Every finding on record at Golden Sonora Care Center

Based on interview and record review the facility failed to ensure professional standards of care were met for one of three sampled residents (Resident 1), when the licensed staff did not obtain a physician's order for care and monitoring or develop a specific care plan related to when Resident 1 sustained an abrasion (wound) to his right thigh during a witnessed fall on 4/8/26. These failures placed Resident 1 at risk of infection and unidentified wound deterioration.Findings:A review of Resident 1's admission RECORD, indicated he was admitted to the facility with diagnoses which included hemiplegia and hemiparesis (weakness or inability to move one side of the body).During an interview on 7/9/26 at 1:24 PM with Resident 1, Resident 1 stated approximately two to three months ago, during a transfer with a mechanical lift (an assistive device used to safely transfer immobile residents between a bed and a chair or wheelchair) staff lost control of him and he was dropped to the floor. Resident 1 further stated he could not remember much else about the incident.During a review of Resident 1's clinical document titled, Alert Charting: Fall/Accident/Injury, dated 4/8/26 at 9:13 PM, the document indicated, .Resident was pulling himself up into a [Brand name mechanical standing aide] with assistance when resident stated, 'I can't pull myself up'. Residents wheelchair was moved behind resident when resident began to slip from [standing aide]. Wheelchair had both breaks on and slid back back [sic], when CNA [certified nurse assistant] then had to assist resident to ground.Resident was assessed, an 8 cm [centimeter, unit of measure] x [by] 4 cm [approximately 3 inches by 1.5 inches] abrasion to right posterior [back of] thigh was noted. (documentation had strike out lines through entire note and strike out reason indicated, not required).During an interview on 7/9/26 at 3:38 PM with licensed nurse (LN) 2, LN 2 stated she was called into Resident 1's room on 4/8/26 by CNA 2. LN 2 further stated when she entered the room, she observed Resident 1 on the floor with his legs still in the standing aide. LN 2 stated she assessed Resident 1 and noted a skin tear to the back of his thigh. LN 2 stated she had no further recollection of the incident.During an interview on 7/10/26 at 10:23 AM with CNA 2, CNA 2 stated on 4/8/26, there were two CNAs in the room transferring Resident 1 from the wheelchair to bed. CNA 2 stated he assisted Resident 1 while the other CNA held the mechanical lift aid device. CNA 2 stated he instructed Resident 1 to pull himself up using the bar on the mechanical lift aide. CNA 2 further stated Resident 1 was unable to pull himself up and the mechanical lift moved away from Resident 1. CNA 2 stated Resident 1 had pushed the wheelchair away when he tried to stand and CNA 2 could not place the wheelchair back under Resident 1, and that was when CNA 2 stated he guided Resident 1 to the floor.During an interview on 7/9/26 at 3:07 PM with the Assistant Director of Nurses (ADON), the ADON confirmed there was no physician's order, care plan, or documentation in Resident 1's clinical record to indicate the LN had routinely monitored Resident 1's abrasion for signs of infection or worsening of the wound. The ADON stated a care plan should have been initiated and an order obtained to ensure proper care was provided. The ADON stated it was her expectation that the licensed nurses would monitor Resident 1's abrasion routinely due to the potential for worsening and/or infection.During a review of a facility policy and procedure (P&P) titled, Skin Integrity, the P&P indicated, .For new skin impairment identified, the LN completes the following: Documents the impairment that includes measurements of location, size, color, presence of odor, exudate, and presence of pain associated with the skin impairment.Bruises, skin tears and abrasions are monitored on the Treatment Administration Record (TAR) weekly, until resolved.Notifies the medical provider and, if needed, obtains a treatment order.Implements interventions and documents on the resident's care plan.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate care and services for bladder incontinence (involuntary leakage of urine) when the facility staff did not perform incontinence care during mealtimes. This failure had the potential for Resident 1 to experience skin breakdown (sores) and/or infection.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia and hemiparesis (weakness or inability to move one side of the body) affecting the right dominant side of the body. During a review of a complaint received by the Department on 5/5/26, Resident 1 reported that the facility nursing staff repeatedly failed to change her incontinent briefs (adult diaper) in a timely manner, especially during mealtimes. Resident 1 stated she was prone to urinary tract infections and could not get to the bathroom on her own. The department conducted an onsite visit on 5/20/26 and confirmed Resident 1 no longer resided in the facility. During a review of Resident 1's clinical document titled, Care Plan Report, dated 3/12/26, the document indicated .Problem.The resident has bladder incontinence r/t [related to] Impaired Mobility.Goal.The resident will remain free from skin breakdown due to incontinence and brief use.Interventions/Tasks.Clean peri-area [area covered by disposable brief] with each incontinence episode. During a review of Resident 1's clinical document titled, Care Plan Report, dated 3/12/26, the document indicated, .Problem.The resident has an ADL [Activities of Daily Living, brushing hair, toileting, getting dressed] self-care deficit [unable to fully do by one's self].Interventions.TOILET USE: The resident is totally dependent on 2 staff for toilet use.TOILETING HYGIENE: Assistance by 1 staff for toileting hygiene. During an interview on 5/20/26 at 12:49 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated the staff were not supposed to provide incontinence care to the residents during mealtimes. CNA 1 further stated the residents became very upset when they did not receive care at mealtimes, but staff explained to them that it was an infection control issue and they could not do it. During an interview on 5/20/26 at 12:58 PM with Licensed Nurse (LN) 2, LN 2 confirmed the staff did not take residents to the bathroom or provide incontinence care during mealtimes unless the residents were insistent or were crawling out of bed. During an interview on 5/20/26 at 4:26 PM with the Assistant Director of Nurses (ADON), the ADON stated residents should receive incontinent care at a minimum of every two hours. The ADON further stated CNAs were taught that resident care comes first and they are consistently reminded that residents can be changed and taken to the bathroom during meals. During an interview on 5/21/26 at 12:32 PM with the Infection Preventionist (IP), the IP stated she educated the staff to provide incontinent care to the residents a minimum of every two hours and more frequently if they had a urinary tract infection. The IP further stated if the residents were not changed in a timely manner there was a potential risk for skin breakdown and/or infection to occur. During a review of a facility document titled, URINARY INCONTINENCE AND INTERVENTIONS, updated 7/2014 the document indicated, .The definition of incontinence is 'the involuntary loss or leakage of urine.' .Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning.The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis or skin erosion. During a review of a facility policy and procedure (P&P) titled, Infection Control Policies and Practices, revised 3/19/25, the P&P indicated, .The objectives of facility infection control polices, protocols and practices are to.Support prevention, detection, investigation, and transmission of infections.All personnel receive training on facility infection control policies, protocols, and practices upon hire, annually, and periodically as necessary.

Based on interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's ammonia levels test results (blood test that measures waste buildup caused by liver or kidney failure) on 3/23/26, 3/26/26 and 3/29/26 were not reported to the MD (medical doctor), and; 2. Resident 2's basic metabolic panel (BMP - laboratory test to check on fluid balance, kidney function and blood sugar levels) laboratory results on 3/23/26 and 3/30/26 were not reported to the MD. These failures had the potential for the facility to not recognize Resident 1 and Resident 2's potential change in conditions which could have resulted in delays in their care and worsening conditions. Findings: 1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses that included hepatic encephalopathy (a brain dysfunction condition caused by advanced liver disease when toxins like ammonia builds up and affects brain function), liver cirrhosis (permanent scarring of the liver caused by long term damage which hinders blood flow and the ability to filter toxins), and chronic kidney disease (condition when the kidneys are permanently damaged and not filtering blood properly). A review of Resident 1's medical record titled, Order Listing Report, indicated, .lab work: check ammonia levels. Notify doctor if labs are about 65 [reference range - 9 to 35] every day shift. was ordered on 3/21/26. A review of Resident 1's medical record, the ammonia level laboratory results were as follows: a. 3/21/26 = 57 b. 3/22/26 = 51 c. 3/23/26 = 66 d. 3/24/26 = 57 e. 3/26/26 = 71f. 3/27/26 = 52 g. 3/29/26 = 93h. 3/30/26 at 1500 (3 p.m.) = 93i. 3/30/26 at 1951 (7:51 p.m.) = 44 j. 4/1/26 = 42A review of Resident 1's medical record titled, Progress Notes, indicated the following dates with ammonia level results above 65, were as follows: a. 3/23/26 -No documentation found for Resident 1's ammonia levels were received and reported to MD.b. 3/26/26 - .Ammonia. Serum level. Drawn this morning. Value 71. no documentation of the result reported to MD. c. 3/29/26 - no documentation found for Resident 1's ammonia levels were received and reported to MD.d. 3/30/26 - .[Resident 1's preferred name] informed this writer regarding his concern about his ammonia level yesterday was 93.Requested to sent out to ER [emergency room] if the result of the ammonia level today (blood drawn 1.5 H [1 hour and 30 minutes] ago) is still high. RN on duty informed [MD] obtained an order to send him out to .ER. During a concurrent interview and record review on 4/1/26, at 2:31 p.m., with Licensed Nurse (LN) 1, Resident 1's medical record was reviewed. LN 1 confirmed Resident 1 had an order for his ammonia levels to be checked daily and to have notified the MD if the result was above 65, dated 3/21/26. LN 1 stated Resident 1 had an order for medication called Lactulose (medication for constipation and to reduce ammonia levels in the blood) to manage his ammonia levels. LN 1 further stated this medication was the reason for the frequent ammonia levels to be checked so the MD could have adjusted the medication dose based on the results. LN 1 stated it was important to have provided Resident 1 with the care that he needed because he relied on the facility for his overall health. LN 1 further stated Resident 1's health could have gone downhill and could get depressed if he was not getting the care he needed. During an interview on 4/1/26, at 3:25 p.m., with LN 2, LN 2 stated when the resident had a laboratory blood draw order, the nurse would have sent the results to the MD for review to determine what was needed to be ordered for the resident. During an interview on 4/2/26, at 10:14 a.m., with LN 3, LN 3 stated if a resident had laboratory blood draw orders and the results were already received, the nurse would have notified by messaging or faxing the results to the MD. LN 3 further stated the nurse would have called the MD right away if the laboratory results were critical or urgent. LN 3 stated the nurse would have documented under the resident's progress notes if the nurse followed up and to have also indicated any MD orders. During a concurrent interview and record review on 4/2/26, at 11:55 a.m., with the Unit Manager (UM), Resident 1's medical record was reviewed. The UM confirmed Resident 1's ammonia daily laboratory order indicated a result of 65 and above should have been reported to the MD. The UM stated Resident 1 had ammonia level results above 65 on the following dates without any documentation that the results were reported to the MD on 3/23/26, 3/26/26 and 3/29/26. The UM further stated the nurses who received laboratory results should have documented in Resident 1's chart that the MD was notified, laboratory results were sent and whether MD ordered anything based on the results. The UM stated it was important to have reported Resident 1's ammonia laboratory results because his Lactulose medication could have been adjusted or he could have been sent out to the hospital if needed. The UM further stated it was important for the nurse to have documented to determine if the results were reported to the MD. The UM further stated Resident 1's ammonia levels could have been unnecessarily high and would also have been hard to track due to the lack of documentation. 2. A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in 2025 with diagnoses that included dementia (a progressive state of decline in mental abilities) and cognitive communication deficit (difficulty with speaking, listening or understanding). A review of Resident 2's medical record under MD orders indicated, .bmp [basic metabolic panel] in the morning every Mon [Monday] for hyponatremia [a condition when the level of sodium/salt in the blood is low]. ordered on 3/23/26. A review of Resident 2's medical record indicated Resident 2 had BMP laboratory results completed on 3/23/26 and 3/30/26. A review of Resident 2's medical record titled, Progress Notes, indicated there was no documentation found for Resident 2's BMP results received, faxed or reported to the MD for the results dated 3/23/26 and 3/30/26. During a concurrent interview and record review on 4/2/26, at 11:55 a.m., with the UM, Resident 2's medical record was reviewed. The UM confirmed Resident 2 had a BMP order in place to be done every Monday for hyponatremia. The UM verified Resident 2 had BMP laboratory results dated [DATE] and 3/30/26 and confirmed no documentation was found in Resident 2's chart that these results were reported or faxed to the MD. The UM stated the nurses who received Resident 2's laboratory results should have at least documented if the results were faxed to the MD. During an interview on 4/2/26, at 3:03 p.m., with the Assistant Director of Nursing (ADON), the ADON stated staff were expected to have documented on a resident's chart upon receipt of laboratory results, whether MD was notified, and have faxed the results to the MD's office. The ADON further stated it was important for the residents to get their laboratory orders completed as ordered and to have reported the results to the MD timely because it could potentially cause a delay in the resident's care.

Based on interview, and record review, the facility failed to obtain laboratory testing for one of four sampled residents (Resident 1) when Resident 1's order for daily ammonia level tests (blood test that measures waste buildup caused by liver or kidney failure) was not completed on 3/25/26, 3/28/26 and 3/31/26. This failure had the potential for Resident 1's ammonia levels to further increase which could potentially lead to confusion, extreme fatigue and severe health issues affecting his brain function. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses that included hepatic encephalopathy (a brain dysfunction condition caused by advanced liver disease when toxins like ammonia builds up and affects brain function), liver cirrhosis (permanent scarring of the liver caused by long term damage which hinders blood flow and the ability to filter toxins), and chronic kidney disease (condition when the kidneys are permanently damaged and not filtering blood properly).A review of Resident 1's medical record titled, Order Listing Report, indicated, .lab work: check ammonia levels. Notify doctor if labs are about 65 every day shift. was ordered on 3/21/26.During a joint interview on 4/1/26, at 1:30 p.m., with Resident 1 and Resident 1's Family Member (FM), Resident 1 stated he was upset because he had an order for his ammonia levels to be checked daily and the facility had not been able to get them done. Resident 1 further stated his last ammonia blood draw was done on Monday (3/30/26) when he went to the hospital and the facility had not drawn his blood since then. Resident 1 stated his ammonia level got high at 93 and went down to 44 when he went to the hospital on 3/30/26. Resident 1's FM stated she was concerned about Resident 1's ammonia levels not being checked daily and that he had to go to the hospital on Monday just to get it checked.During a concurrent interview and record review on 4/1/26, at 2:31 p.m., with Licensed Nurse (LN) 1, Resident 1's medical record was reviewed. LN 1 confirmed Resident 1 had an order in place for ammonia levels to be checked daily since 3/21/26. LN 1 stated the blood draws were done by the facility's nurses and the blood samples were then taken to the hospital laboratory to be processed. LN 1 further stated if Resident 1's ammonia levels were not being checked, it could have caused serious complications of his organs shutting down, toxicity to the brain, and worst case would have been death.During an interview on 4/1/26, at 3:25 p.m., with LN 2, LN 2 stated the laboratory blood draws were usually done in the morning time and the resident would be monitored for 72 hours until the results were received. LN 2 further stated the nurse should have followed up with the laboratory for results to be sent to the MD (medical doctor) to be reviewed.A review of Resident 1's medical record for Resident 1's ammonia laboratory results from the timeframe 3/21/26 to 4/1/26, indicated there were no results for 3/25/26, 3/28/26 and 3/31/26.During a concurrent interview and record review on 4/1/26, at 4:09 p.m., with the Unit Manager (UM), Resident 1's ammonia level results were reviewed. The UM confirmed Resident 1 did not have ammonia level results on 3/25/26, 3/28/26 and 3/31/26. The UM stated the importance of following Resident 1's laboratory orders were due to the need to check his ammonia levels daily because the levels could have changed at any time. The UM further stated the risk of not getting Resident 1's ammonia levels checked would have been extremely high levels which could have caused him to have been lethargic (a decrease in consciousness) and unresponsive.During a follow-up interview on 4/2/26, at 1:17 p.m., with Resident 1, Resident 1 stated he went out of the facility for an appointment at the hospital on 3/31/26 and had returned before lunch time. Resident 1 further stated the facility had time to get his blood drawn that day, but they were not able to do so.During a concurrent interview and record review on 4/2/26, at 11:55 a.m., with the UM, Resident 1's medical record was reviewed. The UM stated all laboratory orders were drawn by the facility nurses during the morning shift. The UM further stated if the morning shift nurse was unsuccessful with the blood draw, it would have been passed on to the evening shift for as long as the sample was drawn before midnight. The UM stated it was important to have blood specimens drawn timely, because the laboratory would have set timeframes to have processed the results. The UM further stated delays in drawing blood could have caused levels to be unknown, either to be high or unstable. The UM stated the residents would be placed on alert charting following the blood draw and the nurse was supposed to have documented and to have followed-up with the laboratory for the results. The UM further stated if the nurse was not able to draw the resident's blood sample or have not obtained the results, the nurse should have notified management to get it addressed and to have documented in the resident's chart. The UM confirmed Resident 1's order for daily ammonia levels to be checked was not followed based on the missing results for dates 3/25/26, 3/28/26 and 3/31/26.During an interview on 4/2/26, at 3:03 p.m., with the Assistant Director of Nursing (ADON), the ADON stated a resident's blood draw could have been drawn every shift by the nurses. The ADON further stated it was her expectation from the nurses to have notified the UM, ADON, Director of Nursing (DON) and the resident's MD if they were not able to complete the blood draw. The ADON stated it was important for the nurses to have kept track of any resident with laboratory orders with documentation that the blood was drawn and to have followed-up with the laboratory for the results. The ADON further stated it was important to have followed the MD's laboratory orders because there could have been critical results that could potentially be missed that needed immediate attention. The ADON stated the risk of missing a resident's laboratory orders could have meant the facility was not meeting the care needed by the resident.During a phone interview on 4/3/26, at 2:15 a.m., with the [LABORATORY STAFF NAME], the [LABORATORY STAFF NAME] stated the facility's staff would come and drop off blood draw specimens to the laboratory to be processed. The [LABORATORY STAFF NAME] further stated ammonia blood draws should have been delivered to the laboratory within 20 minutes of being drawn and was considered a STAT order (order needs to be carried out immediately). The [LABORATORY STAFF NAME] further stated the laboratory kept logs of specimen drop-offs and reviewed the log for Resident 1's ammonia blood specimens the laboratory received from the facility. The [LABORATORY STAFF NAME] confirmed Resident 1's ammonia blood draw specimens were not received by the laboratory on dates 3/25/26, 3/28/26 and 3/31/26. The [LABORATORY STAFF NAME] stated if the laboratory received a blood sample that was not viable (laboratory sample that was properly collected for accurate results), the facility would have been notified to obtain a new sample to be processed.

