11 am, Certified Nurse Assistant (CNA) B was interviewed and stated Resident 1 was in distress during the night shift on 3/31 to 4/1/18 and described him as starving for oxygen, That poor man. CNA B stated LN J refused to give Resident 1 pain medication around 3 am when she requested it for him, LN J had CNA B and CNA C sit with Resident 1 on a 1:1 basis instead. CNA B stated she had been a CNA for [AGE] years and had worked as a Home Health Aide for Hospice (end of life care). CNA B described Resident 1 as gasping for air and grabbing his chest and when asked if he was having pain, said the word pain and help me. She stated Resident 1 kept trying to get up. CNA B stated she and CNA C told the oncoming nurse (LN S) at 6 am and told her about Resident 1's distress. CNA B stated LN S called the physician for an order to send him to the emergency room for treatment because they could not make him comfortable. She stated she later found out Resident 1 passed away shortly after arriving at the hospital on [DATE]. CNA B stated she went home and wrote out a statement to the facility's Administrator and put it under her door with Resident 1's transfer form that was sent with him to the hospital. CNA B's handwritten statement, dated 4/1/18, was reviewed and showed she described Resident 1 as not doing well .restless and kept trying to get out of bed. Her statement described Resident 1 as gray and breathing heavy, stating in pain. CNA B said she went to LN J around 12:30 am and asked him to give Resident 1 something for pain, to which he said, When I get around to it. She indicated Resident 1's oxygen tubing was unhooked from him constantly trying to get out of bed and he was grabbing at his chest, so she went to get LN J and asked if he had given him his meds yet and he said no. When CNA B told him again that Resident 1 was sitting up on the side of his bed, was in pain and needed something, LN J told her to put him back to bed and get back to work. CNA B's statement showed at 1:35 am, she again told LN J Resident 1 was uncomfortable, not looking well, keeps pulling his oxygen off his machine and needed something for pain. CNA B wrote that LN J responded to her, What are you, a pusher? CNA B's statement showed at 3:30 am, Resident 1 would not stay in bed or keep his oxygen on. On 4/26/18 at 5 pm, LN S was interviewed about Resident 1's condition when she came on shift the morning of 4/1/18. She stated Resident 1 was in Respiratory distress sitting straight up and was red and very anxious. LN S stated Resident 1's oxygen saturation (oxygen level in blood, normal > 92 %) was 80%. She stated she called Resident 1's physician at 6:30 am, right after she arrived, because he did not have orders for any [MEDICATION NAME] or [MEDICATION NAME] (drugs used for pain, anxiety and ease breathing difficulty in end of life care). LN S stated she obtained the order and sent Resident 1 to the hospital for comfort care. Resident 1's physicians order (written by LN S), dated 4/1/18 at 6:30 am, read, Send to ER for eval. Unable to keep comfortable. On 4/26/18 at 5:20 pm, CNA C also confirmed Resident 1 was in pain and told her he was in pain. She stated he was trying to get up. She stated it was hard to watch Resident 1. On 4/27/18 at 9:18 am, LN W was interviewed and confirmed Resident 1 was restless and appeared distressed the morning of 4/1/18. He stated he would have already sent Resident 1 to the hospital during the night. On 4/27/18 at 4:40 pm, CNA C was interviewed a second time about Resident 1's pain and condition on night shift of 3/31 to 4/1/18. She stated prior to the shift, she heard LN G (the day shift nurse on 3/31/18) tell LN J Resident 1 was not good .you might want to keep an eye on him and heard LN J respond, I'm not sending anyone out (to the hospital emergency room ). CNA C described Resident 1 as pulling his oxygen tubing from the machine and described his breathing as rattling at about 4 am. She stated when she informed LN J he responded, Oh that's just normal, let days (day shift) deal with it. On 5/18/18 at 5 pm, LN J was interviewed about Resident 1's care on the 3/31 to 4/1/18 night shift. He stated LN G was upset when she reported to him, just prior to his shift, and stated Resident 1 had a severe change of condition. LN J stated LN G told him she had made a call in to Resident 1's physician about his change of condition. When asked about residents needing [MEDICATION NAME] or [MEDICATION NAME] for end of life care, LN J confirmed it is used sometimes but he would not have given it to Resident 1 for his tachypnea (rapid breathing indicative of pain) and restlessness. Although he confirmed Resident 1 had a fever and was breathing rapidly, he stated his vital signs were stable, and stated he did well. LN J confirmed the CNAs had asked for Resident 1 to receive pain medication and he only administered Tylenol. 2. A review of Resident 2's record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's record included a POLST, dated 2/28/18, that showed he wanted Comfort Focused Treatment with the primary goal of maximizing comfort. Resident 2's record included a physician order, dated 3/15/18, for referral to Hospice. Hospice with start of care on 3/17/18. Resident 2's End of Life Care Plan, dated 3/19/18, showed his pain was to be managed and his choice of comfort would be honored. It showed medications would be used to manage his comfort. Resident 2's Hospice Physician Order, dated 3/22/18, showed he continued to need frequent doses of breakthrough pain medication and his routine [MEDICATION NAME] (narcotic) was changed to [MEDICATION NAME] (narcotic, for better pain control) with [MEDICATION NAME] and [MEDICATION NAME] (narcotic) ordered for breakthrough pain. Resident 2's Medication Administration Records showed he received [MEDICATION NAME] (anti-anxiety medication also used for pain) twice daily from 4/1 to 4/14/18 for anxiety control. The facility's Record of Death/Mortician Report for Resident 2 showed he passed away on 4/24/18. On 4/27/18 at 1:34 pm, CNA B was interviewed and stated a few days before Resident 2 was placed on Hospice care, she was caring for him and LN J was his nurse. CNA B stated, she told LN J Resident 2 had requested pain medications, he said no that he got [MEDICATION NAME] (anti-anxiety medication also used for pain relief). She stated she told LN J Resident 2 was in a lot of pain and stated LN J responded, It doesn't matter. He's not getting any. He's addicted to his meds. I've worked in the prison system. I know how these people are with drugs and pain meds. CNA B stated she told LN J, This is not a prison. These are elderly people that deserve [MEDICATION NAME] and sympathy.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1 and 2) were not neglected when a change of condition and increased comfort needs were not addressed. This resulted in both residents experiencing discomfort and their life choices not being respected. Findings: The facility's Abuse Prevention and the Reporting of Alleged Abuse and suspicion of Crime policy, dated 12/12, was reviewed and showed each resident had a right to be free from neglect. Neglect included failure to provide medical care for physical and mental health needs that results in pain. Neglect was also described as negligent failure when having care of an elder to provide the degree of care a reasonable perosn would exericse. The crime of elder abuse included any person that pemits an elder or dependent adult to suffer or inflicts unjustifiable physical pain or mental suffereing, or having care of them permits the health of that person to be endangered. Abuse also included deprivation of care. The facility's Resident Rights, dated 1/2014, were reviewed and showed he understood and acknowledged them on 2/12/18. The Resident Rights showed the facility must care for its residents in a manner that promotes maintenance or enhancement of each resident's quality of life and promotes care for the residents in a manner that enhances each resident's dignity. The facility's Resident Rights showed residents would be treated with consideration, respect and full recognition of dignity and individuality . 1. Resident 1's record was reviewed and showed he was transferred to the facility on [DATE], from another long-term care facility, with [DIAGNOSES REDACTED]. Resident 1's Durable Power of Attorney for Health Care, a legal document with instruction for end of life requests, dated 12/3/15, also specified he wanted comfort care only and read, I want Hospice and no pain, comfort care only . Resident 1's Physicians Order for Life-Sustaining Treatment (POLST, a physician's orders [REDACTED]. This was included, Relieve pain and suffering with medication by any route as needed . Resident 1's Pain Care Plan, dated 3/28/18, showed complaints of pain would be treated and maintained at a level no greater than 4 of 10. It showed the physician would be notified for modifications of medications if not effective. Resident 1's Skilled Daily Nurses Note, dated 3/31/18 at 11 pm, read, Agitation during shift. Resident using tripod positioning (position used by [MEDICAL CONDITION] patients to get air when difficulty breathing) in chair. [MEDICAL CONDITION] +3 (swelling) BLE (both lower extremities) noted. Decreased alertness .put on C[NAME] (change of condition) for decline in condition. It showed his physician was notified. Resident 1's Skilled Daily Nurses Note, dated 4/1/18 at 12 midnight showed Licensed Nurse (LN and a registered nurse) J charted he had a temperature of 100.7 and observed generalized pain .tachypnic rate 24 (breaths per minute, normal 12 to 20). Another entry at 2 am showed Resident 1 was nauseous and vomited. LN J charted again at 6:20 am that Resident 1 was tachypnic (rapid breathing) throughout the night. There was no intervention listed for his tachypnic breathing. Resident 1's record contained a physician's orders [REDACTED]. Tylenol, 650 mg milligrams suppository every 4 hours, as needed for pain level 4-6. Resident 1's Medication Administration Records showed he only had Tylenol for pain (4-6 on a 1-10 scale) and was treated with 650 milligrams at midnight and again at 4:30 am on 4/1/18 by LN J. According to the American Family Physician, 3/15/2017, opiates ([MEDICATION NAME]) are the medication of choice for treating and managing end of life pain and difficulty breathing. Resident 1's Interfacility Transfer Report, dated 4/1/18, showed, Resident had change overnight of respiratory distress (inability to breathe, frightening). Not able to keep comfortable here. No meds available. Resident 1's emergency room Physician Note, dated 4/1/18, showed he arrived from the facility by ambulance and was last seen normal at midnight last night .Staff states they felt they were not able to comfort him appropriately with the medications available to him . It listed Chronic Pain as part of his past medical history. The report showed his heart rate and breathing were faster than normal and he had poor airway movement and appeared uncomfortable. He was assessed to be in [MEDICAL CONDITION] with very low blood sugar before he passed away at 9:45 am. On 4/26/18 at 11 am, Certified Nurse Assistant (CNA) B was interviewed and stated Resident 1 was in distress during the night shift on 3/31 to 4/1/18 and described him as starving for oxygen, That poor man. CNA B stated LN J refused to give Resident 1 pain medication around 3 am when she requested it for him, LN J had CNA B and CNA C sit with Resident 1 on a 1:1 basis instead. CNA B described Resident 1 as gasping for air and grabbing his chest and when asked if he was having pain, said the word pain and help me. She stated Resident 1 kept trying to get up. CNA B stated she and CNA C told the oncoming nurse (LN S) at 6 am and told her about Resident 1's distress. CNA B stated LN S called the physician for an order to send him to the emergency room for treatment because they could not make him comfortable. She stated she later found out Resident 1 passed away shortly after arriving at the hospital on [DATE]. CNA B stated she went home and wrote out a statement to the facility's Administrator and put it under her door with Resident 1's transfer form that was sent with him to the hospital. CNA B's handwritten statement, dated 4/1/18, was reviewed and showed she described Resident 1 as not doing well .restless and kept trying to get out of bed. Her statement described Resident 1 as gray and breathing heavy, stating in pain. CNA B said she went to LN J around 12:30 am and asked him to give Resident 1 something for pain, to which he said, When I get around to it. She indicated Resident 1's oxygen tubing was unhooked from him constantly trying to get out of bed and he was grabbing at his chest, so she went to get LN J and asked if he had given him his meds yet and he said no. When CNA B told him again that Resident 1 was sitting up on the side of his bed, was in pain and needed something, LN J told her to put him back to bed and get back to work. CNA B's statement showed at 1:35 am, she again told LN J Resident 1 was uncomfortable, not looking well, keeps pulling his oxygen off his machine and needed something for pain. CNA B wrote that LN J responded to her, What are you, a pusher? CNA B's statement showed at 3:30 am, Resident 1 would not stay in bed or keep his oxygen on. A review of the group text from CNA B to the Past Director of Nurses (PDON) and the Administrator, showed the CNAs were not willing to work with LN J because he was hostile towards them and dangerous toward the residents. On 4/26/18 at 5:20 pm, CNA C also confirmed Resident 1 was in pain and told her he was in pain. She stated he was trying to get up. She stated it was hard to watch Resident 1. On 4/27/18 at 9:18 am, LN W was interviewed about the morning of 4/1/18 and stated Resident 1 was discolored and restless. He stated he would have already sent Resident 1 to the hospital because he appeared distressed. On 4/27/18 at 12 noon, PDON was interviewed about the events on 3/30 and 4/1/18. He stated he was only temporary as the facility's DON for 3 days and left after that weekend. PDON stated he was worried he could lose his license with the facility's current management, because it was not safe. He stated the facility's ADM was made aware the staff were having problems with LN J's treatment of [REDACTED]. PDON confirmed he saw the handwritten note from CNA B in the ADM/DON's office and it was left on the desk in a folder for the incoming DON to review. PDON stated the facility's Director of Staff Development (DSD and a licensed nurse) was aware of it. He stated he, the ADM, and other staff received a group text about LN J's care of residents and it was discussed during stand up (meeting each day to apprise all staff of resident needs and facility issues). 2. A review of Resident 2's record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's record included a POLST, dated 2/28/18, that showed he wanted Comfort Focused Treatment with the primary goal of maximizing comfort. Resident 2's record included a physician order, dated 3/15/18, for referral to Hospice. Hospice with start of care on 3/17/18. Resident 2's End of Life Care Plan, dated 3/19/18, showed his pain was to be managed and his choice of comfort would be honored. It showed medications would be used to manage his comfort. Resident 2's Medication Administration Records showed he received [MEDICATION NAME] (anti-anxiety medication also used for pain) twice daily from 4/1 to 4/14/18 for anxiety control. Resident 2's Hospice Physician Order, dated 3/22/18, showed he continued to need frequent doses of breakthrough pain medication and his routine [MEDICATION NAME] (narcotic) was changed to [MEDICATION NAME] (narcotic, for better pain control) with [MEDICATION NAME] and [MEDICATION NAME] (narcotic) ordered for breakthrough pain. The facility's Record of Death/Mortician Report for Resident 2 showed he passed away on 4/24/18. On 4/27/18 at 1:34 pm, CNA B was interviewed and stated Resident 2 asked for pain medications when she cared for him and LN J was his nurse. She stated when she requested pain medications from LN J for Resident 2, he said no, that he got [MEDICATION NAME]. CNA B stated this was a few days before Resident 2 was placed on Hospice. CNA B stated she told LN J that Resident 2 was in a lot of pain and stated LN J responded, It doesn't matter. He's not getting any. He's addicted to his meds. I've worked in the prison system. I know how these people are with drugs and pain meds. CNA B stated she told LN J, This is not a prison. These are elderly people that deserve [MEDICATION NAME] and sympathy.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) were treated for [REDACTED]. This resulted in discomfort for Resident 1 and Resident 2 during the last month of their lives. Findings: The facility's Pain Assessment and Management policy, dated 3/15, showed Pain Management was alleviating pain to meet the resident's acceptable levels, based on their clinical condition, and established treatment goals. It included effectively recognizing the presence of pain and modifying approaches as necessary. The policy described behavioral signs of pain as crying, screaming, grimacing, changes in gait, skin color and vital signs, irritability, anxiety. It described physical signs as sweating and increased respirations (tachypnea). It identified End of life . as one of the causes of pain. The policy showed pain management interventions would be consistent with the resident's goals for treatment and significant changes and unrelieved pain would be reported to the physician. The facility's Resident Rights, dated 1/2014, were reviewed and showed residents would be treated with consideration, respect and full recognition of dignity and individuality . and would be transferred to the hospital for their welfare if their needs could not be met in the facility. 1. A review of Resident 1's record showed he was transferred to the facility on [DATE] from another long-term care facility, with [DIAGNOSES REDACTED]. Resident 1's Physicians Order for Life-Sustaining Treatment (POLST, a physician's orders [REDACTED]. This was included, Relieve pain and suffering with medication by any route as needed; use oxygen Resident 1's Durable Power of Attorney for Health Care, a legal document with instruction for end of life requests, dated 12/3/15, specified he wanted comfort care only and read, I want Hospice and no pain, comfort care only . Resident 1's Skilled Daily Nurses Note, dated 3/31/18 at 11 pm, read, Agitation during shift. Resident using tripod positioning (residents with [MEDICAL CONDITION] use to get air when difficulty breathing) in chair. [MEDICAL CONDITION] (swelling) +3 (extreme) BLE (both lower extremities) noted. Decreased alertness .put on C[NAME] (change of condition) for decline in condition. It showed his physician was notified. Resident 1's Skilled Daily Nurses Note, dated 4/1/18 at 12 midnight showed Licensed Nurse (LN and a registered nurse) J charted he had a temperature of 100.7 and observed generalized pain .tachypnic rate 24 (breaths per minute, normal 12 to 20). Another entry at 2 am showed Resident 1 was nauseous and vomited. LN J charted again at 6:20 am that Resident 1 was tachypnic throughout the night. Resident 1's physician orders [REDACTED]. There was no medication ordered for severe pain of 7-10. Resident 1's Medication Administration Records showed he was treated with two Tylenol at midnight and 4:30 am on 4/1/18 by Licensed Nurse (LN and a registered nurse) J. Resident 1's Pain Care Plan, dated 3/28/18, showed complaints of pain would be treated and maintained at a level no greater than 4 of 10. It showed the physician would be notified for modifications of medications if not effective. There was no documentation found in Resident 1's record that his physician was called for end of life medications (opiates) to comfort him or treat his difficult breathing or agitation. According to the American Family Physician, 3/15/2017, opiates ([MEDICATION NAME]) are the medication of choice for treating and managing end of life pain and difficulty breathing. Resident 1's physicians order, dated 4/1/18 at 6:30 am, read, Send to ER (emergency room ) for eval (evaluation) Unable to keep comfortable. Resident 1's Interfacility Transfer Report, dated 4/1/18, showed, Resident had a change overnight of respiratory distress. Not able to keep comfortable here. No meds available. Resident 1's emergency room Physician Note, dated 4/1/18, showed he arrived from the facility by ambulance and was last seen normal at midnight last night .Staff states they felt they were not able to comfort him appropriately with the medications available to him . The report showed he had extremely low blood sugar of 29 and was treated by ambulance staff. It listed Chronic Pain as part of his past medical history. The report showed his heart rate and breathing were faster than normal and he had poor airway movement and appeared uncomfortable. He was assessed to be in [MEDICAL CONDITION] with very low blood sugar before he passed away at 9:45 am. On 4/26/18 at 11 am, Certified Nurse Assistant (CNA) B was interviewed and stated LN J would not give pain medication to the residents when CNA's reported to him the residents needed it. CNA B stated Resident 1 was in distress during the night shift on 3/31/18 and described him as starving for oxygen and flopping around. CNA B stated LN J refused to give Resident 1 pain medication around 3 am when she requested it for him. LN J had CNA B and CNA C sit with Resident 1 on a 1:1 basis instead. CNA B described Resident 1 as gasping for air and grabbing his chest and when asked if he was having pain, said the word pain and help me. CNA B stated Resident 1 kept trying to get up. CNA B stated she and CNA C went to the oncoming nurse (LN S) at 6 am and told her about Resident 1's distress. CNA B stated LN S called the physician for an order to send him to the emergency room (ER) for treatment because they could not make him comfortable. CNA B stated she later found out Resident 1 passed away shortly after arriving at the hospital on [DATE]. CNA B stated she went home and wrote out a statement to the facility's Administrator and put it under her door with Resident 1's transfer form that was sent with him to the hospital. CNA B's handwritten statement, dated 4/1/18, was reviewed. It showed she described Resident 1 as not doing well .restless and kept trying to get out of bed. CNA B's statement described Resident 1 as gray and breathing heavy, stating in pain. CNA B said she went to LN J at around 12:30 am and asked him to give Resident 1 something for pain, to which he said, When I get around to it. CNA B's statement read that Resident 1's oxygen tubing was unhooked from trying to get out of bed and he was grabbing at his chest so she went to get LN J. She asked LN J if he had given Resident 1 his meds yet and he said no. CNA B told LN J again Resident 1 was sitting up on the side of his bed, was in pain and needed something. LN J told her to put him back to bed and get back to work. CNA B's statement showed at 1:35 am she again told LN J Resident 1 was uncomfortable, not looking well, keeps pulling his oxygen off his machine and needed something for pain. It showed LN J responded to her, What are you, a pusher? Her statement showed at 3:30 am, Resident 1 would not stay in bed or keep his oxygen on. CNA B's statement read, He was suffering pulling his oxygen off and flopping. On 4/26/18 at 5 pm, LN S was interviewed about Resident 1's condition when she came on shift the morning of 4/1/18. She stated Resident 1 was in Respiratory distress sitting straight up and was red and very anxious. LN S stated she called Resident 1's physician right after she arrived because he did not have orders for any [MEDICATION NAME] or [MEDICATION NAME] (drugs used for pain, anxiety and ease breathing difficulty in end of life care) and obtained orders at 6:30 am to send him to the hospital for comfort care. On 4/26/18 at 5:20 pm, CNA C stated on the night of 3/31/18, Resident 1 was in horrible pain and stated he was in pain. She stated he was grabbing and trying to get up. CNA C stated it was hard to watch Resident 1 suffer. On 4/27/18 at 9:18 am, LN W was interviewed and stated he would have already sent Resident 1 to the hospital because he appeared distressed. On 4/27/18 at 4:40 pm, CNA C was interviewed a second time about Resident 1's pain and condition on night shift of 3/31 to 4/1/18. She described him as ancy, pacing, panting and sweating and stated he was grey, pulling his oxygen tubing from the machine and described his breathing as rattling at about 4 am. CNA C stated she informed LN J, to which he responded, Oh that's just normal, let days (day shift) deal with it. She stated she heard LN G (the day shift nurse on 3/31/18) tell LN J that Resident 1 was not good .you might want to keep an eye on him and she heard LN J respond, I'm not sending anyone out (to the hospital). On 5/18/18 at 5 pm, LN J was interviewed about Resident 1's care during the 3/31 to 4/1/18 night shift. He stated LN G was upset when she reported to him at the start of his shift and stated Resident 1 had a severe change of condition. LN J stated LN G told him she had made a call in to Resident 1's physician about his change of condition. When asked about patients needing [MEDICATION NAME] or [MEDICATION NAME] for end of life care, LN J confirmed it is used sometimes but he would not have given it to Resident 1 for his tachypnea (rapid breathing indicative of pain) and restlessness. Although he confirmed Resident 1 had a fever and was breathing rapidly, he stated his vital signs were stable and that he did well. LN J confirmed the CNAs had asked for Resident 2 to receive pain medication and he administered Tylenol. 