Based on observation, interview, and record review the facility failed to ensure resident rights were maintained when five of five sampled residents' (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) mobility assist rails (supportive devices installed on the side of a bed to assist individuals with limited mobility in sitting up, shifting positions, or entering and exiting the bed safety) were removed against Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5's wishes.This failure resulted in decreased independence, decreased mobility, feelings of humiliation, frustration and fear in Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5, negatively impacting their physical and psychosocial well-being.Findings:a. A review of Resident 1's clinical document titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included anxiety, depression, muscle weakness, and repeated falls.A review of Resident 1's clinical document titled, Brief Interview for Mental Status, (BIMS, a 15-point assessment tool used to measure cognitive impairment - scores of 0-7 suggest severe impairment, 8-12 moderate, and 13-15 intact) dated 2/6/26, indicated Resident 1 had a BIMS of 15 (cognitively intact).A review of Resident 1's clinical document titled, Device and Bed Rail/Bed Enabler Evaluation and Consent, dated 2/17/26, indicated, . Device . Assist rails . Diagnosis/Symptoms contributing to potential for injury or need for devices . Weakness . Explain why device is not considered a restraint: resident uses assist rails for bed mobility . Benefits/Reasons . what does the device enable the resident to do . Enhances bed mobility . Device informed Consent or Declination . [bubble filled in for] I CONSENT to use the Device . Consent given by . Consent given by . [bubble filled in for] Resident . Verbal Consent Obtained from . [Resident 1] . Date of Consent . 2/17/26 .A review of Resident 1's clinical document titled, Order Details, containing individual physician orders, dated 3/12/26, indicated, . Order Date . 1/27/2026 . May have assist rails for bed mobility .During a concurrent observation and interview on 3/12/26 at 11:55 AM with Resident 1, Resident 1 stated the facility had removed the assist rails from Resident 1's bed. Resident 1 explained the assist rails were used to help with turning in bed. Resident 1 further explained when being changed (incontinence care, changing urine or stool filled adult diapers) the assist rails were used to hold onto to feel safe and secure. Resident 1 stated since the assist rails were removed three days ago, fears of falling out of bed and being scared have persisted. Resident 1 explained the maintenance person removed the assist rails even after Resident 1 requested the assist rails not be removed. An observation revealed there were no assist rails on Resident 1's bed. b. A review of Resident 2's clinical document titled, admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included hemiparesis (partial weakness or reduced sensation on one side) and hemiplegia (total paralysis or inability to move one side) affecting right dominant side, difficulty walking, muscle weakness, and dependence on wheelchair.A review of Resident 2's clinical document titled, Brief Interview for Mental Status, dated 3/6/26, indicated Resident 2 had a BIMS of 15.A review of Resident 2's clinical document titled, Device and Bed Rail/Bed Enabler Evaluation and Consent, dated 2/17/26, indicated, . Device . Assist rails . Diagnosis/Symptoms contributing to potential for injury or need for devices . CVA [Cerebral Vascular Accident - a stroke (oxygen was deprived from the brain)] . Weakness . Explain why device is not considered a restraint: resident uses assist rails for bed mobility . Benefits/Reasons . what does the device enable the resident to do . Enhances bed mobility . Device informed Consent or Declination . [bubble filled in for] I CONSENT to use the Device . Consent given by . Consent given by . [bubble filled in for] Resident . Verbal Consent Obtained from . [Resident 3] . Date of Consent . 2/17/26 .A review of Resident 2's clinical document titled, Order Details, containing individual physician orders, dated 3/12/26, indicated, . Order Date . 1/27/2026 . May have assist rails for bed mobility .During a concurrent observation and interview on 3/12/26 at 12 PM with Resident 2, Resident 2 stated prior to her discharge on [DATE] the assist rails were present on her bed. Resident 2 explained after she returned to the facility on 2/28/26, her assist rails had been removed. Resident 2 stated she had used the assist rails to pull herself up in bed, position herself, and stand and pivot next to her bed and she could no longer do those things now that the assist rails had been removed. Resident 2 stated she had made several requests to staff for the assist rails to be put back on her bed and staff stated they would check, but to date the assist rails had not been put back on her bed. Resident 2 explained she was concerned she would get weaker by not having the assist rails on the bed for assistance with mobility. Resident 2 further explained without the assist rails for support it was scary when she was being turned in bed during changing of her incontinent briefs and feeling like she would fall out of bed. An observation revealed there were no assist rails on Resident 2's bed. c. A review of Resident 3's clinical document titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included muscle weakness, difficulty walking, and lack of coordination.A review of Resident 3's clinical document titled, Brief Interview for Mental Status, dated 2/24/26, indicated Resident 3 had a BIMS of 15.A review of Resident 3's clinical document titled, Device and Bed Rail/Bed Enabler Evaluation and Consent, dated 2/18/26, indicated, . Device . Assist rails . Diagnosis/Symptoms contributing to potential for injury or need for devices . Weakness . Explain why device is not considered a restraint: resident uses assist rails for bed mobility . Benefits/Reasons . what does the device enable the resident to do . Enhances bed mobility . Device informed Consent or Declination . [bubble filled in for] I CONSENT to use the Device . Consent given by . Consent given by . [bubble filled in for] Resident . Verbal Consent Obtained from . [Resident 3] . Date of Consent . 2/18/26 .A review of Resident 3's undated clinical document titled, Care Plan Report, indicated, . Problem . Risk for further decline in ADL [activities of daily living - the essential, routine self-care tasks people perform every day to maintain their personal health and independence] function . Interventions/Tasks . Assist Rail for bed mobility . Date Initiated [assist rail intervention started]: 02/18/2022 .A review of Resident 3's clinical document titled, Order Details, containing individual physician orders, dated 1/27/26, indicated, . Order Date . 1/27/2026 . May have assist rails to assist with bed mobility .During a concurrent observation and interview on 3/12/26 at 1:47 PM with Resident 3, Resident 3 stated she had just gotten the assist rails put back on her bed. Resident 3 explained the assist rails were put back on her bed on 3/11/26 and had been off since 2/24/26. Resident 3 further explained the day after her assist rails were removed, she had a near fall while trying to go the bathroom. Resident 3 explained after her assist rails were removed on 2/24/26 she lost her independence. Resident 3 further explained prior to her assist rails being removed she had been able to change her own incontinent briefs, after the assist rails were removed 2 staff had to change her incontinent briefs and she felt humiliated. Resident 3 said she was very upset about her assist rails being removed.d. A review of Resident 4's clinical document titled, admission RECORD, indicated Resident 4 had been admitted to the facility with diagnoses which included difficulty walking, muscle weakness, depression, anxiety, and obesity.A review of Resident 4's clinical document titled, Brief Interview for Mental Status, dated 12/23/25, indicated Resident 4 had a BIMS of 15.A review of Resident 4's undated clinical document titled, Care Plan Report, indicated, . Problem . Risk for further decline in ADL function . Interventions/Tasks . Assist Rail X2 [times 2, assist rails on both sides of the bed] for bed mobility . Date Initiated: 01/21/2025 [date the assist side rails were started] .A review of Resident 4's clinical document titled, Device and Bed Rail/Bed Enabler Evaluation and Consent, dated 2/18/26, indicated, . Device . Grab/Assist/Mobility Bars/Bed Canes - Bilat [bilateral, both sides of the bed] . Diagnosis/Symptoms contributing to potential for injury or need for devices . Weakness . Benefits/Reasons . what does the device enable the resident to do . Contributes to self-performance . Enables resident to maintain proper body positioning/alignment . Enhances bed mobility . Enhances mobility with self-transfer . Enhances transfer status . Device informed Consent or Declination . [bubble filled in for] I CONSENT to use the Device . Consent given by . Consent given by . [bubble filled in for] Resident . Verbal Consent Obtained from . [Resident 4] . Date of Consent . 2/18/26 .A review of Resident 4's clinical document titled, Order Details, containing individual physician orders, dated 1/27/26, indicated, . Order Date . 1/27/2026 . May have assist rails to assist with bed mobility .During an interview on 3/12/26 at 11:39 AM with Licensed Nurse (LN) 1, LN 1 stated the facility took off the assist rails on the beds. LN 1 explained since the assist rails were removed residents could not assist with turning in bed. LN 1 further explained that the residents were upset due to their assist rails being removed.During an interview on 3/12/26 at 1:19 PM with LN 2, LN 2 stated when she returned to work following a weekend off, the residents' assist rails had been removed. LN 2 explained the residents used assist rails for mobility assistance. LN 2 further explained Resident 3 was upset and Resident 4 was devastated.During an interview on 3/12/25 at 1:33 PM with LN 4, LN 4 stated some of the residents were complaining about the assist rails that were removed. LN 4 explained corporate (legal business entity) wanted to make sure the assist rails were not being used as restraints (manual method, physical/mechanical device, material, or equipment attached to or adjacent to a resident's body that restricts freedom of movement or normal access to one's body and cannot be removed easily by the resident).During an interview on 3/12/26 at 1:43 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated assist rails had been removed from residents' beds. CNA 2 explained removing the assist rails was not a good idea because the assist rails helped the residents during incontinent care and when getting out of bed.During an interview on 3/12/26 at 2:30 PM with the Maintenance Director (MTN Dir), the MTN Dir stated he was directed to remove the assist rails on residents who were not required to have them. The MTN Dir explained he was uncertain if the removal of the assist rails was explained to the residents by the nursing staff, as some of the residents had a problem with the removal of their assist rails.During an interview on 3/12/26 at 3:01 PM with the Assistant Director of Nursing (ADON), the ADON stated the facility had checked which residents had assist rails. The ADON explained that the residents who wanted to keep their assist rails had an evaluation completed (safety check), a physician's order was obtained, and a care plan for assist rails was initiated. The ADON further explained she thought the process was completed at that point but was told to go through the facility again and determine whose assist rails were necessary. A review of the facility policy titled, NOTICE OF RESIDENT RIGHTS UNDER FEDERAL LAW, updated July 2025, indicated, . The right to participate in the development and implementation of his/her person-centered plan of care . The right to see the plan of care, including the right to sign after significant changes to the plan of care . The Resident has the right to a dignified existence and self-determination . The Resident has the right to be treated with dignity and respect . The Resident has the right to reasonable accommodation of individual needs or preferences . The Resident has the right to make choices about aspects of his/her life in the Center that are significant to the Resident . The Resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely .

Based on interview and record review, the facility failed to ensure medications with physician-ordered parameters were safely administered for one of three sampled residents (Resident 1) when metoprolol (a medication used to control blood pressure) was given to Resident 1 on 11/16/25 and 11/29/25 despite her vital signs (VS-includes heart rate (pulse) and blood pressure) being outside the physician's parameters and not documented on her medication administration record.These failures potentially contributed to Resident 1 experiencing hypotension, requiring emergency evaluation on 11/18/25, and increasing the risk of further health complications.Findings:A review of Resident 1's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25 indicated the following physician's order: .Metoprolol Tartrate Oral Tablet 25 MG.Give 0.5 tablet via J-Tube [a tube placed directly into the jejunum [middle part of the small intestine] used to give food and medicine] every 8 hours for hypertension [high blood pressure]. Hold if SBP <100 [Systolic Blood pressure-top number in a blood pressure reading-less than 100], HR <60 [Heart Rate [pulse] less than 60]. A review of Resident 1's Weights and Vitals Summary for 11/2025 indicated the following: on 11/16/25 Morning shift BP 126/77, no pulse was recorded. Afternoon shift BP 90/66, pulse 90. Evening shift BP and pulse were not recorded. On 11/29/25 Afternoon shift BP was 89/65.A review of Resident 1's MAR, dated 11/2025 indicated Resident 1's metoprolol was administered to her on 11/16/25 on the morning, afternoon, and evening shift and on 11/29/25 on the afternoon shift. Further review of Resident 1's MAR also revealed a BP reading and a pulse were not documented by an LN on the MAR on 11/16/25 for all three shifts. During a concurrent interview and record review with Licensed Nurse (LN) 1, on 12/9/25 at 11:56 AM, LN 1 reviewed Resident 1's Medication Administration Record [MAR] and Weights and Vitals Summary for 11/2025 and verified that on 11/16/25, metoprolol was administered to Resident 1 during the morning, afternoon, and evening shift even though Resident 1'a blood pressure and pulse were not documented on the MAR. LN 1 verified during a review of Resident 1's Weights and Vitals Summary that on 11/16/25 Resident 1's BP and pulse were outside of the hold parameters and the metoprolol should not have been administered.A review of Resident 1's Progress Notes dated 11/17/25 indicated Resident 1's physician (MD) documented, .Metoprolol.for hypertension. We will continue to maintain the blood pressure log and monitor closely .A review of Resident 1's Progress Notes dated 11/17/25 at 1:25 PM, indicated that LN 4 documented .Pt will be going to a GI (Gastroenterology, digestive system specialist) consult appointment at 2:15 (PM). A review of Resident 1's Progress Notes dated 11/17/25 at 8:56 PM, LN 7 documented, .Resident was sent to.[the] ER [Emergency Room] following a GI appointment.called for an update and was told.they are going to keep [the] resident [Resident 1] d/t [due to] low HR [heart rate] AND LOW BP.A review of Resident 1's ED [Emergency Department] Physician Notes dated 11/18/25 at 1:43 AM, indicated .(Resident 1) presents for evaluation of low blood pressure. She was at the GI clinic.where they found her blood pressure was 75/49. She looked pale and was dizzy so they sent her here (ED) for evaluation.Reason for visit: Weakness or fatigue. Resident 1 was discharged from ED Observation on 11/18/25 at 3: 57 AM with Diagnoses of Hypotension (low BP) and rapid atrial fibrillation (an irregular, fast heartbeat).During a phone interview with LN 5 on 12/31/25 at 10:28 AM, LN 5 stated that she worked with Resident 1 on 11/16/25 at 10:00 PM (evening shift) when Metoprolol was scheduled for administration. LN 5 stated that the Metoprolol should not be administered if the systolic blood pressure was below 100 and/or the heart rate was below 60. LN 5 stated that administering Metoprolol without checking VS could cause the resident to become hypotensive. During a phone interview with LN 6 on 12/31/25 at 11:00 AM, LN 6 stated that he was the nurse caring for Resident 1 on 11/29/25 at 2:00 PM (afternoon shift) when metoprolol was scheduled for administration. LN 6 confirmed that the physician's order to hold metoprolol for systolic BP less than 100 and/or HR less than 60 was correct and verified that the medication should not be administered when those parameters are not met. LN 6 stated that he typically obtains VS prior to administering metoprolol and was aware that Resident 1's BP frequently ran low. LN 6 stated that the metoprolol should have be held on 11/29/25 for the 2:00 PM dose due to a documented BP of 89/65. LN 6 stated that failure to adhere to the metoprolol hold parameters could result in hypotension.A review of the facility policy titled PREPARATION AND GENERAL GUIDELINES dated 10/17, indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the attending physician.

Based on interview, and record review, the facility failed to immediately notify the responsible party or family member about a resident's death for 1 of 1 resident (Resident 1).This deficient practice violated Resident 1's responsible party (RP), the right to be informed of the resident's change in condition or death. A review of Resident 1's admission RECORD, indicated Resident 1's contact list had 7 different contact persons and Family Member (FM) 1 was the responsible party (RP) for Resident 1. During an interview on [DATE], at 12:53 PM, with Family Member (FM) 1, FM 1 stated she was at the facility the night before and when she came back the next morning, she found Resident 1's room empty and was told that Resident 1 passed away. FM 1 stated that she reviewed Resident 1's medical records, which indicated that the reporting party was notified. FM 1 stated that the facility did not call her, and other family members were reportedly informed but after speaking with them, they confirmed that they had not been notified either. FM 1 stated she was the RP for Resident 1, and everything went through her before the facility reached out to other family members. FM 1 stated Social Services (SS) did not contact her as well. FM 1 stated the hospice agency (provides end-of-life care for terminally ill patients, focusing on comfort and quality of life rather than cure) contacted her after she showed up at the facility and the hospice agency already knew that she was not notified by the facility. FM 1 stated the facility said numerous family members was present at the time of the death, but it was not true.During an interview on [DATE], at 1:46 PM, with License Nurse (LN) 1, LN 1 stated when a resident passed away, as a nurse she needed to assess the resident and notify the hospice nurse. LN 1 stated either the facility, or the hospice would call the family. LN 1 stated the nurses also notified the doctor. LN 1 stated it was important to call the family because they need to know. LN 1 stated the nurses contacted the RP or the emergency contact #1, then would go down the list of contact persons if they could not reach the RP.During a concurrent interview and record review, on [DATE], at 2:01 PM, with the Director of Nursing (DON), the DON stated that when a resident on hospice passed away, she expected her nurses to do an initial assessment, and make appropriate notifications to hospice, to the MD, and to the family of the resident. At 2:03 PM, the Assistant Director of Nursing (ADON) joined the concurrent interview and record review with the DON. The ADON stated that the facility would notify the hospice agency and contact the family for any change of condition (COC) of the resident. The ADON further stated that the nurses would also inform the facility's medical director who oversaw the care. The ADON stated she expected nurses to contact the hospice agency first when a resident passed away. The ADON stated the nurse would talk to the hospice nurse and determine who would contact the family then they would coordinate together. The DON stated it was important to contact the family of the resident that passed away so that they were aware and not be surprised when they made a visit. Resident 1's progress notes, dated [DATE], at 8:30 PM, was reviewed with the DON and the ADON. Resident 1's progress note indicated that the family was at the facility the night before she passed. The ADON confirmed that the family was not at bedside when Resident 1 passed away at around 3 AM on [DATE]. The DON stated that the hospice was contacted by the nurse, and the hospice agency said they would contact the family and would send a hospice nurse to the facility. The ADON stated if a resident was not on hospice, the facility would contact the family for death notification, the nurse would call the RP or the emergency contact #1 or and they would keep calling everybody on the list if the RP could not be reached. The ADON stated the nurse noted that the hospice would notify the family. The ADON stated the nurses should have notified the family even if the hospice agency said they would call the family.During an interview on [DATE], at 2:46 PM, with the Social Service Assistant (SSA), the SSA stated when a resident on hospice passed away, the nurses notified the family of the resident. The SSA stated the nurses were supposed to call the family and the hospice agency. The SSA stated the family of Resident 1 should have been notified and it was important to notify the family, and they should be the first to know or be notified. During an interview on [DATE], at 3:18 PM, with LN 2, LN 2 stated that she would contact the family when a resident passed away, regardless of whether the resident was on hospice care or not. LN 2 stated the nurses also notify the medical director. LN 2 stated that it was important to contact the RP, or the family if the resident was actively dying, has died, or if there was any change in condition. LN 2 stated that the family must be notified because they expected that they would be informed of any changes in condition, regardless of severity, especially if the resident passed away. LN 2 stated even if the hospice agency said they would contact the family, she would still need to contact the family because she would not be sure if the hospice already contacted them or not. LN 2 stated that they used the resident's contact list starting with the responsible party (RP) and continuing with the next person on the list if the RP could not be reached. LN 2 stated that they were required to call all listed contacts until someone was reached and if unsuccessful, they must document the attempts.During a phone interview on [DATE], at 8:12 AM, with LN 3, LN 3 stated she called hospice, and the hospice agency said that a hospice nurse would be coming to the facility. LN 3 stated when she called hospice, she explained the situation and that the RN (registered nurse) pronounced Resident 1 as deceased and she was told that the hospice nurse would come. LN 3 stated the hospice agency did not tell her that they would call the family. LN 3 stated she did not call the RP or the family. LN 3 stated the nursing staff should have contacted the family when a resident passed away.During an interview on [DATE], at 3:27 PM, with the Assistant Administrator (AADM), the AADM stated that death was considered a Change of Condition (COC). The AADM stated the expectation on nurses was to notify the RP when a resident passed away. The AADM stated it was important to contact the RP or family member because a death of a resident could cause significant distress for the family. The AADM stated the facility should have notified the RP or the family.A review of the facility's policy and procedure (P&P) titled, Hospice - Provision of Care by Outside Providers, updated 9/17, the P&P indicated, .The Center (facility) notifies hospice of need to transfer resident out of Center, or of resident's death.A review of the facility's P&P titled, 24-Hour Report - Alert Charting, updated 4/17, the P&P indicated, .The Center (facility) maintains a system for monitoring and communicating changes in resident condition.With change in condition, the LN (License Nurse)/designee initiates an Alert Charting Guidelines sheet and highlights required charting to guide the LN in appropriate evaluation of current condition to guide the LN in evaluation of the resident. Nursing staff briefly documents: a. Nature of the condition/issue. b. Areas to monitor. c. Frequency of monitoring. d. Start and Stop Dates. e. Care Directive complete/updated. f. Family/Resident/MD notification (s) are complete.

Based on observation, interview, and record review, the facility compromised the personal privacy and confidentiality of a census of 173 residents when meal tray tickets (a crucial document that ensures each resident receives the correct and personalized meal based on their individual needs and preferences) were thrown into the trash.This failure had the potential to expose personal and medical health information to non-facility staff.During the initial kitchen tour on 8/4/25, at 10:12 a.m., meal tickets with resident names were observed in the garbage can in the dishwashing area.During the initial kitchen tour on 8/4/25 at 10:22 a.m., the path taken of kitchen trash to the outside dumpsters in the parking lot was observed. The parking lot was not gated or secured from the public.During a review of tray tickets for lunch on 8/5/25, the meal tickets included the following information:Resident name, room location, the area the meal was eaten, therapeutic diet order (which may correlate to diagnosis), fluid texture (which may correlate to diagnosis), resident likes/dislikes, resident food allergies, and special instructions.During an interview on 8/6/25, at 2:45 p.m., with the Certified Dietary Manager (CDM), the CDM stated it was his expectation meal tickets should have been placed into a shred bin. The CDM further stated that meal tickets in the garbage were a violation of HIPAA (Health Insurance Portability and Accountability Act, a federal law that sets a national standard to protect medical records and other personal health information).A review of a facility policy titled, Clinical Operations Manual dated 9/2016, indicated, .Residents have the right to privacy and confidentiality for all aspects of care and services.