2. A review of Resident 2's record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's record included a POLST, dated 2/28/18, showed he wanted Comfort Focused Treatment with the primary goal of maximizing comfort. Resident 2's record included a physician order, dated 3/15/18, for referral to Hospice (end of life care). Hospice start of care was 3/17/18. Resident 2's End of Life Care Plan, dated 3/19/18, showed his pain was to be managed and his choice of comfort would be honored. It showed medications would be used to manage his comfort. Resident 2's Medication Administration Records showed he received [MEDICATION NAME] twice daily from 4/1 to 4/14/18 for anxiety control. On 4/27/18 at 1:34 pm, CNA B was interviewed and stated a few days before Resident 2 was placed on Hospice care, she was caring for him and LN J was his nurse. CNA B stated, she told LN J Resident 2 had requested pain medications, he said no that he got [MEDICATION NAME] (anti-anxiety medication also used for pain relief). She stated she told LN J Resident 2 was in a lot of pain and stated LN J responded, It doesn't matter. He's not getting any. He's addicted to his meds. I've worked in the prison system. I know how these people are with drugs and pain meds. CNA B stated she told LN J, This is not a prison. These are elderly people that deserve [MEDICATION NAME] and sympathy. Resident 2's Hospice Physician Order, dated 3/22/18, that showed he continued to need frequent doses of breakthrough pain medication and his routine [MEDICATION NAME] (narcotic) was changed to [MEDICATION NAME] (narcotic, for better pain control) with [MEDICATION NAME] and [MEDICATION NAME] (narcotic) ordered for breakthrough pain. On 4/27/18 at 4:40 pm, CNA C stated she had worked with Resident 2 before his death. She stated he screamed, flinched and cried out when touched and he was better with pain medications. The facility's Record of Death/Mortician Report for Resident 2 showed he passed away on 4/24/18.

Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for three of 10 sampled residents (Residents 4, 5, and 9) and three residents out side the sample (Residents 17, 16, 15) when: 1. The facility failed to ensure a registered dietitian evaluated Resident 5's nutritional status, in order to recommend nutritional interventions, after an unplanned significant weight loss of 5% (percent), in which further weight loss continued to accumulate to an 8% significant weight loss in a three month period. The physician was not notified of significant weight loss within those time frames. Refer to F 327. 2. The facility's registered dietitian (RD) failed to identify an unplanned significant weight loss in a timely manner for Resident 9 which caused a delay of nutrition recommendations, during which time the weight loss had continued. Once two nutrition interventions were recommended, the facility discontinued both nutrition interventions due to lack of honoring a flavor preference, and based on resident refusal. There was no consultation with the RD for an alternative nutrition approach. Further, the physician had ordered [MEDICATION NAME] (an appetite stimulant) in which the facility failed to provide in accordance with the physician's orders [REDACTED]. 3. The facility failed to provide a magic cup (to increase calories and protein) as ordered for Resident 17 to address low body weight upon admit. The facility failed to provide a health shake (to increase calories and protein) as ordered for Resident 16 to address unplanned significant weight loss. Refer to F514 4. The facility failed to ensure a registered dietitian evaluated Resident 15's unplanned significant weight loss, and failed to notify the physician of the significant change of condition. 5. The facility failed to notify the physician of a significant change in condition when Resident 4 had an unplanned significant weight gain. As a result, the facility's system was not effective at ensuring the registered dietitian evaluated unplanned significant weight loss. The facility had not ensured there was a clear understanding and delineation of the roles between the dietary services supervisor and the registered dietitian amongst the interdisciplinary team which impacted nutritional care for the residents. The facility failed to ensure timely notification to the physician of significant weight changes in which there could be delayed assessment and intervention by the practitioner responsible for the care of the resident. The facility failed to consistently ensure that nutrition interventions to address identified nutritional concerns were implemented, as ordered. Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of [DIAGNOSES REDACTED]. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) Findings: 1. On 4/5/17 at 10:30 A.M., Resident 5's medical record was reviewed. Resident 5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 was [AGE] years old, alert, verbally responsive and with periods of confusion. Resident 5 was not able to make her own health care decisions. The most recent Minimum Data Set (MDS, a resident assessment), dated 2/7/17, a Significant Change in Status Assessment, showed Resident 5 required mostly total dependence from staff and two person physical assistance in Activities of Daily Living (ADLs) such as bed mobility, transfer, hygiene and eating. On 4/5/17 at 10:30 A.M., a record review of Resident 5's Weights and Vitals Summary noted the following weight: 8/1/16 - 180 lbs (pounds) 9/1/16 - 181.6 lbs 10/1/16 - 179.2 lbs 11/1/16 - 170 lbs 11/6/16 - 169 lbs 11/13/16 - 167.8 lbs 11/20/16 - 166 lbs 11/27/16 - 165.8 lbs 12/1/16 - 167 lbs On 4/6/17 at 3:40 P.M., after the registered dietitian (RD 1) reviewed Resident 5's chart, RD 1 stated, There was a 5.1% unplanned significant weight loss from 10/1/16 at 179.2 lbs to 11/1/16 at 170 lbs, and an 8% weight loss in three months from 9/1/16 at 181.6 lbs to 12/1/16 at 167 lbs. RD 1 stated there were no nutrition assessments conducted that evaluated the significant unplanned weight loss for the one month, and three month time period, and stated, They were missed. RD 1 stated that nutrition interventions should have been recommended to promote an increased calorie and protein intake for the resident. A Weight Change Note written by the dietary services supervisor (DSS) dated 9/28/16 indicated, IDT (interdisciplinary team) met to discuss (Resident 5's) weight. She was on an appetite stimulant r/t (related to) poor PO (by mouth) intake and weight loss. Weight is now stable and within weight goal. Doctor has been faxed to DC (discontinue) appetite stimulant. Will continue to monitor weight every 30 days. IDT will address all significant weight variances. According to the Weights and Vital Summary the resident's last weight taken was on 9/1/16 at 181.6 lbs and per the IDT weight is now stable. A Weight Change Note written by the DSS dated 11/3/16 indicated, IDT met to discuss (Resident 5's) weight. On 11/1/16 she was 170# (pounds) on 10/1/16 179.2# down 9.2#, 5.1% x 30 days. Po (by mouth) intake 73% meals on a MechSoft (mechanical soft; diet for chewing and/or swallowing difficulty), fortify (to add calories), NAS (no added salt) diet. Weight goal +/-10# of 170# and 50% meals. [MEDICATION NAME] was DC' d on 9/29/16 due to increase in weight and appetite. Begin weekly weights x 4 weeks to monitor any further weight loss. There was no documentation in regard to a referral to the RD. A Weight Change Note written by the DSS dated 11/9/16 indicated, IDT met to discuss (Resident 5's) weight .Weight goal +/- 10# of 170# ., continue current plan . There was no documentation in regard to a referral to the RD. On 4/7/17 at 11:25 A.M., the DSS was asked how it was determined that resident 5's weight goal was 170 lbs after a significant weight loss occurred, and after it was determined that [MEDICATION NAME] was no longer needed in September 2016 as her weight was stable when she was 181.6 lbs on 9/1/16, and the DSS stated, I'm not sure where the information came from. On 11/13/16 a note was written by a social service designee that indicated, [MEDICATION NAME] 7.5 mg (milligram) was dc' d on 9/29/16. She has lost #11.4 (lbs) .IDT recommend restarting [MEDICATION NAME], will follow up x 2 weeks. A Weight Change Note, dated 11/16/16, written by the DSS included, .(Resident 5) is down 13.8#, 7.6% since 9/1/16 181.6# x 3 months. Comments: Continue current plan of care, weekly weights. IDT will follow up next week. There was no documentation or follow up that the [MEDICATION NAME] that was previously recommended was ordered. There was no documentation of a referral to the RD due to the significant unplanned weight loss. On 4/7/17 at 11:25 A.M., the DSS stated the IDT meetings consisted of the director of nursing (DON), the social services designee, the DSS, and sometimes the activities director. The DSS reviewed the above Weight Change Notes and verified that there was no documented referral to the RD. The DSS stated, We usually agree to refer to RD's and it should be automatic. The facility's policy and procedure titled Weight Change Protocol (approved on 7/21/16) indicated, Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner ., Residents who experience significant changes in weight or insidious weight loss will be assessed by the RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 3# weight loss or gain in 1 week or as facility policy states, 5# weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months. The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate the success of the interventions . A review of a fax, dated 11/18/16 showed the director of nursing (DON) completed a request to the physician to reinstate [MEDICATION NAME] due to poor appetite/weight loss since D/C of med on 9/29/16. The doctor gave the order for the [MEDICATION NAME] on 11/21/16, after the resident had an 8% unplanned significant weight loss within a three month period. On 4/6/17 at 12:55 P.M., DON stated, The IDT meets to discuss significant weight loss and if the IDT determines the need for an intervention then we fax the MD to request an order. The DON was asked for the facility policy and procedure (P & P) in regard to notifying a physician about significant change in condition. Concurrently, the DON looked in the facility's P & P binder, and stated, I didn't know about this policy. The P & P was titled Change Of Condition/Notification (Effective date: 11/16) indicated, Purpose: To keep residents, family and physicians informed of changes in resident's condition in a timely manner. Policy: A facility must immediately inform the resident; consult with the resident's physician .where there is an .significant change, a need to alter treatments ., Procedure: Licensed Nurse will notify MD .when there is .d. A change in weight of 5% percent in thirty days, 7.5% in ninety days and 10% in 180 days unless a different stipulation has been stated in writing by the patients physician . On 4/7/17 at 2:50 P.M., a physician covering for the medical director (MD) on that day stated that he would expect the facility to follow their policies and procedures and ensure the RD had conducted a nutrition assessment, and made recommendations, after Resident 5 had experienced significant weight loss. After a brief record review of Resident 5, the physician acknowledged that due to the facility not notifying the physician of the significant weight loss, not involving the RD in the assessment and nutrition plan of care and not implementing nutrition recommendations to promote increased calorie and protein intake that the unplanned significant weight loss may have been avoidable. On 4/7/17 at 3:30 P.M., the medical records employee (MR) verified there was no documentation that the facility had notified the physician of the 5% weight loss in a month, or of the accumulation of 7.5 % significant weight loss in three months. On 4/10/17 at 12: 20 P.M., Resident 5's primary physician (MD) stated, I don't recall them (the facility) talking about nutrition with me. I would expect the RD to look into significant unplanned weight loss, if they recommend something I usually say yes. I wasn't really aware of significant weight loss during that time. The facility's policy and procedure titled Care Planning/Interdisciplinary Team Care Planning Conference (Reviewed 2/13) indicated, Purpose: To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions .,4. The IDT members include but not necessarily limited to: a. The attending physician ., c. Other appropriate staff in disciplines as determined by the residents needs . On 4/7/17 at 10:22 A.M., via telephone interview with RD 1, she stated, Adequate nutrition is very important. Adequate nutrition may have helped prevent or minimize some complications. She should have been started on a nutrition supplement after the first significant weight loss. The RD stated she would have looked into starting healthshake or magic cup (a frozen nutrition supplement to increase calories and protein), or we have ready care pass the nurses could have given during medication pass to address weight loss and get protein back. The RD stated she would have investigated the root cause for the weight loss and would have evaluated fluid needs and made appropriate recommendations after her evaluation. The RD stated, I feel like the first 5% was probably unavoidable but due to lack of an RD assessment, lack of adequate interventions implemented and no RD involvement in the IDT meetings, and no RD involvement in setting a weight goal when it was lowered during an IDT meeting the three month significant weight loss could have potentially been avoidable. We don't know because we didn't try. Resident 5 was admitted to the hospital on [DATE] according to the hospitals Discharge Summary that indicated, Acute and new diagnoses;[MEDICAL CONDITION] (bacteria in the blood) present on admission secondary to a complicated urinary tract infection. Obstructing renal pelvis stones at 2 cm (centimeters), status [REDACTED]. Acute systemic [MEDICAL CONDITION] response syndrome with acute kidney injury. Severe protein calorie malnutrition ., Urine culture grew E. coli (Escherichia coli - a bacteria) . A review of Resident 5's labs indicated an [MEDICATION NAME] level of 2.6 g/dL (grams per deciliter) (reference range 3.5 - 5.0) on 12/30/16, and another [MEDICATION NAME] level of 2.5 on 12/31/16. ([MEDICATION NAME] is the body's major plasma protein and serves as a transport protein) Resident 5 was re-admitted to the facility on [DATE] per the hospital's Discharge Summary. The facility's Monthly Weights form indicated Resident 5 weighed 153.8 lbs on 1/4/17. There was a physician's orders [REDACTED]. On April 6, 2017 at 9:50 A.M., the medical records employee (MR) was unable to show documentation that the order was provided to Resident 5. The MR stated the resident was discharged to the hospital on [DATE], and re-admitted to the facility on [DATE]. According to Resident 5's labs dated 2/1/17 the [MEDICATION NAME] was 2.4 g/dL (Reference range 3.5 - 5.0 g/dL) On 2/7/17 an RD completed a Registered Dietitian Nutrition Assessment that indicated the resident weighed 163.2 pounds, UBW (usual body weight) prior to hospitalization ,[DATE]# .Rdt (resident) > UBW, exceeding nutritional needs .Interventions: D/C (discontinue) healthshake's TID (three times a day) . A physician's orders [REDACTED]. On 4/7/17 at 10:22 A.M., via telephone interview with RD 1, RD 1 stated that she had worked at the facility for two months. The RD stated that the facility was not her usual building and she had not known the residents very well. The RD stated that she relied on a DSS nutrition screen and just looked back to the residents last weight prior to her hospitalization to determine UBW (usual body weight). RD 1 stated she reviewed Resident 5's medical record thoroughly on 4/6/17 and recognized there was an order for [REDACTED]. A nursing progress note dated 2/23/17 indicated, MD in building an gave orders for .health shakes due to hematuria (blood in the urine), poor po intake and c/o (complaint of) sore throat; order noted and implemented .dietary notified. A physician order, dated 2/23/17, indicated Reinstate Health Shakes TID with meals. On 4/4/17 at 12:10 pm, Resident 5 was observed eating lunch in her room, slowly, while in bed by herself. On 4/4/17 at 12:35 pm, Certified Nursing Assistant (CNA) F came to her room, took the lunch meal tray out and left the 4 ounces (oz.) of milk and healthshake. The lunch meal tray was barely touched. CNA F did not offer any substitute nor alternatives for Resident 5. During an interview on 4/7/17 at 12:40 pm, Resident 5 stated she had not finished her lunch meal tray and it was taken out. On 4/4/17 at 12:50 P.M., Resident 5's lunch meal tray was located on the meal cart with other residents meal trays who had finished eating. The CNA (CNA F) taking care of Resident 5 during that shift was observed to be assisting another resident with his wheelchair down another hall from Resident 5's room. Concurrently, CNA F was asked to review Resident 5's lunch meal tray that was located on the dirty meal cart. CNA F reviewed the lunch meal tray, and stated, She consumed 10% of her lunch because she drank her juice. CNA F was asked how she determined to remove Resident 5's lunch meal tray from her bedside table. CNA F stated she asked resident 5 if she was done and the resident pointed to her milk and healthshake which I left on her bedside table. CNA F was asked if she had offered her anything else to eat, and stated, No. CNA F was asked how she was trained in order to determine when to offer a meal substitute. CNA F stated that she was trained that if a resident consumed less than 50% of her meal then she should offer a meal substitute. CNA F stated, I'm waiting to see if she drinks her milk and healthshake before I offer a substitute. At that time, CNA F showed the ADL (activities for daily living) sheet in which consumption of meals were documented. CNA F pointed to a column that listed Health shake on the form and stated that it was not included in the overall percent consumption to determine 50% of meal consumption, it was counted separately. CNA F was asked if the resident consumed all of her milk would that be less than 50% consumption of her meal since she only drank her juice which was 10%? The CNA then stated, Yes, I will go see if she wants anything else to eat. Concurrently, CNA F returned to the surveyor, and stated, She said she is hungry and wants a cottage cheese and fruit plate. I will bring it to her. Review of the ADL sheet later that day indicated that Resident 5 consumed 70% of her lunch after the cottage cheese and fruit was provided. On 4/5/17 at 12:30 P.M., Resident 5's lunch meal tray was observed to have 4 ounces of juice, 4 ounces of tomato juice and 4 ounces of healthshake. According to her meal tray card located on her meal tray half cup of milk was listed under the likes section. Concurrently, RD 1 observed Resident 5's meal tray and stated that the resident should have received four ounces of milk and had not. The facility's policy and procedure titled Tray Card System (last approved 7/21/16) indicated, Policy: Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies [REDACTED]. The facility's policy and procedure titled Food Substitutions (last approved 7/21/16) indicated, Policy: Residents will be provided a substitute menu item after the planned, served meal or food item has been refused. Procedure: Nursing personnel will question any resident who does not eat his meal or food item as to why he is not eating and offer a food substitution in accordance with the resident's diet order. The facility's undated policy and procedure titled Nutritional Screening/Assessment/Resident Care Planning indicated, Policy: The resident's nutritional status and his nutritional needs will be assessed. A nutritional program specific to his needs will be planned and implemented, and then reassessed periodically for progress ., The Dietary Service Supervisor will complete the Dietitian Assessment & Monitoring Sheet on a daily basis and give this sheet to the Dietitian on each visit. This way the Dietitian will be aware of all dietary changes, new residents, consults, tube feedings, weight changes, resident who eat poorly, etc., as noted on the Dietitian Assessment and Monitoring Sheet .The Dietitian should then complete and/or review the Nutritional Assessment on these residents . 2. On 4/6/17 at 3:10 P.M., Resident 9's medical record was reviewed. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Monthly/Weekly Weight Record located in Resident 9's medical record, the following weights were noted: admitted - 1/17/17 at 117.8 pounds (lbs) 1/22/17 - 109.8 lbs 1/29/17 - 104.2 lbs. On 4/10/17 at 11:30 A.M., an interview was conducted with a registered dietitian (RD 2). RD 2 reviewed Resident 9's medical record and Registered Dietitian Nutrition Assessment that was completed by an RD on 1/23/17. RD 2 stated the RD nutrition assessment had not addressed the resident's unplanned significant weight loss of 6.8% that occurred since admission. RD 2 verified that the assessment was based upon the resident's admission weight of 117.8 lbs, and that the current weight of 109.8 lbs as of 1/22/17 was missed. The RD nutrition assessment, dated 1/23/17, indicated Relevant lab data .alb ([MEDICATION NAME]- the body's major plasma protein and serves as a transport protein) 1.4 (1/19/17), Evaluation: Rdt (resident) has decreased appetite & intake; however is meeting needs with current intake of fortified meals & healthshake's. Rdt states some possible wt (weight) loss recently secondary to decreased intake while in hospital. Goal: 1) PO (by mouth) intake greater 45% meals/shakes, 2) wt goal: 118# +/-5#. Interventions: Multivit (multivitamin) w/minerals (with minerals). RD 2 stated that the RD became aware of the significant unplanned weight loss on 2/7/17 in which the weight loss note indicated, Admit wt 117.8# (1/17/17). Current wt (weight) 102#. 