Based on interview and record review, the facility failed to verify that the Preadmission Screening and Resident Review (PASRR - a federally required screening process designed to ensure that individuals with serious mental illness [SMI], intellectual disability [ID], or related conditions are not inappropriately placed in nursing facilities) was accurate for four out of 38 sampled residents (Resident 11, Resident 81, Resident 131 and Resident 47), when: Resident 81's SMI was not indicated on the PASRR; and,Resident 11's PASRR Level I Screening indicated the need for a Level II Screening, but none was found in the medical record; and,Resident 131 had a positive Level I PASRR screening and the required level II PASRR (Mental Health Evaluation) screening was not completed due to facility not being available on repeated attempts for contact in June of 2025; and, Resident 47's Level II PASRR, recommended specialized services, were not implemented, or followed up on and there was no record of them being reviewed with the medical doctor in August 2023 which resulted in specialized services including psychotherapy/counseling and neuropsychology (studies the physiological processes of the nervous system and relates them to behavior and cognition) consultation not being provided.These failures placed Resident 11, Resident 81, Resident 131, and Resident 47 at risk of not receiving the care and services that could have assisted them in living their highest quality of life. Findings: 1. A review of Resident 81’s previous “admission RECORD” dated 8/17/2021 from the discharging facility indicated that one of her diagnoses included Depressive Schizoaffective Disorder (Depression with episodes of losing touch with reality). A review of Resident 81’s current “admission RECORD” indicated that one of her diagnoses included Depressive Schizoaffective Disorder. A review of Resident 81’s PASRR Level 1 Screening completed by the discharging facility, dated 11/14/2024 indicated that Resident 81 was not diagnosed with SMI. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 8/6/25 at 10:15a.m., the ADON stated that the facility does not have any other PASRR on file for Resident 81, and the PASRR Level 1 document they received from the discharging facility was inaccurate. Section III, number 9 which asks if the individual was Diagnosed with Serious Mental Illness was marked “No,” even though Resident 81’s diagnoses included Depressive Schizoaffective Disorder. According to the ADON, they failed to verify the accuracy of the PASRR from the discharging facility because their “…process of checking submitted PASRR’s for accuracy was not in place or not followed .” A review of the facility’s Policy titled, “PASRR Process Policy and Procedure” published on 1/9/2025 indicated, “…Upon admission to the facility the Admissions Coordinator, Medical Records Director or designee validates a PASRR Level 1…” 2. A review of Resident 11’s “admission Record” indicated that Resident 11 was admitted to the facility in 2024 with diagnoses which included Cerebral Infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), Post-Traumatic Stress Disorder (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), and Major Depressive Disorder (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living). A review of Resident 11’s “PASRR Level I Screening,” dated 4/15/2025 indicated that a Level II Evaluation was needed. A review of a document from “California Department of Health Care Services,” dated 4/17/25, indicated, “…SUBJECT: NOTICE OF ATTEMPTED EVALUATION…In the event of a positive…Level I Screening…Level II Mental Health Evaluation is required to determine if the individual can benefit from specialized services. However .Level II Mental Health Evaluation was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening…” During an interview and concurrent record review of Resident 11’s “PASSR Level I Screening and document regarding Level II Screening status on 8/6/25 at 5:15 pm with the Assistant Director of Nursing (ADON), the ADON confirmed that Resident 11’s Level II document indicated that a PASRR Level II Screening was not completed due to facility staff unresponsiveness. The ADON stated that her expectation was for new admissions, staff verified that the PASSRs were completed. The ADON stated that the PASSRs must be done preadmission. The ADON stated that the facility process to have follow-up was broken and needed to be fixed. The ADON stated that the broken process was recently identified. The ADON stated that the risk to Resident 11 if the PASRR II was not completed was that outside services could have been offered to Resident 11. The ADON acknowledged that the facility policy was not followed. A review of a facility policy and procedure (P&P) titled, “PASRR Process Policy and Procedure,” revised 01/01/2025, indicated, “…Procedure…1. Upon admission to the facility the Admissions Coordinator, Medical Records Director, or designee validates a PASRR Level I is included in the admission paperwork. If there is no PASRR Level I, the Medical Records Director or designee contacts the hospital to obtain…3. If a Level II Evaluation is indicated the Social Worker validates, within a timely period, that a LMHP (Licensed Mental Health Provider) is scheduled to evaluate…” 3. A review of Resident 131’s “ admission RECORD,” indicated Resident 131 was admitted in January of 2024 with diagnoses which included, but were not limited depressive disorder (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living) and unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), unspecified severity, with other behavioral disturbance, and anxiety disorder (a nervous disorder characterized by a state of excessive uneasiness and apprehension that interferes with daily living) During a review of Resident 131's “Department of Health Care Services Letter,” dated 6/5/25, the letter indicated a PASRR Level I screening for Resident 131 was completed on 6/5/25, and indicated Level II Mental Health Evaluation Referral was required for SMI (serious mental illness) and the facility will be contacted within two to four days to schedule an appointment. During Review of Resident 131’s “Department of Health Care Services Letter,” dated 6/8/25, the letter indicated, “…UNABLE TO COMPLETE LEVEL II EVALUATION FOR SERIOUS MENTAL ILLNESS (SMI)…The California Department of Health Care Services (DHCS) administers the PASRR when the Level I Screening returns a positive result for possible SMI. In the event of a positive SMI Level I screening, a SMI Level II Mental Health Evaluation is required to determine if the individual can benefit from specialized services. However, a SMI Level II Mental Health Evaluation was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening… The case is now closed…To reopen the facility must resubmit a new Level I Screening…” During a concurrent observation and interview on 8/4/25, at 11:32 a.m., Resident 131 was observed sitting in a wheelchair in the hall next to the nursing station. Resident 131 stated she was cold. It was observed Resident 131 was not able to respond to or answer questions. During an interview on 8/4/25, at 11:35 a.m., Licensed Nurse (LN) 4 stated Resident 131 was not verbal, always cold and born delayed (a developmental delay). LN 4 explained Resident 131 had lived at the facility for a long time. During a phone interview on 8/5/25, at 4:30 p.m., Responsible Party (RP) 1 stated Resident 131 was born with intellectual and behavioral delays. RP 1 explained Resident 131 was taken care of by her parents and had always had caregivers. RP 1 stated as a child, Resident 131 had learning disabilities and was not sure if she had received outside services to help address her delays. RP 1 stated prior to coming to this facility she had lived in another facility in a different town. RP 1 stated the facility had never questioned him regarding outside services for Resident 131 or her intellectual or behavioral delays. RP 1 stated he was open to the idea of Resident 131 receiving services. RP 1 stated any service Resident 131 would qualify for could not hurt. RP 1 stated Resident 131 takes medications for some of her behaviors. During a concurrent interview and record review on 8/6/25, at 4:04 p.m., the Social Services Director (SSD) stated Resident 131 sometimes gives staff a hard time with her care. Through record review of Resident 131’s clinical record, the SSD confirmed her Brief Interview for Mental Status (BIMS, structured evaluation aimed at evaluating aspects of cognition in elderly patients) was a 1, indicating severe cognitive impairment. The SSD stated Resident 131 has a history of depression and dementia. The SSD stated she was not aware Resident 131 had intellectual or behavior delays. The SSD stated she does not conduct the PASRR for residents and stated the ADON completes them for all residents. During a concurrent interview and record review on 8/6/25, at 5:15 p.m., the Assistant Director of Nursing (ADON) stated regarding the PASRR process for those that require follow-ups, there was a breakdown in the process as there was no clear indication of who (staff member) should follow-up and make sure the PASRR’s are completed. The ADON stated she and other facility staff just became aware of the broken process this morning. The ADON explained based on the outcome of PASRR level 2 the resident could qualify for outside services, and this would not be provided if staff did not follow up. During a concurrent interview and record review on 8/7/25, at 3:51 p.m., the ADON confirmed PASRR level II was not followed up on and the STATE had not been able to schedule the appointment with the facility. 4. A review of Resident 47’s “admission RECORD,” indicated that Resident 47 was admitted with diagnoses which included, but were not limited to, bipolar disorder (a mental illness associated with episodes of mood swings from severe depression to manic highs), other recurrent depressive disorders (a persistent feeling of sadness and loss of interest that can interfere with activities of daily living), bulimia nervosa (a serious, potentially life-threatening eating disorder causing binge eating or eating lots of food at one time and purging or attempts to get rid of the food consumed), and anxiety disorder (a nervous disorder characterized by a state of excessive uneasiness and apprehension that interferes with daily living). During Review of Resident 47’s “Department of Health Care Services Letter,” dated 6/8/22, the letter indicated, “…In the event of a positive screening, PASRR regulations require a more thorough evaluation by an independent clinician contracted with the Department of Health Care Services (DHCS). The results of this Level II Evaluation are then reviewed by a licensed psychologist in DHCS and determinations are made regarding the appropriate level of care and recommendations for specialized services…The results of this Level II Evaluation are provided in the PASRR Determinization Report attached to this letter. Facility staff will receive a copy of this Determination report, will discuss the results with you in a timely manner, and will incorporate the recommendations in your plan…” During Review of Resident 47’s “Individualized Determination Report,” dated 6/8/22, the letter indicated, “…This Determination Report is based on a review of the applicant’s medical and social history which reveals a significant medical condition with mental stressors that require nursing care…Recommended Specialized Services…Medication Education and Training…Psychotherapy/Counseling…Individual and/or group and/or family treatment by a licensed mental health professional…Neuropsychology Consultation…services to gain a better understanding of cognitive functioning, clarify the primary diagnosis, and provide treatment direction…” During a concurrent observation and interview on 8/4/25, at 12:06 p.m., Resident 47 was observed on her bed in her room and stated she had lived in the facility for six years. During a concurrent interview and record review on 8/7/25 at 11:26 p.m., the Social Service Assistant (SSA) 3 stated Resident 47 had been at the facility for a little bit and had diagnoses of bipolar, anxiety, and depressive disorder. Through review of Resident 47’s electronic clinical record the SSA 3 confirmed Resident 47 did not have a mental health provider and stated it was her understanding she had not been seen by one while at the facility. The SSA confirmed Resident 47 had not had a mental health consult while at the facility. The SSA 3 stated Resident 47 was on medications to treat her mental health diagnoses. SSA 3 stated the mental health consult could help with management of her mental health diagnoses and medications. During a concurrent interview and record review on 8/7/25, at 3:51 p.m., the Assistant Director of Nursing (ADON) stated Resident 47’s PASRR report recommendations should have been followed up on but were not. The ADON stated her expectation was the mental health consult and neuropsychology recommendations from Resident 47’s PASRR II should have been shared with her medical doctor and the consultations should have been ordered. The ADON stated she thought they were completed as the PASRR was from 2022 and would check to see if the recommendations were implemented. ADON stated the expectation was these recommendations were followed up on and consults scheduled within two weeks. The ADON stated the risk if the resident did not receive the PASRR recommendations would be delay of specialized services and additional therapy and services Resident 47 was entitled to and could benefit from would not be provided or delayed. Review of https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html, accessed on 8/20/25, indicated “…PASRR is an important tool for states to use in rebalancing services away from institutions and towards supporting people in their homes, and to comply with the Supreme Court decision, [NAME] vs L.C. (1999), under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care…In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care .”

Based on interview, observation, and record review the facility failed to ensure safe pharmaceutical services with resident census of 172 when:1. Non-controlled prescription medications (drugs that can only be prescribed by a doctor for a specific resident) were not disposed and documented to reflect safe and accountable drug disposition.2. Emergency Kits (or Ekit, box of medications for emergency use) for IV (Intravenous- Into the Vein) and oral medications were not replaced in a timely manner, narcotic (opioid) medication removal documented without provider pharmacy approval code and opened Ekit medications were co-mingled unsafely at the East and North station medication rooms.3. Controlled medications (narcotic opioid- drugs of abuse) use and pain level were not accurately documented in Medication Administration Record (or MAR) for Resident 122 and Resident 160. These unsafe medication handling practices could pose health risks to residents, the staff and the risk of drug diversion (unlawful use of medications).Findings:1. During a concurrent interview and inspection of the facility's East Station medication room, accompanied by Licensed Nurse (LN) 1, on 8/4/25, at 10:01 AM, the medication room stored a large plastic container full of residents discontinued or expired medications sitting on top of another plastic container. LN 1 stated she was not sure who was responsible for the destruction of the medications.During a concurrent interview and inspection of the facility's North station medication room, accompanied by LN 2, on 8/4/25, at 2:35 PM, the medication room stored a large plastic container full of residents discontinued or expired medications inside a black plastic container. LN 2 stated the medications were waiting to be destroyed by the staff.During a concurrent interview and review of facility non-controlled prescription drug disposition documents, accompanied by the Director of Nursing (DON) and Assistant Director of Nursing (ADON), on 8/5/25, at 3:09 PM, the undated disposition record sheet had stickers (name of the resident and medication) from various patient medications but no marking for the quantity of each medication or the signature of two licensed staff. The ADON stated as time allowed, the night shift licensed staff should have followed the facility's policy on documenting individual prescription medication with the quantity, date, and co-signature of another licensed staff. The ADON stated the pills, and the liquid medications were disposed of inside a liquid drug destroyer. The ADON stated the disposition sheet should have had a supervisor review to ensure the tasks were done safely and in a timely manner.Review of the facility's policy, titled Medication Destruction, dated 10/2017, indicated .Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed.Non-controlled medication destruction occurs in the presence of two licensed nurses.Medication is destroyed within 90 days from the date the medication was discontinued .2a. During a concurrent interview and inspection of the facility's East station medication room, accompanied by LN 1, on 8/4/25, at 10:01 AM, the Ekit for oral medications was observed to have a yellow tag, indicating it had been opened by nursing staff (the pharmacy seals the Ekit with a Red tag and when nursing opens the kit it would be resealed with a yellow tag). The oral medication Ekit contained a yellow sheet of paper listing the medications that were removed by nursing staff. Further review of the removal sheet indicated the earliest removal was on 7/30/25, then 8/1/25, and again on 8/4/25, for the removal of antibiotic medications. LN 1 stated for each removal the nurse should have filled out a new form and faxed the sheet to the pharmacy for replacement. LN 1 stated if the pharmacy was not notified to refill the emergency medication, then it would not be available for next resident if needed.During a concurrent interview and inspection of the facility's East station medication room, accompanied by LN 1 and LN 3, on 8/4/25, at 10:26 AM, the Ekit medication removal binder (contains documentation of what was removed and when) was reviewed. The documents for Norco (narcotic medication) medication removal on 7/31/25, did not have a pharmacy authorization code. Further inspection of the medication room revealed an undated Ekit Procedure sheet that was posted in the medication room. The Ekit Procedure sheet indicated Call the pharmacy and get prior Authorization code.Document information on the pharmacy form for each med [medication] taken.Fax medication refill form immediately to the pharmacy so they can replace Ekit, staple fax verification to the back of the form and place in designated area (binder or folder). LN 3 stated the nursing staff should have followed the posted procedure.2b. During a concurrent interview and inspection of the facility's North station medication room, accompanied by LN 2, on 8/4/25, at 2:35 PM, the Ekit for injectable medication had a yellow seal indicating it was opened by nursing staff at some point. The Ekit for injectable medications did not have a record of medication removal. Further review of the Ekit contents indicated two medications, digoxin (a medication used to lower heartbeat) and chlorpromazine (medication used to treat mood disease) were stored together in one small box container. The Ekit was also missing a vial of sterile water for injection as noted in the content items. LN 2 stated she was not sure when the Ekit was last opened. LN 2 stated it did not appear that the pharmacy was notified. LN 2 stated the co-mingling of two different medications could contribute to medication errors.During an interview with the ADON, in her office, on 8/5/25, at 3:15 PM, the ADON stated the record of Ekit use should be included inside the Ekit upon re-sealing it and the pharmacy should be notified by phone and/or fax right after each use. The ADON stated she would have to ask their pharmacy provider if the two injectable medications, digoxin and chlorpromazine, should be in the same box inside the Ekit.Review of a facility policy, titled Emergency Pharmacy Service and Emergency Kits , dated 8/2014, indicated .Emergency needs for medication are met by using facilities approved medication supply or by special order from the provider pharmacy. An emergency supply of medication, including emergency drugs.supplied by Provider Pharmacy in limited quantities in a portable sealed container that are in compliance with applicable state regulations.Pharmacy will be called for pharmacist authorization prior to opening the emergency supply for all controlled substances. The emergency supply is maintained at a designated secure area along with the list of supply content. When an emergency or STAT (urgent) medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-Kit slip and re-seal the emergency supply. An entry is made in the emergency logbook containing all required information. As soon as possible the nurse records the medication used on the medication order form and notifies the pharmacy for replacement of emergency drugs. 3a. During a review of Resident 122's MAR and the corresponding Controlled Drug Record (or CDR, a paper-based record of controlled drug use documented by nursing staff), with date ranges of 7/19/25 to 8/3/25, the record indicated a narcotic medication called Norco (given for moderate pain) was signed out on the CDR without documentation of administration in Resident 122's MAR and the pain level for its use did not match ordered pain severity level (Pain level is numerical number range from 0 to 10, or from no pain to most severe pain at 10) as follows: .Norco .10/325 mg (milligram a unit of measure); take 1 tablet every 4 hours as needed for pain (5-10). 7/25/25 at 12:10 PM: there was no documented MAR record of Norco being removed to match the CDR.7/27/25 at 5 AM; Pain level documented as level 4 when the Norco order indicated to be given for pain level between 5-107/30/25 at 6:29 PM: pain level documented as zero when the Norco order indicated to be given for pian level between 5-103b. During a review of Resident 160's MAR and the corresponding CDR, with date ranges of 6/29/25 to 8/4/25, the record indicated a narcotic medication called Percocet (a narcotic used for severe pain) was signed out on the CDR without documentation of administration to Resident 160 on the MAR, and the pain level for use did not match ordered pain severity as follows: .Percocet (oxycodone/Tylenol 5/325 mg); Give 1 tablet by mouth every 6 hours as needed for breakthrough pain 6-10.Start date:6/15/25.7/9/25 at 9:10 PM; there was no documented MAR record of Percocet being removed to match the CDR.7/11/25 at 9:15 PM: Pain level documented as number 2 when order indicated to be given for pain level between 6-107/13/25 at 9:20 AM: there was no documented MAR record of Percocet being removed to match the CDR.7/25/25 at 9:25 PM: there was no documented MAR record of Percocet being removed to match the CDR.7/26/25 at 9 PM: there was no documented MAR record of Percocet being removed to match the CDR.During a concurrent interview and record review of Resident 122 and Resident 160's MAR and CDR, with the ADON, in the conference room, on 8/7/25, at 2:25 PM, the ADON stated she could not find documentation on the MAR or in nursing notes for Norco and Percocet to match the CDR. The ADON additionally stated the pain level documented in the MAR for pain medication use should have matched the doctor's order severity range. The ADON stated she expected the nursing staff to document pain medication use/removal in the MAR once administered to the resident.Review of a facility's policy, titled Procedures for All Medications, dated 4/2008, indicated .After administration, return to cart and document administration on the MAR.Review of a facility's policy, titled Pain Management, dated 9/2009, indicated .The resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to.physician order. This data is collected on the MAR, in the progress notes, and through the daily clinical meeting process.An appropriate pain scale is selected for use based on residence ability and needs .For residents using PRN (as needed) pain medication, a 0-10 pain scale are used to document on the MAR levels of pain both before and after receiving pain medication.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in two out of four medication rooms (a locked room used to store medications and supplies) and three out of 7 medication carts (a mobile cart stored medication and supplies for immediate use) with census of 172 when:The medication room in East station stored expired (the date after which the drug should not be used), undated and unlabeled medications and the sink was kept in an unclean condition.The medication room in the North station stored expired blood tube supplies (a test tube is a cylindrical, transparent container used to store and transport samples of blood for testing) and opened an undated over-the counter medication bottle.Medication cart at North-B station stored undated open inhaler called INCRUSE Ellipta (inhalation medicine used to relieve the symptoms of chronic lung disease) and a pill cutter with white dust inside.Medication cart for wound care at North station stored multiple unlabeled prescription ointments called Santyl (a topical prescription product used to remove damaged tissue from chronic skin ulcers and severely burned areas), open and undated sterile wound cleaning solution, and opened sterile wound care dressing packet.Medication cart at West-B station stored undated open inhaler called TRELEGY Ellipta (inhalation medications used to treat breathing problems) and a pill cutter with white dust inside.These failed practices could contribute to unsafe medication use; medication error, and risk of using contaminated products or supplies on residents.Findings:During a concurrent interview with Licensed Nurse (LN) 1 and LN 3 and inspection of the facility's medication room at East station, on 8/4/25, at 10:38 AM, the following observations were noted:Medication room refrigerator stored expired medications called lorazepam or Ativan in a pre-filled syringes form (drug used to treat anxiety) with expiration date of 7/27/25 on the drug label.The testing agent for Tuberculosis called Aplisol (or TB- a drug in shot form used to test for TB, a serious and contagious lung infection) was open and not dated. The label on the drug box indicated Once entered [open], vial should be discarded after 30 days.Two Insulin products in pen shape form, called Glargine (a long-acting form of insulin used to treat blood sugar disease) did not have an individual label to identify the resident name on it.One bottle of beverage containing alcohol labeled as Cold Hard Mike's in the refrigerator did not have a resident name on it.The double sink in the medication room was unclean with white and yellow stains, dust and pieces of unknown substances. The cabinet under the sink stored cleaning supplies, drug disposition (destruction) containers, a ringing type bell, and a cutting saw.LN 1 stated the expired Ativan should have been discarded, the TB testing vial should have been dated when first opened. LN 1 stated each insulin pen should have a resident name on it so when transferred to the medication cart for daily use it was clearly marked for who it should be used. LN 1 stated the bottle of beverage belongs to a resident and was not labeled as such. LN 3 stated the sink in the medication was not used, but it should be kept clean.2. During a concurrent interview with Licensed Nurse (LN) 2 and inspection of the facility's medication room at North station, on 8/4/25, at 2:35 PM, the following observations were noted:The cabinet in the medication room stored multiple expired blood tube supplies including blue top, red top and yellow top containers (the colors indicated the type of blood test done with these tubes) with expiration dates of 11/30/24, 6/30/24, and 11/30/24 respectively.One opened bottle of a product labeled as Optimum Acidophilus with Pectin (Probiotics used to improve digestion and restore normal flora in the stomach) was stored in the cabinet along with other house supplies of the over-the-counter medication pills. The label on the bottle indicated .Refrigerate after opening to help maximize potency .LN 2 stated the expired blood tubes should have been disposed of and was not sure why the opened bottle was kept in the medication room main supply cabinet.3. During a concurrent interview with LN 9 and inspection of North-B medication cart on 8/5/25, at 9 AM, the following were noted:The pill cutter had white powder-like residue inside and looked unclean. The inhaler called INCRUSE Ellipta was not dated when it was first opened for use. The label on the drug box indicated .Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0.whichever comes first.LN 9 stated the pill cutter should have been cleaned after each use and stated the inhaler should have been dated.4. During a concurrent interview with LN 21 and inspection of North station treatment cart, on 8/5/25, at 9:30 AM, the following were noted:Multiple tubes of Santyl ointment did not have a prescription label or resident names on them. The cream marked as Rx Only (means should be acquired or dispensed based on a doctor's prescription).Bottles of sterile normal Saline (salt solution used to clean skin wound) was open and half used, and the label indicated .No antimicrobial or other substances added .Content sterile unless container is open or damaged Opened packet of wound dressing labeled Non-adhesive foam dressing, Sterile, Single Use, and Do not use if package is damaged.LN 21 acknowledged the findings.5. During a concurrent interview with LN 10 and inspection of West-B station medication cart, on 8/5/25, at 10:35 AM, the following were noted:The inhaler called TRELEGY Ellipta was not dated when it was first opened for use. The label on the drug box indicated Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0.whichever comes first.The pill cutter had white powder-like residue inside and looked unclean. LN 10 stated she would discard the pill cutter as it was not clean and stated she opened the inhaler the day before and marked it as such.In an interview with Assistant Director of Nursing (ADON), in her office, on 8/5/25, at 3:15 PM, the medication storage findings were discussed and ADON stated the nursing staff were trained and reminded to date the multi-dose containers and follow the manufacturer label instruction. ADON stated expired medications should be removed from active storage areas to prevent use.Review of the facility's policy, titled Medication Storage In The Facility, dated 4/2008, indicated .medications and biologicals are stored safely, securely and properly following manufacturer's recommendation. Or those of the supplier . The policy further indicated .updated contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately. Removed from stock, Disposed of according to procedure for medication disposal . Medication storage areas are kept clean, well-lit and free of the clutter and extreme temperatures.Review of the facility's policy, titled Medication Ordering And Receiving From Pharmacy, dated 4/2014, indicated .Medications are labeled in accordance with facility requirements and state and federal laws . Only the dispensing pharmacy can modify or change prescription labels. Labels are permanently affixed to the outside of prescription containers . if a label does not fit directly on to a product. The label may be affixed to an outside container or carton, but residents' name at least must be maintained directly on actual product container.