15.8# (pound) wt loss less than one month. Rdt receiving mechanical soft fortified diet with healthshake's TID (three times a day) ., Rdt was regularly refusing healthshake's until 1-2 days ago. PO of healthshake's last few days 70-100%. Rdt stated she was concerned about how much dairy so was avoiding but is trying to drink now thinks they taste fine. Informed rdt of weight loss & encouraged intake. Rdt agrees to continue ., Rdt now underweight - continue healthshake's as rdt now agrees to. Recommend 1) magic cup BID (two times a day) (+580 kcals (calories)) to promote weight gain back to goal wt. New PO goal greater than or equal to 40% of meals with supplements. Wt goal remains 118# . Concurrently, RD 2 acknowledged there was a delay in the nutrition recommendation of thirteen days after significant weight loss had occurred as it was not identified by the RD at the time of the RD assessment on 1/23/17. According to the monthly and weekly weight records the following weights were noted for Resident 9 : 2/1/17 - 103.8 lbs 2/5/17 - 102 lbs, Re-weight - 102 lbs 3/2/17 - 105.8 lbs 4/1/17 - 99.8 lbs A review of a lab report indicated [MEDICATION NAME] 2.1 g/dL (grams per deciliter) (reference range 3.5 - 5.0). A dietary progress note written by the dietary services supervisor (DSS), dated 3/24/17, indicated DC magic cups BID with lunch with dinner r/t (related to) refusals. Will continue to monitor prn (as needed). On 4/7/17 at 4:15 pm., the DSS stated that the resident told her that she disliked the chocolate flavored magic cup, so she gave the resident vanilla ice-cream instead and the magic cup was discontinued. The DSS was asked if the magic cup was available in vanilla, and she stated, I don't know. I will ask the vendor. The DSS acknowledged that the magic cup was less calories and protein than what the ice- cream provided, and acknowledged that the RD was not involved in the determination when the facility obtained an order to D/C the magic cups. A review of the psychiatry notes dated 3/7/17, indicated Resident 9 has Depression eating only 20-30% of her meals, has lost a lot of weight, poor appetite due to not liking the food. Discussed [MEDICATION NAME] to improve appetite. Patient gave consent and side effects discussed A review of the informed consent form signed and dated by the physician on 3/7/17, to start on [MEDICATION NAME] due to [MEDICAL CONDITION]- weight loss and poor food intake. A review of the Medication Administration Record [REDACTED]. Resident 9 received a total of 24 doses. A review of both the physician's orders [REDACTED]. Resident 9 missed a total of 9 doses for 4/1-4/9/17. During an interview with the Medical Director (MD) on 4/10/17 at 12 pm, he stated that it was his expectation that if [MEDICATION NAME] was recommended by the psych physician and was documented in his notes that it should be acted upon after he was notified. MD stated the medication should be administered as ordered. MD confirmed Resident 9 missed a total of 9 doses for the month of 4/2017. Concurrently, the MD stated that Resident 9 had weight loss prior to admission and was receiving work up for the underlying cause of the weight loss. The MD stated he had expected the [MEDICATION NAME] order to be implemented as ordered, without missed doses, and had not known the reason the magic cup was recommended to be dc' d was because a flavor preference was not honored. The MD stated he was unaware that the significant weight loss had not been captured in a timely manner by the RD via a nutrition assessment, and therefore there were delayed nutrition recommendations. During a concurrent interview and record review on 4/10/17 at 12:40 pm, Licensed Nurse (LN) C discussed the facility process when a consulting physician recommended the order. LN C stated the Psych (psychiatrist) physician recommended the medication and the primary physician should also be notified if he was in agreement with the recommendation. LN C stated the nurse who received the order should placed on a telephone order after the primary physician was notified and in agreement. LN C confirmed this was not captured during recap and thereby it was not brought forward in the physician's orders [REDACTED]. On 4/10/17 at 10 AM, the DSS stated, I called the vendor and they do have vanilla magic cup. They will be here tomorrow. A review of an RD note, dated 4/10/17, included Rec (recommendation) Vanilla magic cup L & D (lunch and dinner) (580 cal (calories), 18 gm pro (grams of protein) . During the interview with RD 2 on 4/10/17 at 11:30 A.M., RD 2 verified that a DSS can monitor implementation of planned nutrition interventions as recommended by the RD, and ordered by the MD, but should not plan, recommend or intervene with planned nutrition interventions as it was within the scope of practice of the RD. The RD 2 stated that on 4/10/17 the DSS asked her if she was allowed to do that during IDT meetings. The RD 2 verified that the DSS should have honored a flavor preference for vanilla magic cup, eighteen days earlier instead of D/C magic cups. A dietary progress note written by the DSS, dated 4/7/17, indicated Communication slip received (dietary). D/C health shakes r/t refusals. Will continue to monitor prn. There was an order dated 4/7/17 that indicated D/C health shakes r/t refusals signed by a licensed nurse (LN C). During the interview with RD 2 on 4/10/17 at 11:30 A.M, the RD verified that the DSS should refer concerns with nutrition interventions to the RD, as an alternative nutrition approach would have been assessed. On 4/11/17 at 9:30 A.M., LN C stated, CNAs reported refusal five days in a row, so I spoke with (name of the DSS) to get confirmation to D/C the healthshake's, and then I called the doctor for the order. The facility's policy and procedure titled Personnel Management (last approved 7/21/16) included Responsibilities of the consultant dietitian; A Consultant Dietitian, registered member of the Academy of Nutrition and Dietetics, (AND, is a staff member who provides regularly scheduled on-premises consultation, to the Administrator, the Dietetic Service Supervisor, the residents, and other facility personnel and staff . The facility's Job Description for Dietary Supervisor (last approved 7/21/16) indicated, .Limitations: 3. Does not complete nutritional assessments or Care Area Assessments . The facility's policy and procedure titled Nutritional Screening/Assessment/Resident Care Planning (last approved 7/21/16) indicated, Policy: The resident's nutritional status and his nutritional needs will be assessed. A nutritional program specific to his needs will be planned and implemented, and then reassessed periodically for progress ., The Dietary Service Supervisor will complete the Dietitian Assessment & Monitoring Sheet on a daily basis and give this sheet to the Dietitian on each visit. This way the Dietitian will be aware of all dietary changes, new residents, consults, tube feedings, weight changes, resident who eat poorly, etc., as noted on the Dietitian Assessment and Monitoring Sheet .The Dietitian should then complete and/or review the Nutritional Assessment on these residents ., The Consultant Dietitian is to complete the Registered Dietitian Nutrition Assessment. All recommendations will be noted on the consultant report ., The Dietary Service Supervisor will complete the dietary recommendations within three days of receiving the Consultant Dietitian report . The facility's policy and procedure titled Weight Change Protocol (approved on 7/21/16) indicated, Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner ., Residents who experience significant changes in weight or insidious weight loss will be assessed by the RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 3# weight loss or gain in 1 week or as facility policy states, 5# weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months. The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate the success of the interventions . 3a. On 4/10/17 at 5:10 P.M., Resident 17's dinner was placed in front of him in the dining room by a certified nursing assistant (CNA J). According to Resident 17's meal tray card a magic cup (a nourishment to provide increased calories and protein) was to be served with dinner. Concurrently, CNA J was asked if the magic cup was served to Resident 17 and she pointed to a container of ice-cream, and said, Yes. CNA J was asked to bring the lid that contained the label for the ice-cream to the kitchen to ask if that was a magic cup. A dietary aide (DA K) stated that it was ice-cream and not a magic cup. DA K stated, We ran out of the magic cup so I gave him ice-cream. On 4/10/17 at 5:13 P.M., the dietary services supervisor verified that Resident 17 was not served his magic cup with dinner as ordered by the physician, and stated, We ran out. A review of Resident 17's

Based on interview and record review, the facility failed to ensure one of 10 sampled residents was free from a significant medication error when [MEDICATION NAME] (an antidepressant medication also used to treat a poor appetite) was not administered, as ordered by the physician, for a total of 9 doses. (Resident 9) This significant medication error contributed to Resident 9's continued unplanned significant weight loss. Refer to F325 and F425. Findings: The facility policy and procedure titled, Specific Medication Administration Procedures, revised 3/4/14, directed licensed staff to administer oral medications in a safe, accurate, and effective manner. Resident 9 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a resident assessment) dated 1/25/17, indicated Resident 9 was [AGE] years old, alert with intact cognition (able to think and reason) and required extensive assistance from staff for Activities of Daily Living (ADLs) such as bed mobility, transfer and hygiene. Resident 9 needed supervision and set up with eating. A review of the monthly and weekly weight record for Resident 9 indicated the following: Admit weight on 1/17/17= 117.8 pounds (lbs.) 1/22/17 =109.8 lbs. 1/29/17 =104.2 lbs. 2/1/17 = 103.8 lbs. 2/5/17 = 102 lbs. 3/2/17 = 105.8 lbs. 4/1/17 = 99.8 lbs. From 1/17/17 to 1/22/17, Resident 9 had a total of 8 lbs. weight loss (6.8%). From 1/22/17 to 1/29/17, Resident 9 had another weight loss of 5.6 lbs., equaling a total of 13.6 lbs. in one month (11.5%) for 1/17. Since admission until 4/1/17 (3 months), Resident 9 continued to have unplanned significant weight loss of 99.8 lbs. (18 lbs.) with a total of 15%. A review of the psychiatry notes, dated 3/7/17, indicated Resident 9 had Depression, eating only 20-30% of her meals, has lost a lot of weight, poor appetite, due to not liking the food. Discussed [MEDICATION NAME] to improve appetite. Patient gave consent and side effects discussed . A review of the informed consent form signed and dated by the physician on 3/7/17, indicated to start [MEDICATION NAME] due to [MEDICAL CONDITION]- weight loss and poor food intake. A review of the nurse's notes, dated 3/8/17 at 1:45 am, indicated, Receives MD order to begin resident on 7.5 mg [MEDICATION NAME] for depression with weight loss due to poor food intake. Consent is signed. The order faxed to pharmacy. A review of the Medication Administration Record [REDACTED]. The medication was started on 3/8/17 at 9 pm. The MAR indicated [REDACTED]. Resident 9 received a total of 24 doses. The facility policy and procedure titled, Psychotherapeutic Drug Management, dated 2/2013, directed the facility staff to monitor all psychotherapeutic medications for effectiveness and side effects. The medication shall be written on the Medication Administration Record [REDACTED] -Medication, dose, and time of administration -Manifestations for the drug -Side effects of the drug A review of both the physician's orders [REDACTED]. Resident 9 missed a total of 9 doses from 4/1 to 4/9/17. A review of the Lexicomp, an online drug reference for healthcare professionals, indicated [MEDICATION NAME] was used to treat [MEDICAL CONDITION] and was reported to have caused an increased in appetite by 17%. During a concurrent interview and record review on 4/10/17 at 12:40 pm, Licensed Nurse (LN) C discussed the facility's process when a consulting physician recommended the order. LN C stated the Psych physician recommended the medication and the primary physician is notified of the recommendation, if he is in agreement with the recommendation an order is written. LN C stated the nurse who received the order from the primary physician should have written a telephone order in the medical record. LN C confirmed the order was not captured during recap, and therefore, it was not brought forward in the physician's orders [REDACTED]. LN C confirmed Resident 9 may not have received the therapeutic effects of the medication when it was not given continuously, as ordered. During an interview with the Medical Director (MD) on 4/10/17 at 12 pm, he stated that it was his expectation that if [MEDICATION NAME] was recommended by the psych physician and was documented in his notes that it should be acted upon after he was notified. MD stated the medication should be administered, as ordered, especially this was to help Resident 9 improved her meal intake. MD confirmed Resident 9 missed a total of 9 doses for the month of 4/2017.