Based on observation, interview, and record review, the facility failed to ensure food served was prepared by methods that conserve nutritive value, flavor and appearance for 172 of 172 residents that consumed facility prepared meals. These failures had the potential for decreased meal intake which could result in weight loss, malnutrition, and negatively impact the residents' quality of life. Findings:1. During an observation of the Journey dining room on 8/4/25 at 11:50 a.m. the lunch meal was served. One resident meal out of the 13 meals served had a heating element ( induction chargers ) under the plate to maintain the temperature of the hot items. During an interview on 8/4/25 at 12:38 p.m., Resident 15 stated, Food comes semi warm and there is a lack of edible food.During an interview on 8/4/25 at 12:54 p.m., Resident 28 stated, The food could be hotter. During an interview on 8/4/25 at 12:54 p.m., Resident 34 stated, Food could be hotter.During a review of Resident Council notes, dated 8/5/25 at 10:00 a.m., the Resident Council notes indicated Resident 10 stated, food was cold and has no taste. The food is bland.During an interview on 8/5/25 at 10:26 a.m. with the Certified Dietary Manager (CDM) in the kitchen, the CDM stated, we do not have enough induction chargers, some resident units in the facility do not receive them.A review of the facility's policy titled, Food: Preparation (Healthcare Services Group, Inc., Revised 2/25) indicated in the policy statement .All foods are prepared in accordance with the FDA Food Code . It further indicated in bullet #4 .The Dining Services Director/ Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F (Fahrenheit which is a unit of measurement) and/or less than 135 degrees F, per state regulation . 2. During the initial kitchen tour on 8/4/25 at 8:41 a.m. in the dry storage, several black bananas were observed in a box. During an interview with the CDM on 8/4/25 at 8:57 a.m., he verified that there were overripe bananas in storage and took several to discard.During an observation on 8/4/25 at 9:50 a.m. during the initial kitchen tour, two hotel pans of cooked zucchini were found being held in the hot box, approximately an hour and 40 minutes before the lunch meal plating would begin.During an interview on 8/4/25 at 12:54 a.m., Resident 15 stated, The food is too dry and hard to chew. During an interview on 8/4/25 at 3:00 p.m., Resident 84 stated, The vegetables are often overcooked.During an interview on 8/5/25 at 8:12 a.m., Resident 54 stated, I received wrinkled, old fruits and vegetables and wilted lettuce. I also received a black banana.During an observation on 8/5/25 at 2:15 p.m. in the kitchen, Dietary [NAME] (DC) prepared for the dinner meal. DC had green beans and broccoli cooking on the stove. The sign on the wall of kitchen stated that dinner meal service would start at 4:55 p.m.During an interview on 8/6/25 at 2:50 p.m. with the CDM, the CDM confirmed that the cook was preparing food (including vegetables) hours before meal service and it could cause issues with palatability (pleasure of taste for foods), nutrient value and toughness of meats.A review of the facility's policy titled, Food Storage: Cold Foods indicated .All Time/ Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.According to the USDA Food Code 2022, Section 3-302.11 titled Packaged and Unpackaged Food - Separation, Packaging, and Segregation indicated .(A) FOOD shall be protected from cross contamination by.(7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under S 6-404.11.3. During a report from the Department on 8/4/25 at 11:15 a.m. Resident 174 stated the menu would change without resident knowledge and Resident 54 stated that the lettuce was often wilted and eggs often cold, and meals were not aligned with the menu. During an interview on 8/4/25 at 12:54 a.m. Resident 34 stated, Food is too dry and needs more sauces and gravies. During an interview on 8/4/25 at 2:54 p.m. Resident 147 stated, Food is always dry.During a review of Resident Council notes dated 8/5/25 at 10:00 a.m. the Resident Council notes indicated that Resident 10 stated that the food is cold and has no taste. Food is described as bland.During an interview on 8/5/25 at 10:26 a.m. with the CDM during a visit to the kitchen, the CDM stated the menu is provided by the Healthcare Services Group and changes to the menu may be made based on the cook's time constraints.During the lunch meal on 8/6/25 at 12:45 p.m., two test trays were removed from the tray cart (a regular diet and pureed texture diets). The food items tested included Sesame Chicken, rice, green peas (instead of the sugar snap peas that were on the menu), a roll, and a brownie. Three out of three of the Department's employees found that the sesame chicken appeared as a baked chicken breast without the expected sauce. The chicken lacked flavor and was tough and dry. The rice was unseasoned and lacked sauce, leaving it bland, and the pureed rice was gummy in the mouth. During a review of the recipe titled, Chicken, Sesame from Healthcare Services Group, indicated the ingredients as chicken, oil, sesame seeds, garlic, black pepper, red pepper chili flakes and parsley.A review of the recipe titled Sesame Chicken from [NAME] Crocker, indicated adding a sauce that contained water, soy sauce, lemon juice, cornstarch and sesame oil.

Based on observation, interview, and record review, the facility failed to provide alternate food choices with similar nutritive value to the main meal for 172 residents who received food from the kitchen. These failures had the potential of not meeting estimated nutrient needs and potential weight loss. During an initial kitchen tour on 8/4/25 at 8:11 a.m., the alternate menu was reviewed. The alternate menu included chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers.During a subsequent interview on 8/4/25 at 8:15 a.m. with the Certified Dietary Manager (CDM), the CDM confirmed that the alternate meal choices were chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers.During an interview on 8/4/25 at 2:54 p.m. Resident 84 stated that they used to get alternatives like sandwiches but all they get now are snack type items. Resident 84 also stated the new company has decreased the portion sizes.During an interview on 8/4/25 at 2:54 p.m. Resident 1 stated they are not getting alternatives to the main meal anymore.During an interview on 8/5/25 at 10:26 a.m. with the CDM during a visit to the kitchen, the CDM stated the menu was provided by the Healthcare Services Group and that they may make changes to the menu based on the cook's time constraints.During an interview on 8/6/25 at 2:47 p.m. with the CDM, the CDM stated that the alternate grilled cheese sandwich comes with a vegetable and side dish of the day. The CDM confirmed additional protein was not added to the alternate meal. During a review of Sandwich, Grilled Cheese Corporate Recipe Number: 4173, the recipe indicated that it included 4 slices of .5 oz of cheese which is a total of 14 grams of protein for an alternate meal.During a review of Chicken, Sesame, Corporate Recipe Number: 7731, the recipe indicated that it included 4 oz of chicken which is a total of 35 grams of protein for the main entree.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:Cool down log was not followed consistently.Sugar and flour were stored in the same container.Bowls and pans were found stored wetSmall wares (pans, bowls, cutting board, can opener) were not replaced when worn.Shelves were found discolored and worn (under microwave and grill).Fans were found with black residue (dust) Forks stored in a manner causing fingers to touch the eating surface.Resident refrigerator logs were not acted upon when out of range, and had foods improperly labeled and not discarded per policy.These failures had the potential to lead to cross contamination and food borne illness for the 172 residents eating facility prepared meals. 1. During the initial kitchen tour on 8/4/25, at 9:41 a.m., macaroni salad with a preparation date of 8/4/25, was observed in the walk-in refrigerator at 76 degrees F.During an interview on 8/6/25, at 2:45 p.m., with the Certified Dietary Manager (CDM), the CDM stated the macaroni salad was made earlier that morning and should have been logged in the cool down logbook for temperature monitoring but was not.During a trayline observation on 8/5/25, at 11:30 a.m., several cold food items were above 41 degrees F and needed to be re-chilled.During an interview on 8/6/25, at 2:45 p.m., the CDM stated cold foods were above 41 degrees F and needed to be chilled prior to starting trayline causing a delay in food being plated and sent to residents.During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods dated 2/2023, the P&P indicated, .all perishable foods will be maintained at a temperature of 41 degrees F or below, except during necessary periods of preparation and service.Review of US Food and Drug Administration's (FDA) 2022 Food Code section 3-501.14 on Cooling indicated .(A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from .135 degrees Fahrenheit (F, a unit of measurement ) to . 70 degrees F: and (2) Within a total of 6 hours from .135 degrees F to .41 degrees F or less. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna . It further indicated that .Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness . 2. During the initial kitchen tour on 8/4/25, at 8:57 a.m., in the dry storeroom the sugar container dated 7/8/25, had a mixture of sugar and flour.During the initial kitchen tour on 8/4/25, at 9:00 a.m., with the CDM, the sugar container was observed. The CDM verified that it was likely a mixture of sugar and flour. The CDM stated this could lead to undesired thickening of foods or liquids.During an interview on 8/6/25, at 2:45 p.m., with the CDM, the CDM stated the flour mixed with sugar could cause an allergic reaction for a resident with a gluten allergy. Review of US FDA 2022 Food Code section 3-302.12 on Food Storage Containers, Identified with Common Name of Food indicated, .Certain foods may be difficult to identify after they are removed from their original packaging. Consumers may be allergic to certain foods or ingredients. The mistaken use of an ingredient, when the consumer has specifically requested that it not be used, may result in severe medical consequences. The mistaken use of food from unlabeled containers could result in chemical poisoning . 3. During the initial kitchen tour on 8/4/25, at 8:57 a.m., small pans stored under the steamer were observed still wet and bowls on top of the steamer were stored still wet.During the initial kitchen tour on 8/4/25, at 9:40 a.m., six bowls stored next to the dry storeroom were still wet inside. During an interview on 8/6/25, at 2:45 p.m., with the CDM, the CDM stated it was his expectation that bowls and pans should be stored once fully dried.Review of the 2022 US Food and Drug Administration's Food Code section 4-901.11 on Equipment and Utensils, Air-Drying Required indicated that .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils . 4. During the initial kitchen tour on 8/4/25, at 8:57 a.m. observations included:Six cups were worn and deglazed by the steamer and by the dry storeroom.Two out of four pans were noted with grime stored in a ready to use area.Three out of three soup containers under the microwave were worn with dark areas on surface.The tip of the can opener was missing metal.Two out of four skillets were observed with dark areas on the surface of the pan.A yellow cutting board was worn with deep gouges.During an interview on 8/6/25, at 2:45 p.m., with the CDM, the CDM stated worn bowls needed to be replaced, they cannot be cleaned properly. The CDM further stated the can opener was worn and could cause food contamination if not changed timely. The CDM confirmed the yellow cutting board (used for chicken) had deep gouges and increased the risk of bacterial growth that could transfer onto food.Review of the US FDA Food Code section 4-501.11 on Good Repair and Proper Adjustment indicated that .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury .Review of the US FDA Food Code section 4-501.11 on Good Repair and Proper Adjustment indicated that .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury .Section 4-501.12 of the 2022 Food Code on Cutting Surfaces indicated .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces .5. During the initial kitchen tour on 8/4/25, at 8:57 a.m., the shelves underneath the microwave and grill were observed worn. Two bottom shelves were white discolored areas covering the front of the shelves. The shelf under the grill was noted with an approximately foot long, circular, reddish/brown discoloration.During an interview on 8/5/25, at 10:54 a.m., with the Director of Maintenance (DM), the DM verified the discolorations.FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens section 4-601.11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . It further indicated that .The objective of cleaning focuses on the need to remove organic matter from . surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted .6. During the initial kitchen tour on 8/4/25, at 8:57 a.m., three out of three fans were noted to have black residue on the blades and screens. The fans were turned on and facing the food service production area and dish drying area.During an interview on 8/6/25, at 2:45 p.m., the CDM confirmed the black residue on three out of three fans in use. The CDM stated there was a risk of food contamination due to the fans blowing onto food and clean dishes.FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens section 4-601.11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . It further indicated that .The objective of cleaning focuses on the need to remove organic matter from . surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted .7. During an observation of the dinner meal preparation on 8/5/25, at 2:15 p.m., Dietary [NAME] (DC) removed the cooked ground beef from a pan. DC used her gloved hand without performing hand hygiene or change of gloves to remove a fork. The container of forks was tightly packed. The forks were stored with the prong (eating side) of the fork sticking outwards, causing DC to touch several other forks in the process with her hand.During an interview on 8/6/25, at 2:50 p.m., the CDM stated the handles should be pointed out of the container to prevent cross contamination of the eating surface. When storing utensils, they should be stored handle up to prevent touching the food contact surface.8.During an interview on 8/6/25 at 9:30 a.m., with Licensed Nurse (LN) 1, LN 1 stated, Food brought that was perishable would be labeled with resident name, date brought to the facility, as well as open date before being placed in a resident refrigerator.During an observation on 8/6/25 at 9:35 a.m., of the east nourishment refrigerator/freezer the following items were found:Two ice creams without a resident name or date brought to facility.Three frozen meals not labeled.During a concurrent observation and interview on 8/6/25, at 10:20 a.m., with the Director of Nursing (DON) in the east nourishment room, the DON verified the lack of labels. The DON discarded foods without labels and stated, food without labels could go to the wrong resident, and food without a date could have bacterial growth and be unsafe for the residents.During an observation on 8/6/25 at 10:00 a.m., of the north nourishment refrigerator/freezer the following items were found:Four boxes of fruit flavored treats and one in a plastic bag, were not labeled.Four yogurt containers in a plastic bag were not labeled.During the same observation the temperature log on the north nourishment refrigerator was noted to have three out of six entries above 41 degree F.During a concurrent interview on 8/6/25 at 10:05 a.m., with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation food items be dated when opened, dated when brought in, and with resident name and room number. The ADON further confirmed the elevated temperatures on the log and that the log did not show any intervention.During the same interview the ADON also stated staff intervention should have included notifying maintenance and discarding affected foods.A review of the facility P&P titled, Food: Safe Handling for Foods from Visitors, dated 2/23. The P&P indicated, .Have temperature monitored daily for refrigeration greater than or equal to 41 degrees F. Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than seven days.

Based on interview and record review, the facility failed to maintain complete and accurate antibiotic monitoring documentation and failed to implement all core elements of the Antibiotic Stewardship Program (ASP, antibiotic use protocols and a system to monitor antibiotic use) for a census of 173 residents when the facility did not have:1. A current infection Surveillance Plan (a written guide that explains how to watch for and track infections), 2. Complete antibiotic tracking data (the information collected by the facility regarding how antibiotics are used and how effective they are against bacteria),3. Documented evidence of antibiotic time-outs (a planned pause usually 48-72 hours after starting antibiotics, to ensure the medication is still appropriate).These failures had the potential to result in incomplete infection tracking, lack of timely antibiotic review, and inappropriate antimicrobial use which may contribute to the development of multidrug resistant organisms (MDRO - germs that have developed the ability to survive antibiotics that were previously used to kill them) and negatively impact resident care.Findings:During a concurrent interview and record review with the Infection Preventionist (IP) on 8/6/25 at 8:22 a.m., the IP stated the facility uses both the Loeb Criteria (set of guidelines that tells when a resident has enough symptoms to safely start antibiotics) and the McGreer Criteria (guidelines used to help determine when an infection in a nursing home resident may not need antibiotics) to evaluate antibiotic use, and reviews laboratory (lab) results to determine antibiotic susceptibility (determines which antibiotic will kill the germ causing the infection). The IP stated these same criteria's are used for monitoring, tracking and evaluating antimicrobial adherence (taking the medication as directed by a healthcare professional, including the correct dosage, frequency, and duration of treatment). The IP reported her daily process includes reviewing progress notes and orders from the previous day, updating the facility's line list (a spreadsheet that tracks residents with infections and antibiotic use), and following up on pending lab results. The IP reviewed records of Resident 86 by going back and forth between their electronic medical record and their line list. Their electronic records showed Resident 86 received Macrobid (antibiotic) every 12 hours for five days for a urinary tract infection (an infection in the urinary tract) which was started on 7/31/25 with a stop date of 8/4/25. Lab results indicated that the urine culture grew Enterococcus Faecalis (a type of bacteria) and was sensitive to Macrobid (the germ would be killed by the antibiotic prescribed). The Line list review for Resident 86 indicated the following: ETIOLOGY: indicated, In house (used to indicate where the illness was contracted instead of the cause of illness) ONSET DATE: indicated, 7/28? (Question mark noted without explanation) TREATMENT: Blank DOT ATB (Days of Therapy [Antibiotics]): Blank MDRO [multi-drug resistant organism]: Blank SIGNS AND SYMPTOMS: indicated, Per Resident and MD Request MEETS CRITERIA: Blank DATE RESOLVED: BlankDuring the same interview, the IP stated the facility's line list does not include the antibiotic start and stop dates. When asked how antibiotic time-outs are conducted for newly admitted residents, the IP explained that newly admitted residents were evaluated during the Interdisciplinary Team (IDT, a group of professionals) meeting. She further stated the physician, or provider was not always present during IDT but can be contacted as needed. When the IP was asked if she could show a sample documentation of antibiotic time-out for a newly admitted resident, she was not able to provide one. The IP also stated that they have no formal antibiotic time-out process or form in place. Furthermore, the IP stated the facility does not have an antibiogram (Antibiograms are used to inform antibiotic selection, particularly in cases where rapid test results are not yet available. They also help track antibiotic resistance patterns within a facility) available and she would work on it. Lastly, the IP stated she was responsible for preparing infection surveillance and antibiotic usage reports and communicates directly with the physician to provide personalized feedback. When asked to present the facility's infection Surveillance Plan, the IP was unable to provide one.During a follow-up interview with the IP and Assistant Director of Nursing (ADON) on 8/7/25 at 10:47 a.m., the IP reiterated that the line list was updated daily, and that antibiotics, including time-outs, are reviewed during IDT meetings and that all information was maintained in the facility's electronic system. However, the IP was unable to provide documentation of their antibiotic time-out reviews. When asked about track & trend data for antibiotic use against infections, the IP and ADON stated that they do not have tracking capabilities at the moment because it was not in their system anymore. During an interview with the Administrator (Admin) on 8/7/25 at 12:00 p.m., the Admin stated she would discuss antibiotic start dates with IP. The Admin stated that they were still searching for their infection Surveillance Plan.Review of document published by the Centers for Medicare and Medicaid (CMS) dated November 22, 2019, with Reference number QSO-20-03-NH, under Long Term Care (LTC) Infection Control worksheet section D.1 indicated, .The facility has a written surveillance plan, based on the risk assessment, outlining activities for monitoring/tracking infections occurring in residents of the facility. Source: CMS QSO 20-03 Updates and initiatives to ensure safety and quality in nursingA review of the facility's Policy titled, Surveillance for Infections updated 04/14/2025, indicated, .The Infection Preventionist.is responsible for gathering and interpreting surveillance data and conducting analysis of data.The facility maintains a tracking system of all identified infections for data collection, and trend analysis.Analyze data to identify trends.Review of an undated online document, published by the Centers for Disease Control and Prevention (CDC) titled, The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use under the section, Develop and disseminate a facility-specific report of antibiotic susceptibility to clinical providers, indicated: .Nursing homes should work with consultant laboratories to create a facility specific summary of antibiotic susceptibility patterns from the organisms commonly isolated in microbiology cultures. One example of a susceptibility summary is called an antibiogram. Antibiograms are tables developed by the microbiology laboratory showing the percent susceptibility for a panel of common bacteria tested against a panel of common antibiotics. Nursing home laboratories may have to tailor the antibiogram based on the facility's diagnostic testing practices.Antibiograms may be updated every 12 to 24 months, based on the number of cultures submitted by a facility. Summaries of susceptibility patterns should be disseminated to frontline nursing staff, clinical providers and consultant pharmacists as an educational tool and to guide management decisions .Perform antibiotic time outs .Antibiotics are often started empirically [a course of treatment or action based on experience and observation rather than on a diagnosis] in nursing home residents when the resident has a change in physical or mental status while diagnostic information is being obtained. However, providers often do not revisit the selection of the antibiotic after more clinical and laboratory data (including culture results) become available.An antibiotic time out is a formal process designed to prompt a reassessment of the ongoing need for and choice of an antibiotic once more data is available including: the clinical response, additional diagnostic information, and alternate explanations for the status change which prompted the antibiotic start. Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated. https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdA review of the facility's Policy and Procedure titled, Antimicrobial Stewardship Program (ASP) updated March 2018, indicated, .2b. Center and Providers: Adheres to guidelines of ASP.Incorporates antibiotic selection and course/duration of treatment based on available data and guidelines. This includes.antibiogram.4e. Implement antibiotic time outs.5. Tracking: Monitor antibiotic use practices and outcomes related to antibiotics to guide clinical practice and track impact of interventions.Review of an undated online document, published by the Centers for Disease Control and Prevention (CDC) titled, The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX B: Measures of Antibiotic Prescribing, Use and Outcomes under the section, Antibiotic starts. Indicated: .Tracking and reporting antibiotic start data could assess the impact of antibiotic stewardship initiatives designed to educate and guide providers on situations when antibiotics are not appropriate . https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf

Based on observation, interview and record review, the facility failed to maintain an effective pest control program when multiple flies were seen in the food preparation area. This failure had the potential of contamination of food and food poisoning for the 172 residents eating facility prepared meals. Findings:During the initial kitchen tour on 8/4/25 at 8:21 a.m. a fly was observed in the kitchen.During the initial kitchen tour on 8/4/25 at 8:44 a.m. in the dry storeroom which was separated by a closed door from the kitchen, another fly was observed.During the initial kitchen tour on 8/4/25 at 10:12 a.m. the dumpsters were observed. The door to the dumpster area was noted to be propped open with rock. The dumpsters were approximately 15 to 20 feet from the hallway door.During the lunch plating observation on 8/5/25 at 11:30 a.m., multiple flies were observed in the kitchen. The food for lunch was mostly uncovered and staff were swatting at the flies to keep them off of the meal.During an interview on 8/6/25 at 2:50 p.m., with the Dietary Director (DD), the DD concurred that the number of flies had increased over the past few days which was a risk for food contamination. He went on to state that the lunch meal should have been covered to minimize the risk to residents. Review of facility provided policy title Pest Control (HCSG Policy 029, Healthcare Services Group, Inc. revised 2/2025 ) indicated in the policy statement that A program will be established for the control of insects and rodents for the Dining Services Department. It further indicated in bullet 2 that All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concerns verbally and in writing .Review of the Illinois Department of Public Health information on flies indicated that The habits of flies favor the spread of bacteria and other disease-causing organisms. Flies often feed and lay eggs on garbage and manure before contaminating human foods and food preparation surfaces by landing on them. When feeding, house flies regurgitate their stomach contents onto food to liquefy it before ingesting it. They also may contaminate food and surfaces by defecating on them .Review of the Ecolab website indicated that Large flies enter through windows and doors and feed on the food debris . Large flies . can . spread foodborne illness, by landing on various . surfaces and landing on . food .