Based on interview and record review, the facility failed to ensure licensed nursing staff and physical therapists documented and communicated instructions and precautions sufficiently to direct care staff regarding the increased risk for fall to Resident 1. LVN 2 failed to supervise, communicate, and instruct direct care staff regarding Resident 1's increased risk for falling and supervisory needs. The facility failed to ensure adequate supervision when Resident 1 was left unattended and without application of an assistive device (a sensory chair alarm). These failures resulted in Resident 1 falling, sustaining a left femur (hip) fracture (reinjuring her left hip which had been recently surgically repaired). Resident 1 was hospitalized where she required a second surgical repair for her broken left hip. Findings: A review of the facility's admission records indicated that Resident 1 was admitted to the facility on [DATE] after falling at home and sustaining a broken left hip which required a surgical repair in a hospital. Additional [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS a standardized resident assessment), dated 9/30/14, indicated that Resident 1 required supervision (oversight, encouragement, or cueing) for eating, extensive assistance for bed mobility, transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), walking in room, dressing, and toilet use, and total assistance from staff was required for locomotion on and off unit (how the resident moves to and from distant areas in the facility), and for personal hygiene. A review of the facility's Investigation Summary Report, dated 11/5/14, indicated, Resident 1 "is alert to herself only" and "is not alert to time or where she is located. (Resident 1) has severe dementia and is not able to distinguish between safe and unsafe decisions. Her actions are impulsive and unplanned." It was indicated that the team from Resident 1's assisted living facility received information on purchasing a Broda chair (a larger, more supportive, multifunctional wheelchair) for Resident 1, "because she responded well using it, but because she might need to use a wheelchair on discharge, therapy initiated use of a wheel chair for a 3 day trial." A review of the Certified Nurse Aide Notes (a document where direct care staff record care provided and any unusual circumstances), dated 8/23/14 at 5:55 a.m., for Resident 1, indicated, "Resident found on floor. Bed alarm was sounding." On 12/17/14, a review of the IDT (Interdisciplinary Team, a group of facility staff members with different areas of expertise who meet to review and plan for resident care needs) notes, dated 10/3/14, revealed that Resident 1 had fallen on 10/1/14, and "was found sitting next to her bedside commode after a staff member left the room to get assistance." The notes indicated that the Broda chair was used for locomotion and to help with proper positioning in the chair, and that Resident 1 "is a high risk for falls." The IDT notes, dated 10/10/14, documented that Resident 1 had a 2nd fall on 10/3/14 and "was found sitting next to her bed on the landing mat, asking for help very loudly," and that her "recent fall risk score was 20." The interventions indicated in the IDT notes on 10/10/14 included: " hi-low bed, tri-fold mat next to the right of bed, bed against left wall, sensor alarm to bed and Broda chair, and Broda chair." The recommendation from the IDT notes, dated 10/17/14, was, "IDT feels that the interventions in place will help reduce Resident 1's risk for falling and assist in preventing injuries if she does fall. IDT does not see a need for further follow-up at this time, continue with current POC (Plan of Care)." On 12/5/14 at 1:40 p.m., an interview with a physical therapist (PT 1) was conducted. PT 1 confirmed working with Resident 1 frequently, and knowing her case well. PT 1 stated that Resident 1 had made significant progress in ambulation, reduction of pain, and mobility. The plan was to discharge her back to her home, an assisted living facility. PT 1 explained that Resident 1 had been doing well in the Broda chair. PT 1 stated that Resident 1's pain was reduced by the Broda chair because it allowed for different angles of positioning of the hip while seated and also provided increased safety in that the angle while sitting made it more difficult for residents to stand up quickly. PT 1 explained that a regular wheelchair seat is higher and easier to stand from and get out of quickly. PT 1 stated that Resident 1 was being discharged back to her assisted living facility and therapy decided to initiate a three day trial in a regular wheelchair, which she had used primarily at the assisted living facility. PT 1 confirmed that Resident 1 was "a severe fall risk" due to her "impulsive behavior" and "poor safety awareness." PT 1 stated, "Resident 1 repeatedly tried to get up out of the chair without assistance from staff" and she would need "to be within staff's view at all times during the three day trial of the regular wheelchair." PT 1 stated, "I talked to the nurses about the change of chairs and Resident 1's need to be supervised during the trial period and also the importance of the pad alarm at all times." Pt 1 confirmed he talked to the licensed nursing staff right after the change was made to the regular wheelchair from the Broda chair. PT 1 stated, "nursing knew for Resident 1...pad alarm and visual at all times." During a telephone interview on 12/17/14 at 11:15 a.m., the Director of Rehabilitation (DOR) stated that Resident 1 "needed close supervision with line of sight visual monitoring during wheelchair trial" because "she is quick and could fall if not seen," and "staff would have to intervene quickly." DOR explained that Resident 1 needed to be in a place where she could be observed at all times. "If the dining room is closed she should have her meals at the nurses station." She added that Resident 1's needs fluctuated with the time of day. At nighttime, more supervision was needed. She stated, "it helped when Resident 1 had something to do like folding towels or looking at her memory book to divert her attention." DOR stated that on 10/30/14, she "care planned the wheelchair trial" and "PT 1 verbally informed nursing staff about changes." A review of the physical therapy short term care plan note, dated 10/30/14, indicated DOR documented, "Trialing Reg (regular) W/C (wheelchair) for D/C (discharge) to ALF (assisted living facility) x 3 day. & Re-eval. If she does not tolerate put back in Broda chair (Rm 9)." The Physical Therapy Department did not sufficiently convey in the care plan the need for, or give sufficient instructions or guidance pertaining to, Resident 1's increased fall risk condition after initiating the trial of wheelchair. On 12/17/14 at 10:10 a.m., an interview was conducted with the day shift licensed nurse (LVN 1) responsible for Resident 1 on 10/30/14. LVN 1 recalled and explained that on 10/30/14 at approximately 2 p.m., "just before change of shift, (PT 1) came to nurses station and let us know they had just started a three day trial from the Broda chair to the regular wheelchair and Resident 1 would need increased supervision." LVN 1 stated that Resident 1 "was confused and impulsive, and really quick, and she tries constantly to get out of her chair, and the chair alarm is constantly going off." LVN 1 added that on 10/30/14 she had Resident 1 eat lunch at the nurse's station so she could "keep an eye on her." She also gave her towels to fold and stated, "she did better when she was occupied with a task." LVN 1 commented that in the past, Resident 1 had fallen in her room when left alone and she was not comfortable with leaving her in her room unattended, due to fall risk. LVN 1 stated, "(Resident 1) needs constant supervision, and whether in the dining room or by the nursing station, she needs to be visible at all times and have her chair pad alarm on." When asked, how changes are communicated to nursing and direct care staff and how are they documented, LVN 1 explained that "physical therapy does the care planning and this goes in the chart. The day charge nurse reports to the evening charge nurse and documents on the Charge Nurse 24 Hour Report, and the nursing staff "huddles" with nurse aides to discuss changes at change of shift and any other time it is needed." LVN 1 stated that on 10/30/14, at or just before change of shift, "all nursing staff members knew to always keep Resident 1's chair alarm on, keep an eye on her, and when in chair has to be in visual sight of staff." The Charge Nurse 24 Hour Report (a nurse to nurse communication tool) for day shift to report to evening shift, dated 10/30/14, was reviewed. The comments documented by LVN 1 for Resident 1 were, "going home on Wednesday, in W/C no more Broda." There were 44 residents listed on the report. There was documentation that 12 residents were high risk for falls. However, it was noted there was no documentation of Resident 1's fall risk on the report. Resident 1 had no documentation of increased fall risk, or line of sight intervention, or that she should have meals at nursing station, or that she should not be left unattended. There was no documentation of the increased risk for fall or of new interventions that would help prevent a fall. LVN 1 stated that she did give a verbal report at change of shift to LVN 2 using the Charge Nurse 24 Hour Report document as a tool, and she verbally informed CNA's of changes and increased need for supervision of Resident 1. LVN 2 was not available for interview. During an interview on 12/17/14 at 10:45 a.m., the Director of Nursing (DON) explained that LVN 2 voluntarily resigned and it was her knowledge that LVN 2 was no longer residing in America. A concurrent review of personnel documents and payroll records revealed that LVN 2 was the PM (evening shift) licensed nurse on 10/30/14, and LVN 2's last day worked at the facility was 11/11/14. The DON confirmed that the dining room was closed on 10/30/14 as a precaution due to an outbreak in the facility of upper respiratory infection (URI). The DON stated "there was more staff to supervise residents in the dining room, and less supervision when residents dine in their rooms." The DON stated, "Resident 1 is safer when in a group" and "the wheelchair was risky." The DON went on to explain that this incident (Resident 1 falling) "happened after IDT was gone for the day and they were not involved." On 12/17/14 at 10:10 a.m., an interview was conducted with the day shift Certified Nurse Aide (CNA 1) who was assigned to Resident 1 on 10/30/14. CNA 1 has worked at the facility since 5/2014. CNA 1 confirmed that Resident 1 needed bed and chair alarms due to fall risk. CNA 1 stated when physical therapy makes a change to the care plan, "CNA's get notified either by one of the physical therapists or by the charge nurse on duty." She could not recall which of the two made the notification on 10/30/14 regarding Resident 1, but she does recall that she was notified. CNA 1 recalled the dining room was closed for "a couple of days" but was "not sure if it was closed day shift on 10/30/14." CNA 1 stated that on 10/30/14, "I gave a verbal report to CNA 2, who was assigned to Resident 1 on the PM shift, about Resident 1's change to the wheelchair." When asked where changes are documented, CNA 1 stated, "The change might be documented on the Kardex (a document kept in the resident's room used by direct care staff as a quick reference guide regarding care needs of the resident), but I'm not sure if it was." On 12/17/14 the Kardex for Resident 1 was reviewed and was found to have missing pertinent information regarding falls and accidents. On 10/30/14, the facility failed to update Resident 1's Kardex to reflect and communicate to direct care staff the need for increased supervision, line of sight observation at all times, meals at nursing station, or the change from Broda chair to regular wheelchair. On 12/5/14 at 2:55 p.m., an interview was conducted with CNA 3. CNA 3 was a regular caregiver to Resident 1 but was not assigned to Resident 1 on 10/30/14. CNA 3 described Resident 1 as "determined when she wanted to try and get out of her chair" and "she was mostly alert and confused" and "her bed and chair alarms would go off a lot." CNA 3 stated that on 10/30/14, "it was a crazy day, we were really busy, I heard Resident 1's roommate calling help, help, please help. I saw Resident 1 on the floor, on her back, and her leg just looked wrong, she was trying to get up. I asked the nurse for help, and the MDS Nurse called 911. The female physical therapist came in to evaluate Resident 1 who kept saying she wanted her leg to be straight." CNA 3 stated that when she came in the room and saw Resident 1 lying on the floor "the chair alarm was in place but it wasn't going off." By that time CNA 2 had come into the room. CNA 3 stated that CNA 2 stated to her," I didn't turn it on" referring to the chair sensor alarm. When asked how direct care staff is notified of changes in the care plans of residents and where would she find changes documented, CNA 3 stated, "sometimes the physical therapists would verbally tell you, or they would tell the charge nurse and then they would tell us." CNA 3 stated that she did not remember talking to the physical therapist about Resident 1 being taken out of the Broda chair and put into a regular wheelchair. She did say that she vaguely remembered "some talk that day about the switch," but could not remember who was reporting it. CNA 3 stated that there had been a lot of talk amongst staff that the change to the wheelchair might cause a fall. CNA 3 stated the change to the wheelchair "might get documented on the Kardex." On 12/5/14 at 2:20 p.m., an interview with CNA 2 was conducted. CNA 2 confirmed that she worked the PM (evening) shift on 10/30/14, and was assigned to care for Resident 1. CNA 2 explained that on 10/30/14 "I was working a three (three CNA's for entire building), I was caring for an entire hallway by myself." CNA 2 described Resident 1 as "constantly trying to get up and go, is confused, keeps looking for her dog, and wanting to go home, and her bed and chair alarms go off a lot on the PM shift." CNA 2 stated that on 10/30/14, just prior to Resident 1's fall, she and CNA 3 had just toileted Resident 1. When they were done, CNA 3 left the room and CNA 2 prepared Resident 1 for dinner by setting her up in the wheelchair and putting her tray table in front of the wheelchair. CNA 2 stated, "the dining room was closed," but could not remember why. She then left the room leaving Resident 1 unattended. When asked for how long was Resident 1 unattended before she was found on the floor by CNA 3, CNA 2 stated, "it was just a minute or two, I was in the charting room when CNA 3 found Resident 1 on the floor and she alerted other staff members. When I came in the room I could see that Resident 1's hip was obviously malformed." CNA 2 stated, "I locked the wheelchair in place and placed the tray table in front of Resident 1, but I forgot to set the chair alarm, it wasn't on, I just forgot." CNA 2 stated, "Resident 1 was at risk for standing, I didn't think she should be in a regular wheelchair." When asked how the change from the Broda chair to the regular wheelchair was communicated to her on 10/30/14, and where would this change be documented for direct care staff, CNA 2 replied, " I got report from the day shift CNA about the change to the wheelchair, but the nurses did not communicate to me that day any special instructions regarding the wheelchair or supervision." When asked if the care plan had been updated on the Kardex, CNA 2 stated, "I don't remember looking at the Kardex that day." Resident 1's Fall Risk Evaluation (an assessment tool used to score a resident's potential to fall) documents were reviewed, indicating that Resident 1's score was elevated each month as follows: In 8/2014, the score was 18; on 9/30/14 the score was 20; and on 10/30/14, the score was 22, yet no new interventions were ordered on [DATE]. It was noted that the Fall Risk Evaluation done on 10/30/14 was not signed by the nurse and there was no indication of the time of day the evaluation was performed. According to the Fall Risk Evaluation document, "if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls." The facility's Fall Prevention Program policy, dated 2/2013 required, "All residents' environment shall remain as free of accident hazards as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents."

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents remained free from accidents which caused six injuries, from 14 falls, over a nine month period, and that Resident 1 received adequate supervision and care to prevent 14 falls. This resulted in a broken left hip, lacerations to the front and back of the head, and bruises to the right knee, left forehead, and left elbow. (Resident 1) Findings: Resident 1 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set (MDS) (an assessment tool), dated 12/26/12, indicated that Resident 1 needed extensive assistance with ambulation and mobility, and had long and short term memory problems. The facility's "Fall Risk Assessment" (a tool used to evaluate Resident 1's risk for falls), dated 11/20/12, was reviewed. The assessment indicated that residents with a score of 10 or above were a high risk for falls. Resident 1 was identified to be at high risk for falls with a score of 12 due to disorientation, a history of falls, difficulty with ambulation and balance, and receiving medication for high blood pressure, pain, and psychosis. Resident 1's record indicated that over a seven month period, from 11/19/12 through 7/13/13, Resident 1 fell 14 times, either from his bed or from a wheelchair (or Geri-chair) to the floor and six of the 14 falls resulted in injury. There was no comprehensive care plan developed for the Resident's fall risk and falls. On 4/1/13, Resident 1 was found on the floor and sustained a right knee abrasion and left shoulder discoloration. On 4/3/13, two days later, the facility completed a "Post Fall Assessment." The mental status/judgement section identified Resident 1 as having poor judgement and possible side effects from an adjustment in medication. The facility's intervention in response to the fall included, "During increased agitation get up in Geri-chair at Nurse's Station." There were no additional fall prevention interventions in place. On 4/17/13, Resident 1 was found on the floor and sustained a laceration to the right back side of his head. No additional interventions were added to a care plan. The facility completed a "Post Fall Assessment" on 4/18/13. The mental status/judgement section described Resident 1 as being alert and confused with poor judgement. The facility's action taken to prevent falls from recurring read: "Continue with current safety interventions." There were no further interventions documented on the care plan. The same day, 4/18/13, Resident 1 was again found on the floor and sustained a laceration to the right forehead. A "Post Fall Assessment" was completed on 4/19/13. Resident 1 was described as alert and confused with poor judgement. The action taken to prevent recurrence included: "Multiple falls so far the month. Nursing and MD are working on effective pain management. Safety measures in place to prevent further injury with falls." In an interview on 7/25/13 at 11:20 am, the DON was asked to describe the specific safety measures in place, but was unable to do so. On 4/28/13, Resident 1 fell from his chair and sustained a bump on the left forehead. The facility's "Post Fall Assessment" was completed on 4/29/13. Resident 1 continued with confusion and poor judgement. The "Action taken to prevent falls from recurring" section read: "Resident is continuing to have falls...Resident will no longer be up in Geri-chair d/t (due to) increased for injury." No comprehensive care plan was developed or revised, for the period of 4/1/13 through 4/28/13, to meet the individualized needs for Resident 1's falls and continued risk for falls. On 6/17/13, Resident 1 had an unwitnessed fall and was found sitting on the floor in the hallway. A hip x-ray, obtained at the facility on 4/18/13, confirmed a broken hip. Resident 1 was then transferred to the hospital for further evaluation. The "Post Fall Assessment," completed on 6/18/13, continued to describe Resident 1 having poor judgement. The action taken by the facility to prevent falls from recurring was to re-evaluate Resident 1 when he returned from his hospital stay due to a broken hip. Resident 1 returned to the facility, and on 7/9/13, Resident 1 had an unwitnessed fall and was found on the floor next to his bed. He sustained a skin tear to the left elbow. The "Post Fall Assessment" was completed on 7/10/13. The section, "Action taken to prevent falls from recurring:" read, "Continue with current safety interventions, resident continues to have unwitnessed falls and behaviors." No additional interventions were added to the care plan. In an interview on 7/25/13 at 11:20 am, the DON was asked about specific interventions the facility used to prevent Resident 1 from falling, she stated, "We have put him in a high back chair but we have run out of options for him now and haven't tried anything else." When asked if Resident 1's falls were preventable, the DON stated, "Honestly, it was going to happen and it was just a matter of time. He is always at risk, but we have run out of options."