Based on observation, interview, and record review, the facility failed to ensure privacy and dignity were maintained for one of 38 sampled residents (Resident 127) when Resident 127's urinary catheter bag (catheter bag - a bag that collects urine draining from the bladder) did not have a privacy cover (a cover designed to discreetly conceal the visible urine in a urinary catheter bag, improving resident dignity, comfort, and self-worth in public or social settings) over it.This failure had the potential to negatively impact Resident 127s feelings of dignity and self-worth.Findings:During an observation on 8/4/25 at 11:15 AM, in Resident 127's room, a urinary catheter bag was observed hanging under Resident 127's bed and it was not covered with a privacy cover.During a concurrent observation and interview on 8/4/25 at 11:32 AM with Certified Nurse Assistant (CNA) 6 in Resident 127's room, CNA 6 confirmed the catheter bag hanging under Resident 127's bed did not have a privacy cover. CNA 6 stated, Resident 127's catheter bag should have been covered with a privacy cover to preserve Resident 127's dignity.During a concurrent observation and interview on 8/4/25 at 12:03 PM with Licensed Nurse (LN 21) in Resident 127's room, LN 21 confirmed a urinary catheter bag was hanging under Resident 127's bed, needed a privacy cover, and did not have one. LN 21 stated, it was important to provide Resident 127 with a privacy cover over his catheter bag to preserve dignity. During an interview on 8/7/25, at 10:20 AM, with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 127's catheter bag should have been covered with a privacy cover to maintain (Resident 127's) dignity. The ADON stated it has always been the facility's policy to use a privacy cover for urinary catheter bags.A review of a facility policy titled, RESIDENT RIGHTS, dated 12/21, indicated, .Employees shall treat residents with kindness, respect and dignity.These rights include the resident's right to.a dignified experience.be treated with respect, kindness and dignity.A review of an undated facility policy titled, Accommodation of Needs, indicated, .In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure the storage of bedside self-administered medication was reviewed and approved by a doctor and the care team for one resident (Resident 1) out of 12 sampled residents observed for medication administration when Resident 1's albuterol inhaler (a medication used to treat shortness of breath) was found on her bedside table.This failure had potential to contribute to unsafe and unsecure medication use by Resident 1 and other residents including Resident 1's roommates.During a medication administration observation with Licensed Nurse (LN) 10, at the facility's [NAME] Station hallway, on 8/4/25, at 8:37 a.m., LN 10 was observed giving six medications to Resident 1, which included TRELEGY Ellipta (inhalation drug to treat chronic breathing disease) as a scheduled drug to treat a breathing condition. Further observation of Resident 1's room revealed the presence of an albuterol inhaler (a medication used to treat shortness of breath) at the bedside table.During a concurrent observation and interview with Resident 1 in Resident 1's room, on 8/4/25, at 8:46 a.m., Resident 1 acknowledged having the inhaler at her bedside table. Resident 1 stated she used the inhaler by herself around twice a day. Resident 1 stated she wanted the inhaler with her because it was too much of a hassle to get it from the nurses. Resident 1 stated she did not tell the nurse when she used the inhaler. A review of Resident 1's medical record titled, Order Summary Report, dated 8/2025, indicated the following orders as it related to Resident 1's albuterol inhaler use:1.Resident is (SPECIFY: incapable) of administering own medications.Start Date 03/02/2025. 2.Albuterol .Inhalation Aerosol.(Albuterol) 2 puff inhale orally every 6 hours as needed for wheezing related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE (a chronic breathing disease).Start Date 03/01/2025. Further review of Resident 1's Order Summary Report did not indicate an order for Resident 1's inhaler medication to be kept at the bedside or to be self-administered.A review or Resident 1's Medication Administration Record (MAR, a document showing doctor's orders, instructions, and the nurse's medication administration record) report for the month of 8/2025, did not indicate any nursing documentation on Resident 1's use of the albuterol inhaler. Further review of Resident 1's medical record did not reveal there was a care plan (a roadmap for individualized care, detailing the resident's needs, goals, and the interventions needed to achieve those goals) created for Resident 1 regarding her albuterol inhaler medication kept at the bedside for self-administration. During a concurrent observation and interview with Resident 1, in Resident 1's room, on 8/5/25, at 10:00 a.m., Resident 1's albuterol inhaler was not observed on the bedside table. Resident 1 stated the nurse took the inhaler away. Resident 1 stated she was told she was not allowed to have the inhaler any longer. During an interview with LN 10, on 8/5/25, at 10:35 a.m., LN 10 stated she had no idea how Resident 1 got the albuterol inhaler and would not let the nurses take it from her. LN 10 stated she had attempted to take the albuterol inhaler from Resident 1, but she refused. LN 10 stated she has never been told by Resident 1 if she ever used the albuterol inhaler. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 8/5/25, at 3:20 p.m., the ADON reviewed Resident 1's medical record and verified Resident 1 had no care plan regarding the self administration of the albuterol inhaler, no documented evidence of the albuterol inhaler use on the MAR report, and no doctor's order in place to self-administer the albuterol inhaler. A review of the facility's policy titled, Self-Administration of Medication, updated on 9/2017, indicated .Policy Statement: If the resident desires to self-administer medication, the Center evaluates the resident's ability.Procedure: 1. If the resident desires to self-administer medications, the Self-Medication Evaluation is completed. This evaluation is completed before the resident is able to self-administer. 2. If it is determined the resident may self-administer medications, the nurse: a. Obtains a physician order for self-administration for the specific medication(s). b. Initiates the Self-Medication Administration Care Plan. c. Determines whether medications will be stored at nursing stations or resident's room. d. Initiates the Bedside Self-Medication Administration Record. If medications are stored in bedside. e. Obtain and initiate proper safety mechanisms if medications are stored at the bedside (i.e. lock box). f. LN has a key to any lock box or locked drawer holding medications.A review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, dated 4/2008, indicated .BEDSIDE MEDICATION STORAGE.Policy.Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the facility's interdisciplinary (team approach to care) resident assessment team.Procedures.A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and the medication label for the appropriate medications. C. For residents who self-administer medications, the following conditions are met for bedside storage to occur.The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is deemed inappropriate. 2) The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy or in the original container if a nonprescription medication. 3) The bedside medication use as reported by the resident is reviewed during each nursing shift and administration information is documented on the resident's MAR.

Based on interview and record review, the facility failed to immediately inform the Responsible Party (RP - an individual chosen by a resident or appointed by a judge to make personal and/or financial decisions for an adult who cannot care for or make decisions for themselves) for one out of thirty-eight sampled residents (Resident 153), when Resident 153 had a change in condition (any change in a resident's physical, mental, or emotional state from their normal baseline, possibly indicating a new illness or injury or worsening of a condition, recognized and treated to prevent serious complications, and to maintain resident health and safety), was sent to the emergency room (ER), and an RP was not notified in a timely manner.This failure resulted in miscommunication between the facility, the RP, and the ER when medical decisions were made for Resident 153 without input from the RP.Findings:During an interview on 8/5/25 at 12:06 PM, with RP 3, RP 3 stated, Resident 153 had an unwitnessed fall on Saturday, 7/19/25 and the facility did not notify an RP until Sunday, 7/20/25. The RP stated, the notifications on Sunday were left on the office phone of RP 3 even though the facility was given specific direction on how to contact an RP after regular business hours and on weekends via a letter sent to the facility dated 3/13/25. RP 3 further stated, the facility left three voicemails on her desk phone on Sunday, 7/20/25, and the messages were left at 6:36 AM, 7:39 AM, and 7:20 PM.During a concurrent interview and record review on 8/7/2025 at 10:35 AM with the Assistant Director of Nursing (ADON), Resident 153's admission RECORD [a comprehensive collection of documents and information gathered at the time a resident is admitted or readmitted to a facility], dated 1/18/25, was reviewed. The admission Record indicated, Resident 153 had two emergency contacts, RP 3 and RP 4, and each RP contact number listed was an office number. The ADON continued, the numbers listed on the admission Record were the only numbers the facility had to contact the RP, and confirmed the numbers were for (regular) office hours 9 AM to 5 PM. The ADON confirmed, if an RP provided alternate numbers for nights and weekends, the information should have been added to Resident 153's admission Record and used anytime there was a change in condition after hours.During a concurrent interview and record review on 8/7/2025 at 11:23 AM with Social Services Assistant (SSA - a person who assists Residents in addressing their social, emotional, and psychosocial needs) 1, a letter from Calaveras Health and Human Services Agency [CHHSA - a county department that provides RPs to adults in their county], dated 3/25/25, was reviewed. SSA 1 confirmed, she had found the letter with updated contact information for Resident 153 on her desk and it contained the following information, .is dedicated to streamlining our practices to ensure clients and facilities can reach our team during the day, after hours, and on weekends.can also contact the PG [Public Guardian - also referred to as the RP] office during business hours by calling [phone number].if you need to speak with our office after hours, on the weekend, or holiday regarding a conservatee, please contact [phone number].This number is specifically for after-hours emergencies.Please remember, when team members are out, if you email or call a team member directly, your call may be unanswered. SSA 1 stated, she had received the letter in March but had not added the numbers to Resident 153's admission Record, but should have. SSA 1 further stated, the problems of not updating Resident 153's admission Record would be that staff could not contact an RP in case of an emergency occurring after hours or on weekends, and if a voice message was left on office phone numbers, the RPs would not receive information until the next business day.During an interview on 08/07/2025 at 12:48 PM with the Administrator (ADMIN), the ADMIN stated the facility should notify the RP for all changes in condition for Resident 153. The ADMIN stated, if an illness, injury, or any type of incident occurred after regular office hours or on weekends regarding Resident 153, facility staff should not leave voice messages on an RP desk phone or office line but make every attempt to reach an RP via methods provided to the facility via the letter dated 3/25/25. The ADMIN further stated, updated RP contact information should be updated in the facility's computer system as soon as it is received.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/21, the P&P indicated, .Federal and State laws guarantee certain basic rights to all residents of this facility.These rights include the resident's right to.appoint a legal representative [a person authorized by the resident or by a judge to make personal, medical, and/or financial decisions for an adult who cannot make decisions for themselves].Notified of his or her medical condition and of any changes in his or her condition.During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, the P&P indicated, .The following is to be documented in the resident medical record.Changes in the resident's condition.Events, incidents or accidents involving the resident.Notification of family.

Based on interview and record review, the facility failed to immediately resolve a grievance and did not respond in writing within five business days to one out of 38 sampled residents (Resident 81), in accordance with facility policy when Resident 81 submitted a grievance form in June 2025, but the facility did not provide a resolution or follow-up until August 2025.This delay in addressing the grievance negatively impacted the psychosocial wellbeing of Resident 81.Findings:A review of Resident 81's Inventory of Resident Personal Items dated 3/9/25 indicated that she brought the following items with her upon admission: 13 pairs of pants, 12 blouses, 7 sweaters, 5 pairs of slippers, and 13 pairs of pajamas among other items.A review of the Grievance/Complaint Resolution Report dated 6/30/25 and signed by the Social Services Director (SSD), showed that Resident 81 reported several missing items, including white slacks, a summer dress and some blouses. The grievance form indicated that an inquiry was made with the laundry department, but the missing items were not found. It was explained to Resident 81 that she would be reimbursed if she could provide receipts for the lost clothing. However, Resident 81 stated that she just wanted her missing items returned.During an interview with Resident 81 on 8/6/25 at 7:57a.m., she stated that she initially reported the missing items to Social Services Assistant (SSA) 1 and was told to file a grievance. Resident 81 confirmed that the facility had contacted the laundry department, but the items were still not found. Resident 81 also stated she was informed that receipts were required for reimbursement. Unfortunately, she does not have any receipts as most of her clothing was purchased by her mother. According to Resident 81, she later on spoke with the SSD, who reassured her that the business office and the facility Administrator (ADMIN) would be contacted regarding possible reimbursement. However, as of 8/6/25, Resident 81 had not received any follow-up or resolution. Additionally, Resident 81 stated that on 7/30/25, during a Resident Council meeting, she brought up the issue with the activities director (AD), who then referred her to the Director of Nursing (DON). Resident 81 expressed confusion as to why this referral was made.During an interview with the Assistant Director of Nursing (ADON) on 8/6/25 at 10:15 a.m., the ADON stated that the facility has a process for finding and reporting missing items, and the nurses were re-educated by Social Services Assistant (SSA) 2 in the afternoon of 8/5/25.During an interview with the SSD on 8/6/25 at 10:49 a.m., the SSD stated that the facility provides residents with a copy of the grievance form and explained to them it was the form to use when submitting complaints such as, missing items, care that they are receiving etc The SSD stated that the grievance process is currently broken and needs to be fixed.During an interview with the Activities Assistant (AA) on 8/7/25 at 8:09 a.m., the AA stated that when a resident reports missing items to them, they would refer the complainant to the social services department. The AA also stated that reports regarding lost items are not included in the Resident Council meeting minutes.During an interview with the Activities Director (AD) on 8/7/25 at 9:00 a.m., the AD stated that Resident 81 informed her during the Resident Council Meeting on July 30, 2025, about the missing items. The AD stated that she directed Resident 81 to file a grievance to social services.During an interview with Certified Nursing Assistant (CNA) 1, on 8/6/25 at 3:06 p.m., CNA 1 stated that if a resident reports a missing item, she would first check the resident's inventory sheet and report the issue to the nurse. Then she would search the resident's room as well as the laundry room. If the item was still not found, she would either call the Social Services Department to report the complaint or fill out a form and slide it under the Social Services Department door, as their mailbox is often full. CNA 1 also stated she would notify the family member. During an interview with Licensed Nurse (LN) 17 on 8/6/25 at 3:08 p.m., LN 17 stated that if a resident reports a missing item, he would search the resident's drawer and closet. If the item is not found, he would contact Social Services by phone and document the issue in the progress notes. LN 17 added that, if the laundry department was open, he would also check there.During an interview with CNA 2, on 8/6/25 at 3:11 p.m., CNA 2 stated that if a resident reported a missing item to her, she would assist by first checking the resident's closet. If the item was not found, she would also check the closet of the resident next door, as items are sometimes misplaced there. If the item was still not located, she would inform her team to keep an eye out for it. She would also notify the Social Services by completing a form. During an interview with CNA 3, on 8/6/25 at 3:16p.m., CNA 3 stated that she was from registry. According to CNA 3, if a resident reported a missing item to her, she would check the laundry area, the roommate's closet, and the closets of neighboring residents. If the item was still not found, she would ask other staff members for assistance.A review of the facility's Theft and Loss Report Form dated 8/6/26 indicated that, Resident 81's loss's occurred from June to July. The missing items were itemized as follows:1. Size 12-14 [NAME] Slacks2. Black and white plaid long sleeve shirt3. Blue and [NAME] plaid long sleeve shirt4. White/corral blue blouse5. Gray/crew neck pull over6. Magenta slippers7. [NAME] slacks8. Purple [NAME] pull over9. Black Sweats drawstrings.A review of the facility's Grievance Procedure Policy updated on March 2025, indicated that, .Grievances are resolved immediately.When immediate resolution is not possible, the grievance is routed to the Grievance Official promptly.responds within five business days.The person with the grievance has the right to a written decision regarding his/her grievance.If a Grievance is not resolved in five business days, the Administrator reviews the Grievance daily at the meeting until resolution is obtained.

Based on interview, observation, and record review the facility failed to provide an environment free of hazards to prevent an accident from occurring for two of two sampled residents (Resident 1 and Resident 2) when: 1. The facility did not also remove the brackets that held the footboard in place when the footboard had been removed from Resident 1 ' s bed which resulted in a laceration (a cut) to Resident 1 ' s right lower leg on 2/13/24 and an infection to the laceration on 2/22/24; and 2. The mattress keeper rod to hold Resident 2 ' s mattress in place on the bed frame was not in the correct position. This failure resulted in an extensive injury to Resident 1 ' s leg which required an emergency room intervention of ten staples (metal material used to close a wound to help it heal). Subsequently Resident 1 ' s injury became infected which had the potential for further bodily harm. The failure of the mattress rod not being in place had the potential for bodily harm to occur to Resident 2. Findings: 1. Review of Resident 1 ' s ADMISSION RECORD indicated Resident 1 was admitted with diagnosis which included but not limited to difficulty in walking. Review of Resident 1 ' s Nursing Note, dated 2/13/24, indicated, .At approximately [2 p.m.] [Resident 1] yelled out while CNA [Certified Nursing Assistant] was passing his room, per [Resident 1] I was trying to get around my bed when my leg got caught on the metal piece under the bedframe. CNA reported skin tear to nurse, this writer completed a further assessment. Site was cleansed with Normal saline to see depth of wound, upon assessment this LN [Licensed Nurse] noted tissue was visible and wound was producing large amounts of blood, closure of wound not possible with steri-strips [thin adhesive bandages] . During a review of Residents 1 ' s Emergency Department (ED) Physician Notes, dated 2/13/24, the note indicated .Patient reports laceration occurred on his bed .diagnosis of skin laceration, muscle injury, boney injury, tendon [connects muscles to your bone] laceration, vascular [blood vessels] injury .with a 6 cm [centimeters, unit of measurement] gaping laceration right .lower extremity .10 staples . During an interview on 2/26/24, at 1:30 p.m., Resident 1 explained that he had got out of bed on his own, had got too close to the end of the bed, and sliced his leg on the bedframe. Resident 1 stated the footboard was never on his bed that he recalled. When asked if he requested the footboard to be removed, Resident 1 stated he did not request for the footboard to be taken off his bed. During an interview on 2/26/24, at 1:58 p.m., CNA 3 stated she was assigned to care for Resident 1 on the day the injury occurred. CNA 3 stated Resident 1 was trying to get up out of bed and hit his leg on a metal piece that was sticking out at the end of his bed. CNA 3 stated the bracket at the end of the bed that Resident 1 injured himself on was there to hold the footboard in place and the footboard had been removed at a time that she was unaware of. During an interview, on 2/26/24, at 2:05 p.m., the Director of Maintenance (DOM) stated for the removal of resident footboards, staff should call the maintenance department to let them know that there was a need to remove the foot board. The DOM stated that he would then remove the footboard and the accompanying brackets because the brackets stick out from the bed and were a hazard. The DOM reported that he was not aware of the removal of Resident 1 ' s footboard prior to the accident. During an interview on 2/26/24, at 2:57 p.m., the Administrator (ADM) stated the risk of not having a footboard in place could result in an injury to the resident if the footboard was removed. The ADM stated that if a resident did not want the foot board on their bed, maintenance should be notified by staff, and the maintenance department would remove the footboard and brackets. During a review of Resident 1 ' s Nursing Note, dated 2/22/24, indicated, .During wound care today resident ' s lacerations to his R [right] shin was noted to be inflamed and warm to touch. MD [medical doctor] notified and ordered [name of antibiotic] . for 10 days . During an interview on 3/11/24, at 12:35 p.m., the Assistant Director of Nursing (ADON) stated an injury to a resident could lead to skin impairment which could result in a wound infection. The ADON explained, a wound infection could potentially result in complications such as sepsis (a serious life-threatening medical emergency in which the body responds improperly to an infection) and loss of limb. 2. Review of Resident 2 ' s ADMISSION RECORD indicated Resident 2 was admitted with diagnosis which included but not limited to unspecified sequelae (consequence) of cerebral infarction (stroke), difficulty in walking, and muscle weakness (generalized). During an observation on 2/26/24, at 1:42 p.m., in Resident 2 ' s room, it was observed that Resident 2 did not have a footboard on his bed and that the mattress slip bar was in the down position and was not securing Resident 2 ' s mattress in place. During a subsequent interview on 2/26/24, at 4:10 p.m. with the DOM, he stated that the purpose of the mattress bar on the bed was to keep the mattress from slipping off the bed. The DOM confirmed that Resident ' s 2 bed mattress bar was not in the correct place. The DOM stated that it was the nursing staff ' s responsibility to ensure the mattress bar was in the correct placement. The DOM was not sure what the purpose of the footboard was for. The DOM stated that there were bed extenders that could be placed on the bed if the patient needed more room for their legs. During a review of a facility P&P titled Bed Safety dated 12/2007, the P&P indicated, .The resident ' s sleeping environment shall be assessed by the interdisciplinary team, considering the resident ' s safety, medical conditions .To try to prevent death/injuries from the beds and related equipment(including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote .inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. During a review of [manufacture name] CS Series Beds .User Manual, the manual indicated, WARNING .The mattress keeper rods are an integral part of the bed rail system. By securing the mattress in place, the mattress keeper rods prevent unsafe gaps from forming between the bed ends or rails and the mattress. Install the mattress keeper rods correctly to decrease the risk of patient entrapment. The mattress keeper rods hold the mattress in place. Install them in the head and foot of decks .

ased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure that one of 39 sampled residents (Resident 108's) functional abilities did not diminish when Resident 108 had a decline in his ability to transfer and walk, and services were not provided to determine the cause and/or to maintain his abilities. This failure resulted in Resident 108's decline in range of motion, (ROM, the full movement potential of a joint) to his left leg, and a decline in his transfer and ambulation abilities. Findings: A review of Resident 108's ADMISSION RECORD indicated he was admitted ,d+[DATE] with diagnoses which included, displaced intertrochanteric fracture (fracture that occurs 3-4 inches from the hip bone) of left femur (thigh bone) and muscle weakness. During a concurrent observation and interview on 6/20/23, at 9:06 AM, in Resident 108's room, Resident 108 stated, .I can't straighten my left leg . Resident 108 attempted to straighten his leg. His left knee remained in a bent position. A review of Resident 108's MDS (minimum data set, a resident assessment and screening tool) Section G, dated March 28, 2023, indicated, .Transfer .limited assistance, one-person physical assistance . Walk in room .activity occurred only once or twice .Functional Limitation in Range of Motion . lower extremity .no impairment . During an interview on 6/21/23, at 7:43 AM, certified nurse assistant (CNA) 6 stated, Resident 108 .cannot straighten his left leg, I do not know how long it has been like that, I do range of motion with him . During an interview on 6/21/23, at 10:11 AM, licensed nurse (LN) 11 stated, Resident 108 .does not bear weight on his left leg. He cannot stand and pivot. He uses the Apex machine (mechanical lift used to transfer residents) to transfer. LN 11 further stated, He has not walked since he has been on this wing. During an interview on 6/21/23, at 11:12 AM, the director of rehabilitation (DOR) stated Resident 108 received rehabilitation services in late 2022 for a left femur fracture. He was walking 25 feet when he was discharged to long term care. He was able to straighten his left leg at that time. A review of Resident 108's clinical document titled, Physical Therapy PT Discharge Summary, dated 11/30/2022, indicated, . Patient will safely ambulate on level surfaces 25 feet using Two -wheeled walker with CGA [care giver assist] 95% of the time to allow patient to get to bathroom with decreased assistance .Prognosis to maintain CLOF [current level of function] = excellent with consistent staff support .Mobility .bed mobility = CGA, Transfers = Min (A) [minimum assist], Level surfaces = CGA. A review of Resident 108's clinical document titled, Documentation Survey Report v2, dated, March 2023, indicated, Resident 108 was Independent/no set up or help on March 24 and 25 for the care area walk in room. All other dates in March indicated, not applicable or activity did not occur or there was no documentation. For the care area of transferring, Resident 108 required supervision only on March 14, 25, and 26. The care area was documented as did not occur or not applicable on 24 shifts. It was documented as refused on March 19. A review of Resident 108's clinical document titled, Documentation Survey Report v2, dated, April 2023, indicated, Resident 108 was independent for the care area walk in room on April 1, 9, 10, 17 and 18. The care area walk in room was documented as not applicable on 47 shifts. For the care area transferring Resident 108 required limited assistance on April 1, 7, 8, 9, 17, 18, 26 and 29. Resident 108 was totally dependent for transfers on April 3, 6, 8, 9, 11, 15, 16, 19, 20, 21, 25 and 26. The care area transferring was documented as not applicable on 16 shifts and there were several omissions in documentation. A review of Resident 108's clinical document titled, Documentation Survey Report v2, dated, May 2023, indicated, Resident 108 was totally dependent on May 1, 6, 8, 9, 12, 13, 14, 15, 19, 21 and 31, for the care area walk in room. Resident 108 required limited assistance on May 20th. All other dates and shifts were documented as not-applicable or there was no documentation. For the care area transferring Resident 108 required limited assistance on May 1, 4, 8, 9, 12, 13, 14, 15, 17, and 19. Resident 108 required maximum assistance or was totally dependent on May 2, 6, 7, 10, 17, 20, 21, 26, 29, 30 and 31. All other shifts and dates indicated not applicable or there was no documentation. During a concurrent interview and record review on 6/21/23, at 1:32 PM, the assistant director of nurses (ADON) reviewed Resident 108's clinical records for March, April, and May 2023. The ADON stated, Resident 108 is .showing a steady decline . There is no documentation about his left leg being unable to straighten. There should have been some intervention. Staff should inform us so we can intervene as soon possible .the documentation is lacking so we do not have an accurate picture of what the resident is doing . The director of nurses (DON) stated, .for any change of condition that is significant, the staff need to tell the unit manager .They should inform the interdisciplinary team (IDT-a team of professional staff from different disciplines) so we can discuss interventions and update the plan of care for that change in condition. Without intervention there is the risk of continued decline, weakness, and contractures [a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff]. During an interview on 6/22/23, at 8:24 AM, the Medical Doctor (MD) stated, .I rely on physical therapy to make decisions about physical declines and changes in mobility. I depend on the nurses to make me aware of any changes. If [Resident 108] has lost mobility, restorative nursing aide services could help slow the progression . During a concurrent observation and interview on 6/23/22, at 10:20 AM, in Resident 108's room, the MD asked Resident 108 to straighten his left leg. Resident 108 raised his left leg, his knee remained bent, and he was unable to straighten the leg. The MD stated, he would .order rehabilitation services for the contracture to the left lower extremity . The MD further stated, he should be informed when there were changes in a resident's function and mobility. A review of a facility policy and procedure (P&P) titled, QUALITY OF LIFE Activities of Daily Living (ADLs)/Maintain abilities, dated, 11/2017, indicated, .the facility will provide the necessary care and services to support the resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such a decline in function is unavoidable .a resident is given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living including .Mobility-transfer and ambulation . A review of a facility P&P titled, QUALITY OF CARE Restorative Nursing Program, dated 6/2018, indicated, .Purpose: The facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility unless a reduction is clinically unavoidable Policy: To assist our residents in obtaining and maintaining their highest practicable functional levels, prevent unnecessary declines, and provide an active and healthy living environment .Guidelines: Residents will be routinely assessed for the need for a formalized Restorative Nursing program .

Based on interview and record review, the facility failed to prevent one (Resident 1) of three sampled residents from developing Pressure Injuries (PI- an area of injured skin when force is applied to the surface of the skin) when Resident 1: Developed Wound #1 (described as the same wound located on the right buttock or sacrum-bone at the base of the spine, or coccyx- tailbone), initially a Stage 2 (skin blisters or forms an open area) Pressure Ulcer (PU- sores to the skin caused from prolonged pressure) to the right buttock/sacrum/coccyx that progressed to a Stage 3 (full thickness skin loss extending into the layer under the skin) PU and; Developed a Deep Tissue Injury (DTI- persistent nonblanchable deep red, purple, or maroon areas of intact skin caused by damage to underlying soft tissues) to the right heel, and; Developed a PI to the left heel and PIs to the feet that were not identified by the facility. These failures caused Resident 1 to be hospitalized for wound infection and sepsis (body's response to infection that can lead to tissue damage, organ failure or death) and to undergo surgical debridement (removal of infected and dead tissue from wound) to treat the wounds. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia, Type 2 diabetes (an impairment in the way the body regulates and uses sugar), diabetic polyneuropathy (disorder of the nerves that can cause numbness, tingling, or pain), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 1's Minimum Data Set (MDS-an assessment tool) Cognitive Patterns, dated 7/14/22, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 that indicated he was cognitively intact. A review of Resident 1's MDS Behavior, dated 7/14/22, indicated he did not exhibit rejection of care. A review of Resident 1's MDS Functional Status, dated 7/14/22, indicated he required extensive assistance of two or more persons for bed mobility and transfers. A review of Resident 1's MDS Skin Conditions, dated 7/14/22, indicated Resident 1 was at risk of developing PUs or PIs, but did not have any unhealed PUs, PIs, or DTIs upon admission. A review of Resident 1's MDS Functional Status, dated 8/7/22, indicated Resident 1 required extensive assistance for bed mobility and transfers. A review of Resident 1's MDS Skin Conditions, dated 8/7/22, indicated Resident 1 had one Stage 3 PU, one unstageable (full thickness skin loss that is covered by necrotic, dead tissue) PU, and one unstageable DTI. A review of Resident 1's NSG (nursing) Admission/Readmission Evaluation, completed 7/19/22, indicated scattered bruising to LUE (left upper extremity) and to the RUE (right upper extremity). No pressure injuries or pressure ulcers were documented. A review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (assessment tool to document a resident's risk for developing pressure sores), dated 7/19/22, 7/21/22, 7/25/22, and 8/1/22, reflected a score of 16 that indicated Resident 1 was at risk for developing pressure sores. A review of Resident 1's PCC (point click care- electronic medical record used by the facility) Skin & Wound - Total Body Skin Assessment, dated 7/20/22 and 7/28/22, indicated neither assessment identified any new wounds. A review of Resident 1's Order Summary Report indicated order Stage 2 on coccyx, Cleanse NS [normal saline], Pat dry, apply zinc oxide [skin cream] apply dry dressing every day shift for coccyx wound, order date 7/19/22. A review of Resident 1's Progress Note, dated 7/20/22, indicated order .Skin/Wound: St. [stage] 2 pressure ulcer resolving. Treatment performed as per MD [medical doctor]. No s/s [signs or symptoms] of infection or swelling, no discharge noted .The resident requires extensive assist with bed mobility . A review of Resident 1's Progress Note, dated 7/26/22, indicated .Wound MD rounded on this resident this AM via telehealth visit. This resident has a stage 3 PU to the Rt. [right] buttock. Moderate drainage noted to wound. Wound noted to contain 70% slough [yellow, tan dead tissue in a wound], 30% eschar [black or brown dead tissue in a wound]. No s/s [signs or symptoms] infection. New tx [treatment] received .Wound MD will round weekly. A review of Resident 1's Surgical and Wound Care Visit Report, dated 7/26/22, indicated .Wound Assessment(s) Wound #1 Right Buttock is a Stage 3 Pressure Injury Pressure Ulcer .Initial wound encounter measurements are 4.5cm [centimeter] length x 5.5cm width x 0.3 cm depth . A review of Resident 1's Skin & Wound Evaluation, dated 8/2/22, indicated Resident 1 had a new In-House Acquired (acquired while a resident in facility) Stage 3 to the Sacrum that measured 6.9 cm in length and 4.0 cm in width, depth Not Applicable. A review of Resident 1's Progress Note, dated 8/7/22, indicated pt has unstageable wound to coccyx, tunneling at 6cm deep, foul odor with eschar and slough; [name of MD] recommended transfer to ED [Emergency Department] at [Name of Hospital] for evaluation and treatment . A review of Resident 1's Order Summary Report indicated order Clean blister with wound cleanser and cover with dry foam dressing .every shift for Blister right heel, order date 7/30/22. A review of Resident 1's Progress Note, dated 7/30/22, indicated .Blister to right heel remained intact . A review of Resident 1's Skin & Wound Evaluation, dated 8/2/22, indicated Resident 1 had a new In-House Acquired Deep Tissue Injury to the Right Heel that measured 4.1 cm in length and 5.2 cm in width with the surface intact.; A review of Resident 1's Progress Note, dated 8/1/22, indicated .Skin/Wound: pt [patient] has stage 2 pi to sacrum, stage 3 pi to R [right] buttocks, blister to rt heel . A review of Resident 1's Progress Note, dated 8/2/22, indicated .Wound MD rounded on this resident this AM shift. This patient has a stage 3 P/U to the Rt buttock measuring 6.9 L [length] x 4.0 W [width] x 0.3 D [depth] .Patient also noted to have new DTI to right heel measuring 4.1 L x 5.2 W x 0.0 D . A review of Resident 1's Surgical and Wound Care Visit Report, dated 8/2/22, indicated .Wound Assessment(s) Wound #1 Right Buttock is a Stage 3 Pressure Pressure Ulcer .Subsequent wound encounter measurements are 6.9cm length x 4cm width x 0.3cm depth .Wound #2 Right heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer .Initial wound encounter measurements are 4.1 cm x 5.2 cm width with no measurable depth A review of Resident 1's Treatment Administration Report, for July 2022 and August 2022, reflected Resident 1 received wound treatments as ordered and did not refuse any treatments. A review of Resident 1's Care Plan for impaired ADL (Activities of Daily Living) function, initiated 7/8/22, indicated Interventions- .Bed Mobility: The resident requires extensive assistance by (2) staff to turn and repositioning [sic] in bed . A review of Resident 1's Care Plan for potential for impairment to skin integrity, initiated, 7/19/22, indicated Interventions- .Heel protectors to Bilateral feet to prevent skin breakdown, initiated 8/4/22 .Pressure Relieving Air Mattress, initiated 8/4/22 . A review of Resident 1's Care Plan for skin breakdown, initiated 7/19/22, indicated .[Resident ] 1 has Stage 2 pressure ulcer development r/t [related to] immobility .Interventions- Monitor St [stage] 2 pressure ulcer for increased redness, swelling, Drainage, s/s infection. Notify MD of lack of response to tx [treatment] . A review of Resident 1's Care Plan for Stage 3 pressure ulcer to sacrum, initiated 8/2/22, indicated Interventions- Monitor Stage 3 Pressure Ulcer to Sacrum for increased redness, swelling, drainage, temp [temperature]. Notify MD of lack of response to TX . A review of Resident 1's Care Plan for DTI to right heel, initiated 8/2/22, indicated Interventions- Heel protectors to Bilateral feet to prevent skin breakdown, initiated 8/7/22, .Monitor DTI to right heel for increased redness, swelling, drainage, temp [temperature]. Notify MD of lack of response to TX . A review of Resident 1's hospital document ED Physician Notes, dated 8/7/22 indicated .Skin Symptoms: Large foul-smelling decubitus ulcer [pressure ulcer]. Decubitus skin damage right heel. Skin injury distal [away from the center of the body] right foot .CT [computerized tomography scan-an imaging procedure] PELVIS [the lower part of the trunk between the abdomen and thighs]: IMPRRESSION: Posterior fluid and air collection near the sacroiliac junction [connection between the spine and the pelvis] consistent with sacral ulcer with probable underlying subcutaneous abscess [collection of pus in the soft tissue] . A review of Resident 1's hospital document History and Physical Examination, dated 8/7/22, indicated .Exam demonstrated large foul-smelling right buttock wound with evidence of purulent [thick discharge from a wound] drainage. Also noted to have bilateral [both sides of the body] calcaneal [heel] ulcers right greater than left .IMPRESSION: Sepsis-likely due to infected decubitus ulcers . A review of Resident 1's hospital document General Surgery Consultation, dated 8/7/22, indicated .Pt. BIBA [brought in by ambulance] from facility with a wound to sacral R buttocks area started as stage 3 now unstageable by staff .He was found apparently to have a large pressure related wound over the right sacral/gluteal region which has now become very foul-smelling and has extensive amounts of tissue necrosis [tissue death] .He also has some open pressure related wounds over his right calcaneal [heel] region, left calcaneal area and over the dorsal [top side] aspect and plantar [bottom or sole of the foot] aspect of his feet bilaterally [both sides of the body] .Assessment/Plan .has developed a large pressure area over the right gluteal/ sacral region for which he will require a fairly aggressive large debridement in an operative setting under general anesthesia . A review of Resident 1's hospital Progress Note, dated 8/8/22, indicated .The patient was admitted to the hospitalist service with sepsis secondary to an unstageable infected sacral decubitus ulcer as well as a probable infected decubitus ulcer of the right heel and possibly the distal, dorsal, lateral right foot. He had a CT scan of the abdomen and pelvis demonstrating the sacral abscess with air extending into the tissues, which appears open and has dimensions of approximately 7 x 7 x 3 cm . A review of Resident 1's hospital document Wound Pressure Injury Photo Note, dated 8/8/22, indicated .The right buttock injury is unstageable. There is a very foul odor noted. Moderate amount of purulent drainage is present from the opening .The right groin has a linear deep purple deep pressure injury .The left great toe has a callus [thickened layers of skin] noted on the medial [inside of foot] aspect .The right heel has a suspected tissue injury noted. The wound is boggy and purple .The plantar [bottom of the foot] surface of the foot below the 5th metatarsal [bone on the outside of the foot connected to the small toe] has a dark purple wound with intact skin . A review of Resident 1's hospital document Operative Note, dated 8/10/22, indicated .Operation- Right Sacral Decubitus Ulcer Debridement, Incision and drainage and Debridement Right Sacral Decubitus ulcer, and Debridement of right heel ulcer .Findings Right heel with 4 x 4 cm pressure ulcer stage II, Right side of foot 5 x 2.5 cm blister, unroofed, intact underlying skin/dermis [middle layer of skin], Right sacral decubitus ulcer, stage IV [full thickness skin and tissue loss with exposed muscle, tendon or bone], 7 cm length x 4 cm wide by 5 cm deep with approximately 2 cm undermining in cephalad [toward the head] direction . A review of Resident 1's hospital document Operative /Procedure Note, dated 8/19/22, indicated .PROCEDURES: Formal debridement sharply, right heel with application of wound VAC [Vacuum-Assisted Wound Closure-treatment to help a wound heal] . During an interview on 9/9/22 at 11:15 a.m. with the Administrator (ADM), the ADM stated that Resident 1 was initially admitted to the facility for pneumonia and to receive therapy. Resident 1 was admitted on [DATE] and had no PU upon admit according to the MDS, dated [DATE]. The ADM acknowledged that Resident 1 developed PUs and PIs while in the facility. A coccyx PU and DTI to right heel were identified on 8/2/22 according to the Surgical and Wound Care Visit Report, dated 8/2/22, and treatment orders were received. Resident 1 was seen by the wound MD weekly. Resident 1 was sent to the hospital on 8/7/22 because the coccyx wound had developed tunneling (wound had progressed to form passageways underneath the surface of the skin) and had a foul odor. During a joint interview and record review on 9/9/22 at 11:35 a.m. with the Director of Nursing (DON) and the ADM, the DON stated Resident 1's sacral wound was identified as a Stage 2 PU on 7/19/22. A blister was identified on the right heel. No wounds were identified on the left heel. Treatment orders for the sacral wound were received on 7/19/22 according to Resident 1's Order Summary Report and Resident 1's Care Plan for skin breakdown, initiated 7/19/22. Treatment orders for the right heel were received on 7/30/22. The DON stated that it was identified on 8/2/22 that the sacral wound had progressed to a Stage 3 PU. The DON stated that the right heel did not progress, and on 7/30/22 and 8/2/22 it was documented as a blister. On 8/7/22, tunneling on the sacrum was identified and Resident 1 was sent to the hospital. The DON acknowledged that there were no notes prior to 8/7/22 regarding tunneling of the wound. The DON stated that Resident 1 refused treatment and refused turning and repositioning. The DON stated Resident 1 was able to turn and reposition himself. Reviewed with the DON that Resident 1's MDS, dated [DATE], indicated Resident 1 required two person extensive assistance for bed mobility and transfers. The DON stated the expectation is that residents are turned every 2 hours if they have a wound and every four hours if they do not have a wound. The DON stated that refusals to turn are documented and it should be documented if treatment was refused. The DON stated that there was not a care plan for Resident 1's refusals of care, including turning and repositioning. The ADM stated, Refusals should be care planned. Reviewed order for pressure relieving air mattress on 7/29/22, 10 days after identification of Stage 2 sacral PU. The DON stated it was ordered on 7/29/22 to prevent further worsening of the sacral PU. Reviewed order for heel protectors on 8/7/22 after right heel blister identified on 7/30/22. The DON stated that Resident 1 did not necessarily need the the heel protectors as he was was able turn himself in bed. During an interview on 9/9/22 at 2:30 p.m. with the ADM, reviewed the PCC Skin & Wound - Total Body Skin Assessment, dated 7/20/22, and that the sacral wound was not indicated even though it was identified on 7/19/22. The ADM acknowledged it was not documented and that there was a Breakdown of skin and wound documentation. The ADM stated that wound documentation should have been under the skin and wound tab in the electronic record. The ADM acknowledged that the wound information was not in the electronic record. Reviewed MDS, dated [DATE], and progress notes 7/19/22 through 7/26/22, 7/28/22, 7/31/22, 8/1/22, and 8/7/22, that indicated Resident 1 required extensive assistance for bed mobility. The ADM acknowledged Resident 1 was unable to move self in bed and that the DON was incorrect when she said that Resident 1 was able to self turn. The ADM acknowledged that there was no documentation in the clinical record that Resident 1 refused treatment per the Treatment and Administration Report, for July 2022 and August 2022, or refused turning and repositioning. Reviewed Resident 1's hospital document General Surgery Consultation, dated 8/7/22, indicating Resident 1 had right and left heel wounds, foot wounds, as well as Stage 3 PU to the right buttocks. The ADM acknowledged, after review of Resident 1's clinical record, that the left heel wounds and foot wounds were not identified by the facility. The ADM acknowledged that wound care charting was not complete or done correctly. During a joint telephone interview on 9/22/22 at 3:07 p.m. with the Wound Care Nurse (WCN) and the Assistant Director of Nursing (ADON), the WCN stated Resident 1 had a wound to the right buttocks and a DTI to the right heel identified on 8/2/22 by the wound MD. The wound MD classified the sacral wound as the right buttock wound. The WCN acknowledged that there was not a progress note indicating a sacral PU had been identified on 7/19/22. The WCN acknowledged that the PCC Skin and Wound -Total Body Skin Assessment, dated 7/20/22 and 7/28/22 , did not indicate any new wounds. The ADON acknowledged that on 7/19/22, there was no documentation that the wound was identified on 7/19/22, except for orders to treat and monitor stage 2 pressure ulcer beginning 7/20/22. The ADON stated that, There were documentation problems, a breakdown with documentation. The right buttock wound was identified as a stage 3 wound on 7/26/22. The ADON stated Resident 1 was noncompliant with turning and repositioning. The ADON stated Resident 1, Needed care plan for noncompliance, refusing turning and repositioning, but did not have one. The ADON acknowledged that care plans were not updated timely, the same day concern identified, and need something better to be done. The ADON stated that Resident 1 did not refuse wound care treatments. The ADON stated that the tunneling was identified on 8/7/22 after wound eschar had been removed with treatment and the wound opened up. The ADON stated that the right buttock wound progressed from a stage 2 to a stage 3 due to Resident 1 being resistive to turning. The ADON stated, Can't prove it, documentation is not there. Reviewed hospital document General Surgical Documentation, dated 8/7/22, with the ADON. The ADON acknowledged that left heel and foot wounds were not identified in the facility. The ADON stated, Not seen, just the right heel. A review of the facility's policy titled Quality of Care Skin Integrity, dated 8/20/18, indicated PURPOSE: To promote the prevention of avoidable pressure ulcers/ injuries (PU/PI) and provide care and services consistent with professional standards of practice which will prompt the healing of existing PU/PI. POLICY: The facility, based on resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing .GUIDELINES: .The facility will assess residents upon admission, and thereafter, to identify if the resident is at risk for developing or has a PU/PI, or has pre-existing signs suggesting that tissue damage has already occurred .If a PU/PI is present, the facility will provide treatment to heal it and will provide treatment in an effort to prevent the development of additional PU/PIs .Based on the comprehensive assessment and the resident's clinical condition, choices and identified needs, interventions may include, but not be limited to: Pressure redistribution; .Provision of pressure-redistributing support surfaces .If a resident is refusing care and treatment, the facility will attempt to identify the basis for the refusal and identify potential alternatives .Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan .Repositioning needs to maintain the resident's skin integrity will be considered for residents who are reclining, are seated in bed, seated in a chair or wheelchair, as well as for residents who are lying in bed .Repositioning needs/plans will be reflected in the care plan .Facility staff will monitor residents skin condition and be alert to potential changes in the residents' skin condition. Identified changes will be reported .Existing PU/PIs will be identified and causative factors recognized, assessed and addressed. Preventive measures will be re-evaluated when a resident develops a new PU/PI or an existing PU/PI shows delayed healing