Based on observation, interview and record review, the facility failed to ensure that one of 12 sampled residents (Resident 10) received the necessary care and services, in accordance with the comprehensive assessment and accepted standards of clinical practice, to maintain his highest practicable well-being by failing to: Ensure specific policies and procedures for assessment, site care and dressing changes, and emergency plans were readily available for a central venous [MEDICAL TREATMENT] (a specialized procedure to remove toxic wastes from the blood when the kidneys are not functioning) catheter (a centrally placed catheter inserted into a large vein near the heart); Obtain physician's orders [REDACTED]. Develop and implement a comprehensive plan of care to include assessment, care, and maintenance of a central venous catheter (See F279); Ensure that pre-[MEDICAL TREATMENT] medication administration was accurately documented by licensed nursing staff (See F514); Ensure that licensed nursing staff were trained and competent to provide central venous catheter care and manage emergencies and complications (such as bleeding, infection, catheter dislodgment). (See F500 and F501). These failures placed Resident 10 at risk for not having his individual care needs met and complications of life-threatening irregular heart rhythms, low blood pressure, dehydration, central line intravenous catheter contamination, local infection (site specific), systemic (body-wide) infection, blood clotting, catheter dislodgement, air embolism (a life-threatening occlusion caused by an air bubble), excessive bleeding and death. Findings: Resident 10, a [AGE] year old male, was admitted from a hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a central venous [MEDICAL TREATMENT] catheter for [MEDICAL TREATMENT] treatment. A review of a hospital consultation report, dated 7/3/11, disclosed that Resident 10 had a bleeding and clotting complication with his right central jugular venous catheter, due to pulling or trauma during the night while in the hospital. According to physician progress notes [REDACTED]. Abnormal potassium levels can cause life-threatening irregular heart rhythms). A review of Resident 10's Minimum Data Set (MDS), an assessment tool, dated 9/1/11, indicated that Resident 10 was alert, with periods of confusion and had short term memory problems. The assessment indicated that he received [MEDICAL TREATMENT] services. Review of a care plan titled, "Chronic Renal (kidney) Failure Care Plan," dated 7/15/11, revealed that the problem/need for the care plan and Resident goal sections were not completed (they were blank). The care plan indicated that the [MEDICAL TREATMENT] center would change the "shunt site" dressing two times weekly and weigh the resident before and after each [MEDICAL TREATMENT] treatment. The nursing staff were to monitor the "shunt site" (noted to be a right [MEDICATION NAME] line - a large vein that goes into the heart) every shift (but did not specify what was to be monitored) and ensure restriction of fluids taken in, as per physicians orders. There were no further revisions or added interventions to the renal care plan after 8/14/11. Review of Resident 10's physician's orders [REDACTED]. A review of the Resident 10's intake for this time disclosed that facility staff had not recorded Resident 10's intake until 8/1/11, with seven missing entries, totals below the ordered amount, and one total of 1140 mls through 8/14/11. Resident 10's physician's orders [REDACTED]. The physician specifically ordered that the facility was to provide Resident 10 with 200 mls of fluids during the night shift, 800 mls during the day shift, and 500 mls during the pm shift. A review of Resident 10's fluid intake records, dated from 8/22/11 through 10/9/11, indicated that Resident 10 did not receive his total 1500 ml, as ordered by the physician, for 1 of 29 days. For the remaining 28 of 29 days, the entries were either incomplete (blank with no documentation) or below the ordered fluid amount. The facility did not ensure that Resident 10 received the specific fluid ordered by his physician. During an interview with the DON on 10/13/11 at 4:30 pm, she stated that she was unaware that Resident 10 was still on a fluid restriction and confirmed that the physician's orders [REDACTED]. A review of physician orders, dated 9/29/11, indicated that Resident 10's [MEDICAL TREATMENT] was on hold, therefore, effective 9/29/11, the resident was no longer receiving care from the [MEDICAL TREATMENT] center, as care planned, and there were no care plan updates to demonstrate the facility's plan of care for Resident 10 (such as weights and central venous [MEDICAL TREATMENT] catheter care). A review of Resident 10's Treatment Administration Records (TAR's), since admission on 7/15/11, indicated that the facility had no documented evidence that the licensed nursing staff were monitoring Resident 10's central venous catheter site every shift, as per his care plan. On 10/14/11 at 9 am, the DON was asked for the facility's policy for residents receiving [MEDICAL TREATMENT], however, a policy was not provided. The DON confirmed that Resident 10's care plan was not updated to reflect his [MEDICAL TREATMENT] was on hold. The DON confirmed the missing assessments of Resident 10's central venous catheter site every shift, the lack of clear documentation as to the catheter type (there were differing vein insertion sites in the records), and confirmed that that the facility had no specific physician's orders [REDACTED]. treatments. During an interview with the charge nurse, Licensed Vocational Nurse (LVN) G on 10/13/11 at 9:20 am, she stated that Resident 10's [MEDICAL TREATMENT] had been put on hold since 9/29/11 because his blood pressure had been dropping and that he had critically low potassium blood levels (which can cause serious heart irregularities). On 10/13/11 at 2:30 pm, in a concurrent observation and interview, Resident 10 stated that he wanted the [MEDICAL TREATMENT] catheter out since he was not receiving [MEDICAL TREATMENT] and he was concerned it would cause him an infection. Resident 10 then showed the surveyor his [MEDICAL TREATMENT] catheter. The [MEDICAL TREATMENT] catheter site was observed uncovered, without a dressing and open to air. Black stiches were observed at the insertion site and the catheter had two lumens (vein access ports) that were dangling and unsecured. Resident 10 stated he did not know for how long the catheter site had been without a dressing. On 10/13/11 at 3 pm LVN G was notified that Resident 10 was observed by the surveyor to have no dressing covering his [MEDICAL TREATMENT] catheter site. LVN G stated that she had noticed the site was without a dressing an hour ago. On 10/14/11 at 9:15 am, Resident 10's [MEDICAL TREATMENT] catheter site was observed. A clear adhesive dressing that did not completely cover the catheter site or lumens was observed to be loose, exposed to air, and the lumens were dangling and unsecured. On 10/14/11 at 9:20 am, LVN G stated she had applied a dressing to Resident 10's [MEDICAL TREATMENT] catheter site on 10/13/11, and neither LVN G nor the resident wore a mask. (Throughout the survey from 10/11 to 10/14/11, LVN G was observed repeatedly coughing and on several occasions was overheard to say that she was sick, placing Resident 10 at risk for developing an infection at his [MEDICAL TREATMENT] catheter site). On 10/14/11 at 10:10 am, Resident 10's dressing was observed. The dressing was loose and did not completely cover the [MEDICAL TREATMENT] catheter site or cover/secure the lumens, as was observed on 10/14/11 at 9:15 am. On 10/14/11 at 10:30 am, the DON was asked for the facility's policy for central line dressing changes, related to central venous [MEDICAL TREATMENT] catheters. A policy was not provided at this time. On 10/14/11 at 11:30 am, when asked for the facility's plan to provide care for Resident's [MEDICAL TREATMENT] catheter, the DON stated that two night nurses were the designated nurses trained to assess and provide care for Resident 10's central venous catheter site. In an observation on 10/14/11 at 2 pm, Resident 10's [MEDICAL TREATMENT] catheter dressing was observed to be loose and exposed to air, not completely covering the catheters site or lumens, as was in the previous two observations. On 10/14/11 a 2:20 pm, during a concurrent interview and document review, the DON presented another copied document from the Lippincott manual 8th Edition, 2006, titled, "Catheter Maintenance Guidelines" that did not address the procedure for a central venous catheter dressing change. On 10/14/11 at 3 pm, in a concurrent interview and document review, the DON presented another copied document from Lippincott's Nursing Manual, "Central Venous Access Devices" which did not address how to perform central venous cathter care or dressing changes, but rather catheter insertion information. The DON stated that she had called the [MEDICAL TREATMENT] clinic who said they were too busy and could not come to apply a sterile dressing to Resident 10's [MEDICAL TREATMENT] catheter, however, she obtained a policy from the facility's contracted pharmacy. The policy titled, "Central Venous Access Device ([MEDICAL CONDITION]): Dressing Change," dated 12/30/10, required that a mask would be worn during dressing changes and indicated that the procedure purpose was to provide standardized sterile dressing changes to reduce or prevent complications and systemic infection. She stated that the facility's pharmacy was going to send a nurse to change the dressing and that it would take the nurse about four hours to get to the facility. The DON stated she was not trained to perform the sterile dressing change herself. The DON provided another copied document from the Lippincott's Manual titled,"[MEDICAL TREATMENT], General Procedures and Treatment Modalities" which did not instruct on access site care, but indicated that infection, catheter clotting, ischemia (lack of circulation) of the hand and aneurysms (abnormal dilation of a blood vessels) were common complications. It further disclosed the importance of the sterile maintenance of the closed [MEDICAL TREATMENT] catheter system, and monitoring of a [MEDICAL TREATMENT] resident by a specially trained nurse. According to Center for Disease Control (CDC) Guidelines, in controlling Central Line Infections, "Dressing changes are to be performed using sterile technique, including masks for both patient and nurse. [MEDICATION NAME] (CHG, an anti-bacterial cleansing agent) skin preparations are preferred. These should be applied with...plenty of friction to allow the solution to get as far as possible into the skin...skin preparation solution must be allowed to dry before dressing application. For additional protection against line infection...use a CHG-impregnated sponge at the catheter exit site. Sterile securement device MUST be used to comply with this standard ...transparent, semi-permeable dressings (TSM)...allow visualization of the insertion site at all times...and should be changed at least weekly and when they are no longer clean, dry and adherent on all sides." A review of The National Kidney Foundations (NKF) guidelines for vascular access disclosed there is a higher rate of infection in [MEDICAL TREATMENT] patients when new or inexperienced staff manipulate the patients vascular access. The article recommends to keep the catheter dressing clean and dry, not to get the catheter dressing wet as moisture can cause infection. The foundation instructs that professionals changing the dressing should wear a mask and ensure the clamps of the catheter are tightly closed when the catheter is not being used for [MEDICAL TREATMENT]. The NKF Vascular Access Guidance, included, "airborne contaminants from both patients and staff are best prevented by the use of surgical masks when the catheter lumens or exit site are exposed. Wearing clean gloves and avoiding touching exposed surfaces further decreases the risk for infection. Aseptic technique includes minimizing the time that the catheter lumens or exit site are exposed." On 10/14/11 at 4:45 pm, the concerns surrounding Resident 10's individual care needs and central venous [MEDICAL TREATMENT] catheter care were discussed with the DON. The DON confirmed that physician's fluid restriction orders had not been followed since admission to the facility and that licensed nursing staff had not monitored fluid intake, as ordered by the physician, or assessed Resident 10's central venous catheter site every shift. The DON confirmed that Resident 10's [MEDICAL TREATMENT] catheter should be covered with a sterile dressing and a comprehensive plan of care was needed, however, the facility was unable to provide such a plan of care. The DON stated that the facility did not have a central venous catheter care policy, that they relied on the [MEDICAL TREATMENT] center who were no longer treating the resident, and that neither herself nor the facility's licensed nursing staff were trained to provide the central venous catheter care. The DON confirmed that LVN G (the charge nurse) had not obtained a physician's orders [REDACTED]. The DON confirmed that the facility had no measures in place to address an emergency, such as if the [MEDICAL TREATMENT] catheter were to become dislodged, or to ensure that the site is sterile, the lumens are secured, and the site is kept dry, such as when bathing. On 10/14/11 at 5:40 pm, an Immediate Jeopardy (IJ) was called in the presence of the facility administrator and DON due to the inability of the facility to provide a comprehensive plan of care to meet Resident 10's individual care needs, including central venous catheter care, in accordance with accepted standards of clinical practice. These actions caused or were likely to cause serious injury, harm, impairment, or death to Resident 10. On 10/14/11 At approximately 5:45 pm, Resident 10 was observed being wheeled down the hallway toward the front door. The DON stated that the Resident was being transported to a local emergency room for evaluation and treatment of [REDACTED]. The DON indicated at that time that Resident 10 was expected to return to the facility that same day. The facility had no plan in place to care for a central venous catheter, upon the resident's return to the facility. The DON indicated the facility was working on a plan of correction to address the resident's care needs in anticipation of his return. A review of the hospital records, dated 10/16/11, revealed that Resident 10 had a PermaCath central line (a brand name of an intravenous catheter that is either inserted in the [MEDICATION NAME] or internal jugular veins and then advanced either into the superior vena cava vein or the right atrium (chamber) of his heart). The physician's documentation indicated the catheter was inserted in the jugular vein, not the [MEDICATION NAME] vein. On 10/16/11 at 4:50 pm, the facility's administrative staff were informed that the IJ was abated when the Department was able to determine that Resident 10 was no longer expected to return to the facility, as he had been admitted to the hospital, and that the [MEDICAL TREATMENT] catheter had been removed. Resident 10's admitting [DIAGNOSES REDACTED].