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received necessary care to attain or maintain the highest practical physical well-being when: 1. Staff failed to ensure Resident 1's dentures were in place prior to lunch on 4/3/21; 2. Speech Therapy (ST) did not assess Resident 1 on 4/2/21 or 4/3/21 after a diet upgrade occurred on 4/1/21; 3. Staff were unaware of ST specific recommendations for Resident 1 to ensure a safe transition with a diet change and ST had been unaware of a previous choking incident for Resident 1 during lunch on 7/6/20; 4. Staff did not attempt to assist Resident 1 to the wheelchair prior to lunch on 4/3/21; and 5. A registered nurse (RN) did not assess Resident 1 when a significant change of condition occurred during lunch on 4/3/21, and no RN was in the facility at the time the event occurred. These failures led to Resident 1 choking on a piece of chicken, which led to difficulty with breathing and a rapid decline in her condition, a delay in Resident 1 receiving a higher level of care, and ultimately contributed to Resident 1's death. Findings: A review of Resident 1's Admission Record, indicated, Resident 1 was originally admitted to the facility late 2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS- an assessment tool), dated 3/3/21, indicated, Resident 1 scored two out of 15 in a Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The functional status section of the MDS indicated, Resident 1 required supervision (oversight, encouragement, or cueing) and one-person physical assist for eating. 1. During an interview, on 5/3/21, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 explained, she had worked with Resident 1 for the last four months but did not recall Resident 1 having dentures in her mouth. CNA 1 stated, on the day of 4/3/21 she did not assist Resident 1 to place dentures in her mouth and explained if Resident 1 had dentures she would have assisted her to place them. During an interview, on 5/3/21, at 11:06 a.m., Licensed Nurse (LN) 1 stated, Resident 1 had top dentures only, no bottom dentures. Review of Resident 1's Inventory of Personal Items, dated 11/13/17, indicated, Dentures: 1. Upper 2. Lower . had been marked as present on admission to the facility. Review of Resident 1's care plan, revised 4/25/17, indicated, Focus .[Resident 1] is edentulous [lacking teeth] and receives a mechanically altered diet [food is chopped/blended so that it can be easily swallowed] .Interventions .Assure dentures are in place before meals-prompt and assist resident as needed . 2. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 5/3/21, at 11:36 a.m., the Director of Rehab (DOR) stated, after a diet upgrade a resident would be seen by ST for a week to two weeks to ensure a resident was safe on the new diet. The DOR confirmed, Resident 1 had been expected to be followed by ST for one to two weeks post diet upgrade. The DOR explained, Resident 1 had been followed by ST five times a week, on a Monday through Friday schedule. The DOR stated, Resident 1's diet had been changed on 4/1/21 (Thursday). The DOR confirmed, Resident 1 had not been seen by ST on 4/2/21 or 4/3/21, following the diet change. The DOR explained, a ST had worked on 4/2/21 (Friday) for an hour and a half but did not see Resident 1. The DOR stated, she was not sure why Resident 1 had not been seen on 4/2/21 (Friday). 3. During an interview, on 4/22/21, at 9:03 a.m., Licensed Nurse (LN) 1 stated, she had been assigned to Resident 1 on the day shift on 4/1/21 (date of the diet change) and 4/3/21. LN 1 explained, Resident 1's diet had just recently been upgraded on 4/1/21, but LN 1 did not receive any specific recommendations to ensure a safe transition for a diet upgrade for Resident 1. During an interview, on 5/3/21, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 stated, she had been assigned to Resident 1 on the 4/3/21 day shift. CNA 1 stated, she was unaware of Resident 1's recent diet change and did not receive any education regarding Resident 1's new diet or any specific instructions. During an interview, on 4/22/21, at 11 a.m., the Director of Rehab (DOR) stated, speech therapy (ST) will give a nursing communication form to nursing staff if there are any specific recommendations related to a diet upgrade. During an interview, on 4/22/21, at 12:06 p.m., Speech Language Pathologist (SLP) 1 stated, Resident 1 required intermittent cueing and a visual reminder to drink liquids between bites to ensure Resident 1 emptied her mouth of food. When asked if Resident 1 had choked in the past, SLP 1 stated, she had not been aware of any past history for Resident 1 related to issues with eating. During an interview, on 4/27/21, at 5:08 p.m., Speech Pathologist Clinical fell ow (SPCF) 1 stated, Resident 1 required reminders while eating to complete a liquid wash (alternating solid foods with liquids). SPCF 1 explained, other recommendations for meals for Resident 1 included upright for all meals, small bites, and her food cut up. When asked if Resident 1 had choked in the past, SPCF 1 stated, she had not been aware of any past history related to Resident 1 in regard to issues with eating. Review of Resident 1's Progress Note, dated 7/6/20, indicated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Give her a tap on the back still res noted to still choking .did [MEDICATION(S)] manaveur [sp] .resident cough out a piece of her dinner roll . Review of Resident 1's care plan, revised 4/25/17, indicated, Focus .[Resident 1] is edentulous [lacking teeth] and receives a mechanically altered diet .Interventions .RESOLVED: Resident has an episode of choking on bread, speech therapy is going to eval and treat. Date Initiated 07/07/2020 .Resolved Date: 04/05/2021 . 4. During an interview, on 4/22/21, at 9:03 a.m., Licensed Nurse (LN) 1 stated, she was not sure why CNA 1 decided not to get Resident 1 up on 4/3/21 for her lunch meal. LN 1 stated, if staff went into Resident 1's room to get her up, Resident 1 would usually agree to get up in the chair. LN 1 stated, being up in the chair for a meal is always the best practice, especially with a diet change. During an interview, on 4/22/21, at 10:37 a.m., the Director of Staff Development (DSD) stated, the expectation would be for every resident to be up in their chair for every meal, if able. During an interview, on 4/22/21, at 12:06 p.m., Speech Language Pathologist (SLP) 1 stated, there had been a sign on Resident 1's bulletin board which had stated Patient to be up in wheelchair for all meals. During an interview, on 4/29/21, at 3:34 p.m., the DSD explained, if a resident was at high risk for choking, the resident should be up out of bed in their wheelchair in a location where they can be visualized by staff. During an interview, on 5/3/21, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 stated, she had been assigned to Resident 1 on 4/3/21. CNA 1 stated, Resident 1 never really refused cares. When asked if an attempt had been made to get Resident 1 up for the lunch meal on 4/3/21, CNA 1 stated, an attempt had not been made because She just looked like she didn't want to get up. CNA 1 further explained, Resident 1 did not seem like she wanted to get up, so I didn't even try. Review of Resident 1's nutrition care plan, revised 1/29/20, indicated, Interventions .HIGHER RISK FOR CHOKING Date Initiated: 06/14/2016 . Review of an online document from [NAME] [NAME] indicated: Aspiration from Dysphagia, (undated), in the section How is aspiration from dysphagia treated?, indicated, .The symptoms of dysphagia also need to be managed. This may include doing things such as: .Not eating in bed . In the section What can I do to prevent aspiration from dysphagia?, indicated, .Getting dental treatment (such as dentures) when needed .Sitting with good posture when eating and drinking . (https://www.[NAME]-[NAME].org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html) 5. During an interview, on 4/22/21, at 9:03 a.m., Licensed Nurse (LN) 1 confirmed, she had been the nurse assigned to Resident 1 on 4/3/21 when the choking event occurred. LN 1 stated, she heard a noise, entered Resident 1's room, and found Resident 1 had pocketed some food (holding food in the mouth without swallowing it). LN 1 stated, a phone call had been placed to the physician and the physician had requested for LN 1 to call the family to see if the family wanted to send Resident 1 to the hospital. During an interview, on 4/22/21, at 10:16 a.m., LN 1 stated, she had been at the facility on 4/3/21 up until the time Resident 1 had been sent to the emergency department (ED). LN 1 stated, from the time the choking incident occurred, to the time Resident 1 went to the ED, a registered nurse (RN) did not come to assess Resident 1. During an interview, on 4/22/21, at 10:37 a.m., the DSD stated, the facility is required to have a RN on duty 24 hours a day. During an interview, on 4/28/21, at 1:16 p.m., Resident Representative (RR) 1 stated, a licensed nurse had called on 4/3/21 and stated Resident 1 had choked on some chicken and asked, Do you want her [Resident 1] to go to the hospital? RR 1 explained, she did not know what to do and asked the licensed nurse what the doctor recommended. RR 1 explained, the licensed nurse responded, He said to call you. RR 1 stated, the licensed nurse told her Resident 1's oxygen saturations [measure of oxygen level in the blood] went back up to 89 percent, but did not state how much oxygen Resident 1 required at the time. During an interview, on 4/29/21, at 3:34 p.m., the Director of Staff Development (DSD) stated, a new need for oxygen would be considered a significant change in condition. During an interview, on 6/1/21, at 4:32 p.m., LN 2 stated, if a resident had a significant change in condition, and if the Director of Nursing or another RN in administration was not in the building, the RN working on the floor would assess the resident. During a concurrent interview and review of the staff schedule, on 4/29/21, at 12:29 p.m., the Staffing Coordinator (SC) stated, on 4/3/21 there was no RN scheduled or on duty for the day shift (6 am to 2:30 p.m.). The SC stated, a RN is required to be in the building 24 hours a day. Review of Resident 1's meal ticket, dated 4/3/21, indicated, .REGULAR .SATURDAY .LUNCH 4/3/21 FRIED CHICKEN .BUTTERED WHOLE KERNEL CORN .CORNBREAD .DUTCH APPLE PIE .POULTRY GRAVY .CRANBERRY JUICE - 8 oz [ounces] . Review of Resident 1's Progress Note, dated 4/3/21, indicated, .At approximately 1320 [1:20 p.m.] this LVN [Licensed Vocational Nurse] heard this resident coughing. Upon entering the room this LVN assessed situation and found resident had pocketed her lunch and seemed to be choking. This LVN assisted resident to spit out remaining chicken. Resident still seemed to be having a hard time, assisted resident to lean forward and encourage her to cough. Upon doing so, another piece of chicken was dislodged .MD [medical doctor] notified of occurrence and new orders obtained for suction and PRN [as needed] O2 [oxygen] .Suction administered. O2 raised from 74% to between 88-91% on 4L [liters]-6L via mask . Review of Resident 1's Progress Note, dated 4/3/21, indicated, .Writer received resident up in chair at nurses station with O2 via NC [nasal cannula] on 8L with saturations at 80%. Oxygen tank was changed and resident dropped to 53%. Resident was placed on non re-breather [a type of facemask used to deliver oxygen to a person] at 15 L and residents O2 went up to 67% .[Resident 1] was transferred to ER [emergency room ] at 4:36 pm . Review of Resident 1's SBAR [Situation Background Assessment Recommendations] Communication Form, dated 4/3/21, in the section SITUATION, indicated, .change in condition: [CONDITION(S)] [absence of enough oxygen in the tissues to sustain bodily functions] This started on: 04/03/2021 Since this started it has gotten: Worse . Things that make the condition or symptom worse are: Inability to clear airway .Things that make the condition or symptom better are: O2 and suctioning . In the section BACKGROUND, indicated, .Vital Signs .RR [respiratory rate - normal respiratory rate for adults is 12 to 20 breaths per minute]: 26 .Pulse Oximetry [measures the oxygen levels in your blood - normal range 92% to 100%, a level of at least 90% will prevent tissue injury] (if indicated): 71% on .O2 (Oxygen via Mask) .Respiratory Evaluation .Abnormal lung sounds .labored or rapid breathing .shortness of breath .cough .productive . Review of Resident 1's undated Order Summary Report, indicated, O2 [oxygen] to keep sats [oxygen saturations measured with a pulse oximeter] [greater than] 90 as needed for SOB [shortness of breath] . Order Date 04/03/2021 .Start Date 04/03/2021 . Review of Resident 1's Weights and Vitals Summary, in the section O2 sats Summary, indicated, 04/03/2021 07:18 [a.m.] 97% (Room Air) . In the section Respiratory Summary, indicated, 04/03/2021 16:45 [4:45 p.m.] 26 Breaths/min [minute] .04/03/2021 07:18 [a.m.] 16 Breaths/min . No other O2 saturations or respiratory rates recorded for the date of 4/3/21 on Resident 1's Weight and Vitals Summary. Review of an outside medical record for Resident 1, titled ED [Emergency Department] Physician Notes, dated 4/3/21, indicated, .Dyspnea [difficult or labored breathing] Associated Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .According to EMS [Emergency Medical Services], [facility name] told them that the patient [Resident 1] aspirated chicken around 2 PM. They apparently tried to suction her airway by instilling saline, but she continued to be with increased work of breathing and hypoxic [the body or a region of the body is deprived of adequate oxygen supply at the tissue level] so they [the facility] called 911 three hours later . In the section Reexamination/Reevaluation, indicated, 1700 [5 p.m.]: on arrival patient [Resident 1] is in significant distress with RR 30's, O2 75% on OxyMask [oxygen delivery mask] . Review of an outside medical record for Resident 1, titled Discharge Summary, dated 4/8/21, in the section FINAL DIAGNOSIS, indicated, Acute aspiration pneumonia acute hypoxic respiratory failure [CONDITION(S)] [the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death] secondary to aspiration pneumonia dementia with agitation [CONDITION(S)] [low blood pressure] secondary to [CONDITION(S)] . In the section HOSPITAL COURSE, indicated, .patient continued to be struggling, and desaturating [oxygen levels dropping]. She would frequently remove her oxygen and refused deep suctioning and other interventions .transition to comfort measures only after discussion with the family. This transition was made .Ultimately patient passed away in the hospital on April 8, 2021 . Review of Resident 1's CERTIFICATE OF DEATH dated 4/26/21, in the section CAUSE OF DEATH indicated, .the chain of events --- diseases, injuries, or complications --- that directly caused death .Immediate cause (final disease or condition resulting in death) .A. RESPIRATORY FAILURE [when the lungs can't get enough oxygen into the blood] .B. ASPIRATION PNEUMONIA . with a Time Interval Between Onset and Death of DAYS for both diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility document titled [facility name] JOB DESCRIPTION, revised 6/18, indicated, JOB TITLE: Licensed Practical Nurse/Licensed Vocational Nurse .Conducts appraisals of the resident's status and situation that contributes to ongoing data collection .Must perform duties inside the nurse practice act . Review of a facility document titled [facility name] JOB DESCRIPTION, revised 6/18, indicated, JOB TITLE: Registered Nurse .Assume responsibility for care interventions consistent with skill level and professional standards of care . Review of the California Nurses Association (CNA) and the National Nurses Organizing Committee (NNOC) Nursing Practice & Patient Advocacy Alert Patient Assessment: Roles of RNs [Registered Nurse] and LVNs [Licensed Vocational Nurse], (undated), in the section, The RN carries legal responsibility for analysis, synthesis and evaluation of patient data indicated, The RN is legally responsible for analyzing, synthesizing and evaluating data collected on patients through the RN direct observation, as stated in the Nursing Practice Act, Business and Professions Code Sec 2725(b) (4). The practice of RNs include: Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (1) determination of whether such signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics; and (2) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. Under the Nursing Practice Act, only the RN can perform assessments, which includes analysis and formulation of a nursing diagnosis. This responsibility cannot be delegated or assigned to an LVN. In the section, The LVN's scope of practice includes data collection only, indicated, The Vocational Nursing Practice Act allows the LVN to perform services requiring technical and manual skills that are performed under the clinical direction of a licensed physician or a registered nurse, The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) further states that the LVN may use and practice basic assessment (data collection) in performing basic nursing services. The LVN is required to report and/or refer abnormal values to the RN. According to the BVNPT the LVN cannot analyze, synthesize and evaluate data. In the section, The RN must directly observe the patient, indicated, The Standard of Competent Performance for the RN requires direct observation of the patient. Title 16 of the California Code of Regulations, 1443.5 states that the competent RN: Evaluates the effectiveness of the care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, reactions to treatment and through communication with the client and health team members, and modifies the plan as needed. In addition, Title 22 of the California Code of Regulations, Section (a) states the RNs shall directly perform ongoing assessments as defined in Title 16 above, and shall document the findings in the patient record. (https://www.nationalnursesunited.org/sites/default/files/nnu/files/pdf/rn-lvn-role-assessment.pdf)

Based on interview, record review, and policy review, the facility failed to ensure staff confirmed a resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) and ensure basic life support (a level of medical care used for people with life-threatening illnesses or injuries until they can be given full medical care at a hospital) was provided in an emergency for 1 of 5 sampled residents (Resident 1). These failures contributed to Resident 1's death. Findings: According to record review of the admissions record, Resident 1 was admitted to the facility in 2017 with [DIAGNOSES REDACTED].), chronic [MEDICAL CONDITION] (usually happens when the airways that carry air to the lungs become narrow and damaged. This limits air movement through the body, which means that less oxygen gets in and less carbon [MEDICATION NAME] gets out; this gradually develops over time and requires long-term treatment), and ischemic [MEDICAL CONDITION] (an ongoing condition causing insufficient blood flow to the heart muscle when one or more of the heart arteries (blood vessels that carry [MEDICATION NAME] blood) becomes blocked or narrowed, often resulting in chest pain). The admission record indicated Resident 1 was his own Responsible Party (able to make his/her own decisions). According to record review, a valid POLST form, dated [DATE], was signed by Resident 1 and his physician. The POLST form indicated Resident 1 had selected, Attempt Resuscitation/CPR . Full Treatment-primary goal of prolonging life by all medically effective means. According to clinical record review, a care plan referring to Resident 1 adapting to long-term placement in the facility, revised [DATE], indicated Resident 1 chose CPR and full treatment on his POLST (Physician order [REDACTED]. According to record review, Resident 1 had a physician's orders [REDACTED]. According to record review, Resident 1 had a physician's orders [REDACTED]. If there was no relief, then call the physician. Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], was reviewed. The MDS indicated Attempt resuscitation / CPR. The MDS specified a Brief Interview for Mental Status (BIMS- a tool to assess understanding) score of ,[DATE] indicating Resident 1 was cognitively intact. Resident 1's nursing progress note, dated [DATE] at 12:16 p.m., was reviewed. The note indicated Licensed Nurse (LN) 3 went into Resident 1's room at 9:20 a.m. to administer his medications. Prior to administering the medication, Resident 1's blood pressure was ,[DATE] with an irregular heart rate of 96 beats per minute. At 9:45 a.m., Resident 1 informed LN 4 he was having chest pain. LN 4 notified LN 3 of Resident 1's chest pain and LN 3 administered one [MEDICATION NAME] tablet to Resident 1, then he laid his head down. LN 3 exited the room and asked Certified Nursing Assistant 1 (CNA 1) to take Resident 1's blood pressure. LN 4 notified LN 3 that Resident 1 is blue and unresponsive. LN 3 went back into Resident 1's room at 9:50 a.m. Resident 1 was found cyanotic (bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation) no breathing, no vital signs (blood pressure, pulse). (LN 3) attempted to arouse (Resident 1) with sternal rubs (vigorous rubbing on the center of the chest) and calling out his name with no response. While in (Resident 1's) room (LN 3) told (LN 4) to call (Resident 1's) MD (medical doctor). (LN 4) told the MD that (Resident 1) was cyanotic and unresponsive. MD asked what happened he then advised (LN 3) to call (Resident 1's) daughter and explain the situation and what led up to the incident. According to record review, no documented evidence was found in Resident 1's clinical record indicating LN 4 responded to Resident 1 when LN 4 learned Resident 1 was unresponsive. According to record review, no documented evidence was found in Resident 1's clinical record indicating CPR was initiated or 911 was called when Resident 1 was found unresponsive. According to record review, Resident 1's progress notes, dated [DATE] at 12:16 p.m., indicated Resident 1 died in the facility on [DATE]. A review of the Lippincott manual of Nursing Practice, seventh edition, copyright 2001, Standards of Care Guidelines, Chest Pain, pages 357 through 359, indicate nursing assessment for the patient with chest pain should include; assessing the quality (how the pain feels) .intensity (how strong the pain is) .location (chest, arm) .and duration (when the pain started) .When administering anti-[MEDICAL CONDITION] medications, monitor the patient for the progression of the chest pain, the response to drug therapy and any adverse effects and take vital signs every 5 minutes until [MEDICAL CONDITION] pain subsides or the doctor is called. Document all assessment findings. In an interview with CNA 1 on [DATE] at 10:55 a.m., CNA 1 stated, (On [DATE], LN 3) asked me to take (Resident 1's) blood pressure and I found (Resident 1) unresponsive and blue. I went out and told (LN 4) and (LN 4) went out to find (LN 3) .(LN 4) didn't go to check on (Resident 1) first. (LN 3) went in to check on (Resident 1) and (LN 4) went to the nurse's desk. That's where (LN 4) found the shift report form and it said that (Resident 1) was a DNR (Do Not Resuscitate). (LN 4) didn't look at (Resident 1's) POLST; no one looked at (Resident 1's) POLST. The shift report form is a list of the residents with their doctor's name, their diets, and the CNAs put the vital signs on it. The nurses will use it during report. I guess it has their code status on it too. I went to get the crash cart but the Director of Nurses (DON) told us not to touch (Resident 1) because (Resident 1) was a DNR. Then (LN 3) looked in (Resident 1's) chart and saw that (Resident 1) was actually a full code. We're supposed to call for help in an emergency. In an interview with the DON on [DATE] at 12:10 p.m., the DON stated, (On [DATE], LN 3) gave (Resident 1) a nitro pill then left (Resident 1) to go use the restroom. Then (CNA 1) found (Resident 1) unresponsive. (LN 3) went to check on (Resident 1) while LN 1 looked on the shift report form for (Resident 1's) code status. (LN 4) said (Resident 1) was a DNR, so no one started CPR. No one looked at his POLST or his orders. I told everyone if (Resident 1) is a DNR not to touch him. (LN 3) should have looked for (Resident 1's) POLST, not relied on that report form. (Resident 1) should have gotten CPR. The nurses are supposed to call 911 and start CPR if a resident is a full code. The nurses don't use that shift report form anymore, I pulled it from all the nurses stations. I don't have the one from the 29th., I shredded it. The DON acknowledged that Resident 1's POLST, dated [DATE], was valid. The DON stated, This is a valid POLST (dated [DATE]); the nurses should have started CPR and called 911. In an interview with the ADON on [DATE] at 12:40 p.m., the ADON stated, I was walking past (Resident 1's) room and (Resident 1) complained to me of having chest pain. I told (LN 4) and (LN 4) went to find (Resident 1's) nurse (LN 3). (LN 3) gave (Resident 1) a nitro. I left the station and shortly after I heard what happened, that (Resident 1) died . The nurses are supposed to look on the POLST for the resident's code status. We keep a binder at the nurse's station just for that purpose, easy access. The nurses should not have looked on the shift report form. I expect the nurses to start CPR if a resident is a full code, even if they are cyanotic. (LN 3) should have stayed with (Resident 1) to monitor him. In a review of Resident 1's clinical record, the ADON confirmed that Resident 1 had a valid POLST form (dated [DATE]). The ADON stated, The nurses should have called 911 and started CPR. In an interview and concurrent record review with the Director of Staff Development (DSD) on [DATE] at 1:00 p.m., the DSD stated, Resident 1 had a valid POLST form (dated [DATE]) included in the clinical record. The DSD stated, (Resident 1's) POLST form (dated [DATE]) was valid, the nurses should have started CPR. In an interview with the facility's Administrator (AD) on [DATE] at 1:45 p.m., the AD stated, I know the nurses are supposed to look at the resident's POLST for their code status, not the shift report form. In a telephone interview with LN 3 on [DATE] at 6:00 p.m., LN 3 stated, Around 9:20 a.m. (on [DATE]) I took (Resident 1's) meds to him, but he just wanted his inhalers. I left his meds at the bedside. Around 9:45 a.m., the Assistant Director of Nurses (ADON) told (LN 4) that (Resident 1) was having chest pain. (LN 4) told me. I gave (Resident 1) a nitro([MEDICATION NAME]) tablet. I really didn't assess (Resident 1). I left (Resident 1) and went to the restroom. I asked (CNA 1) to check (Resident 1's) blood pressure and a few minutes later (LN 4) came to the restroom and told me (Resident 1) was unresponsive and blue. I tried to take (Resident 1's) vitals and did a sternal rub, called out his name, but (Resident 1) didn't respond. (Resident 1) wasn't stiff; I was able to get him flat on the bed. Resident 1's medications were still at the bedside. He didn't take them. I asked (LN 4) to see if (Resident 1) was a DNR. (LN 4) looked on the shift report form; it had that (Resident 1) was a DNR. I should have went right to the POLST form for his code status, not the shift report form. Then I read in (Resident 1's) chart that (Resident 1) was a full code. I should have had another nurse watch him when I went to the restroom. I should have called 911 and started CPR. In a telephone interview with LN 4 on [DATE] at 2:00 p.m., LN 4 stated, (On [DATE]) the ADON came to me and told me (Resident 1) was having chest pain. I went to find (LN 3). A few minutes later (CNA 1) told me (Resident 1) was unresponsive. I went to the restroom to find (LN 3). I should have went to check on (Resident 1) first and called for help but I didn't. I went to find (LN 3) first. I didn't look for (Resident 1's) DNR. I thought (LN 3) did because I heard (LN 3) say that (Resident 1) was a DNR. It was (LN 3) that looked at the shift report form. I couldn't tell you where the POLST binder is. We're supposed to look at the POLST. The DON told us not to touch (Resident 1), to leave the room and close the door; (Resident 1) is a coroner's case. A few minutes later (LN 3) read in (Resident 1's) chart that (Resident 1) was a full code, then it was too late to do CPR. We should have called 911 and started CPR. We've been using the shift report form for about a year or two. We just use it to put information on and pass it on for report. The DON took them away. It shouldn't have been used to find the code status. In an interview with the facility's Medical Director on [DATE] at 2:00 p.m., the Medical Director stated, (On [DATE], LN 3) called to tell me (Resident 1) wasn't breathing and didn't have any vital signs, and (Resident 1) was a DNR .I told (LN 3) not to start CPR, don't call 911. It wasn't until the next day ([DATE]) that I found out that (Resident 1) was a full code. Had I known from the start (Resident 1) was a full code I would have told the nurse to start CPR and call 911. Review of the facility's policy titled, Emergency Procedure-Cardiopulmonary Resuscitation, revised ,[DATE], indicated, 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation (an automated external computerized device used to restart a heart that has stopped beating) exists for that individual .7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. According to record review of the Certificate of Death, date of death [DATE], indicated Resident 1's immediate cause of death was [MEDICAL CONDITION] (a condition in which the heart malfunctions and suddenly stops beating, resulting in loss of consciousness, pulselessness, and death, without immediate intervention.).

Based on interview, record review and policy review, the facility failed to ensure adequate supervision was provided for two out of three sampled residents (Resident 1 and Resident 2) when the facility did not implement measures (create and implement a fall risk care plan) to minimize the likelihood of a fall from occurring when Resident 1 and Resident 2 were identified as a risk for falls on admission. This failure resulted in: 1. Resident 1 fell which resulted in a [MEDICAL CONDITION] femoral head (partial or complete break of a bone in the leg). 2. Resident 2 fell twice which resulted in a dislocation of an internal hip prosthesis (an artificial body part). Findings: 1. During a review of records, Resident 1's Admission Record, it indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of records, the Minimum Data Set (MDS an assessment tool) discharge assessment, dated, 10/10/20, in the functional status section of the MDS, indicated, Resident 1 required supervision (oversite, encouragement or cueing) to move in bed or transfer between surfaces. During a review of records, Resident 1's MDS admission assessment, dated 10/20/20, indicated, the Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The functional status section of the MDS indicated, Resident 1 required extensive assistance to move in bed or transfer between surfaces with one to two person assistance. The MDS also indicated, Resident 1 had a fall within the last month prior to admission. During an observation on 10/27/20, at 9:57 a.m., Resident 1's call light button was found under the resident's pillow. During a concurrent interview with Resident 1, on 10/27/20 at 9:57 a.m., Resident 1 was unable to find the call light button to call for assistance, when asked where it was. Located on Resident 1's bedside table was a bell and a sign on the wall stated, Keep bell by pt. (patient) (not call light) Encourage use!!! Resident 1 rang the bell located on the bedside table at 10:02 a.m., again at 10:06 a.m., and for a third time at 10:11 a.m. By 10:17 a.m., 15 minutes had passed, and no one came to the resident's room. During a concurrent observation and interview on 10/27/20, at 10:19 a.m., Certified Nurse Assistant 1 (CNA 1) stated, I didn't hear the patient ring the bell, I was probably down the hall helping another patient. CNA 1 confirmed, Resident 1's call light button was located under the resident's pillow and the resident would not be able to reach it. CNA 1 stated, unsure if both the bell and the call light button are to be used because the sign says to use the bell. During an interview on 10/27/20, at 10:02 a.m., LN 1 stated, residents are assessed for fall risk upon admission, readmission, and after a fall. LN 1 stated, a lot of the residents were cognitively impaired and attempted to get up on their own. LN 1 explained, falls at the facility could be related to a staffing issue, sometimes it can take staff up to 20 minutes to answer a call light. During an interview on 10/27/20 at 10:43 a.m., Licensed Nurse 3 (LN 3) stated she was assigned to Resident 1. She was not aware of the bell in Resident 1's room; however, it was expected for the call light button to be placed where a resident can reach it. During a concurrent interview and record review on 10/27/20, at 12:26 p.m., the Director of Nursing (DON) stated, staff should complete a fall risk assessment within the first 24 hours of admission and, if a resident is identified as a fall risk, a care plan for falls should be initiated. The DON confirmed, Resident 1 was identified as a risk for falls on the admission assessment. The DON confirmed, the first fall risk assessment for Resident 1 was conducted on 10/9/20 (3 days after Resident 1 was admitted ) and the first fall risk care plan with interventions for Resident 1 was initiated on 10/15/20, after Resident 1 fell on [DATE]. During an interview on 2/10/21, at 9:02 a.m., LN 4 stated, the facility does not have any standard interventions in place to prevent residents from falling, prior to the completion of a fall risk assessment and the implementation of a fall risk care plan with interventions as indicated. LN 4 stated, all new admission residents are at risk for falling. LN 4 explained, staff should complete a fall risk assessment on admission and implement a resident at risk for falling care plan with interventions. Review of Resident 1's admission assessment titled, NSG (Nursing) Admission/Readmission Evaluation V 4, dated 10/6/20, in the section Alerts indicated, Resident 1 was at risk for falls. Review of Resident 1's nursing progress note, dated 10/9/20, indicated at 8:24 p.m. Resident was found on the floor after attempting to self ambulate to the restroom . Review of Resident 1's nursing progress note, dated 10/10/20, indicated at 8:50 a.m. NOC (night) nurse endorsed resident had been complaining of severe pain in her right hip throughout the night. This nurse assessed the resident and, resident unable to move leg due to pain .sent resident to ED (Emergency Department). Review of the hospital discharge summary, dated 10/14/20, indicated, Patient (Resident 1) sustained displaced fracture of right femoral neck. Orthopedics was consulted who performed RIGHT Hip prosthesis Cemented .status [REDACTED]. 2. A record review of Resident 2's Admission Record indicated, Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a record review of Resident 1's MDS discharge assessment, dated, 7/19/20, in the functional status section of the MDS, indicated, Resident 2 required extensive assistance to move in bed or transfer between surfaces with one person assistance. During record review of Resident 2's admission MDS assessment, dated 7/27/20, the BIMS indicated, Resident 2's cognitive skills for daily decision making were severely impaired. The functional status section of the MDS indicated Resident 2 required extensive assistance to move in bed or transfer between surfaces with two person assistance. The MDS also indicated Resident 2 had a fall within the last month prior to admission. Review of Resident 2's admission assessment titled, NSG (Nursing) Admission/Readmission Evaluation V 4, dated 7/17/20, in the section Alerts indicated, Resident 2 was at risk for falls. According to the Fall Risk Assessment, Resident 2's first fall risk assessment was completed on 7/18/20, with a score of 18, which indicated the resident was at high risk for falls. During an interview on 10/27/20, at 11:02 a.m., CNA 3 stated, the nurse or off going CNA would update the staff if a fall occurred and what new interventions were put in place, but the facility staff lately have dropped the ball on communication. During a concurrent interview and record review of Resident 2's care plans, on 10/27/20, at 1:05 p.m., the DON confirmed Resident 2's first fall risk care plan with interventions was initiated on 7/23/20, after Resident 2 was identified as a fall risk on 7/17/20 and after two falls had occurred (7/18/20 and 7/19/20). During an interview on 1/20/21, at 11:20 a.m., Family Member 1 (FM 1) explained, while in the facility as a one on one sitter for Resident 2, It took them (facility staff) forty five minutes to answer the call light. FM 1 explained, when FM 1 talked to the facility regarding Resident 2's falls, the facility explained that they are understaffed. Record review of Resident 2's nursing progress note, dated 7/18/20, indicated at 12:47 p.m. nurse was called to residents room where she was located on the floor laying on her right side with her head against the bathroom door Resident has previous humerus fx (fracture a break in the large bone of the upper arm) noted and is complaining of pain in that arm . Record review of Resident 2's nursing progress note, dated 7/19/20, indicated at 6:06 p.m.Unwitnessed fall with head injury: .resident was on the floor . When found she was c/o (complaining of) pain on her right hand, hip and LLE (left lower extremity, left leg). MD (medical doctor) was contacted intermediately (sic) and he ordered to send resident to ER (emergency room ). Record review of Resident 2's hospital discharge summary, dated 7/22/20, indicated, Evaluation in the emergency department showed .Patient (Resident 2) was found to have posterior (situated behind or at the rear) dislocation of .right hip prosthesis .recommended closed reduction (a procedure to set a dislocated bone without surgery) in the emergency department. Review of a facility policy and procedure titled, QUALITY OF CARE Accident Hazards / Supervision / Devices, dated 7/2018, indicated, .Individualized interventions will be developed to reduce the potential for accidents .Resident specific interventions will be reflected in the resident's person centered, individualized care plan .The facility will initiate and implement a comprehensive, resident centered fall prevention plan for residents at risk for falls or with a history of falls .

Based on staff interview, record review, and review of facility documents, the facility failed to ensure one of three sampled residents (Resident A) was transferred safely using a mechanical lift. This failure resulted in Resident A sustaining a left humeral (long bone of upper arm) fracture. Findings: Resident A was originally admitted to the facility in 2013 and [DIAGNOSES REDACTED]. Review of Resident A's Quarterly MDS (Minimum Data Set-an assessment tool), dated 7/20/17, described Resident A as having clear speech, usually able to understand others, able to make herself understood, long and short term memory problems, and severely impaired cognitive skills for daily decision making. The MDS described Resident A has having inattention (resident has difficulty focusing attention, for example being easily distractible, or having difficulty keeping track of what was being said) and disorganized thinking. The MDS indicated Resident A needed extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and was dependent upon staff for locomotion on and off the unit. Resident A's clinical record was reviewed and contained an order, dated 1/25/17, for assistive lift for all transfers every shift. A care plan specific for falls, initiated 10/21/15 and revised 8/25/17, was documented in Resident A's clinical record. The care plan indicated Resident A was at risk for falls r/t (related to) her [DIAGNOSES REDACTED]. Under the section Interventions was listed Resident is at high risk for falls and Passive lift (mechanical lift) for transfers. Review of the facility document, Facility Reported Event, indicated on 8/21/17 at approximately 2:23 p.m., CNA 1 was assisting Resident A with a transfer from the bed to the wheelchair when Resident A's right leg slipped from the lift. CNA 1 slowly lowered Resident A to the floor and called for a nurse. Resident A complained of pain in her left shoulder and was noted to have a slight bruise to her left shoulder. The Facility Reported Event indicated on 8/22/17 at 10:55 a.m. a new MD order was received for an x-ray to Resident A's left shoulder to rule out injury/fracture. Resident A's Progress Note, dated 8/22/17 at 3:11 a.m., indicated there was still swelling of her left shoulder with complaint of mild pain especially on movement. The evening nurse faxed MD requesting for x-ray, awaiting for reply. Review of Resident A's radiology results, dated 8/23/17, indicated Resident A sustained a fractured left proximal (nearer to the center of the body) humeral shaft with some medical angulation (bending in the middle) and offset. Review of a Progress Note, dated 8/23/17 at 12:15 a.m., indicated the facility received the x-ray report. Resident A was transferred to the ER for further evaluation. A Progress Note, dated 8/23/17 at 7:19 a.m., indicated Resident A returned to the facility around 4:20 a.m. with a shoulder immobilizer and to followup with an orthopedist (a physician who treats injuries or disorders of the skeletal system and associated muscles, joints, and ligaments). Review of Resident A's IDT (interdisciplinary team) Note, dated 8/22/17 at 9:38 a.m., indicated the CNA was alone during the transfer and has been disciplined for not using 2 staff members during transfer with a lift. Review of the facility's policy, Facility Safe Patient Handling Policy, undated, indicated, Ensure high-risk patient handling tasks are assessed prior to completion and are completed safely, using patient handling equipment and other approved patient handling aids and appropriate techniques. The policy also indicated, Safe Patient handling Assessment, Algorithms, and Care Plan - assists nurses in selecting the safest equipment, and number of staff required for completing high risk patient handling tasks based on specific patient. During an interview with the Assistant Administrator, on 9/11/17 at 11:08 a.m., she confirmed the assistive lift is a 2 person transfer. The Assistant Administrator confirmed what was stated in the IDT note, dated 8/22/17, that CNA 1 was alone during the transfer and there should have been 2 persons while using the lift.

Based on record review, and interview, the facility failed to ensure adequate supervision and direct assistance with a meal for one of three sampled residents (Resident 1) and failed to ensure his meal was provided in a texture Resident 1 could safely swallow. This failure resulted in an obstruction of resident 1's airway and death due to choking. Findings: Resident 1 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool), dated 6/26/14, indicated Resident 1 had long and short term memory problems and some difficulty in daily decision making in new situations. The MDS indicated Resident 1 needed extensive assistance with meal setup and one person physical assistance while eating. Resident 1 ate in the dining room. Review of the clinical record for Resident 1 identified a physician's orders [REDACTED]. Review of the facility Dietary Food Preferences, completed by the Dietary Manager (DM) and Resident 1's Responsible Party, indicated in the section for food dislikes, both wheat and white bread were circled. Review of the clinical record indicated a Dietary Memo/Diet Order form, dated 12/26/13, indicated as New Orders the following: mechanical soft and "ground meat " written on the form. A Dietary Memo/Diet Order form, dated 6/2/14, indicated handwritten notes, "extra sauce/gravy" and "ground meat" underlined. Review of the Diet Manual, dated 2011, page 17, titled Mechanical Soft (Ground), indicated, "All meat (such as beef, fish, poultry and pork) should be ground or chopped. Gravy or sauces should be added to moisten dry ground and chopped meats ...for lubrication." Under definitions of terms, ground was described as "1/8" (inch) or less - consistency of ground meat." Another form titled, Mechanically Altered/Texture Modified Diets, declared the intended use was for "residents with chewing and/or swallowing problems." The form indicated the facility provided, "Two levels of mechanically altered diets on the Menu Spreadsheets ... Puree and Mechanical Soft Ground." Record review revealed Resident 1's "Dysphagia" (difficulty swallowing) care plan. There was no problem onset date. The plan indicated, "Resident is at risk for choking." Goals were "No choking episodes" and "Diet texture as ordered." The Approaches (what the facility would do to assist the resident to reach the Goals) were listed as "ST (Speech therapy) screens as appropriate, Follow recommendations from therapy, To dining room for all meals," and "Assistance/supervision with all meals." Review of the "Dysphagia" care plan, dated 12/19/2013, for Nutritional status, indicated as the Goal, "Resident food preferences will be honored through next review." The facility approaches were, "Encourage resident to consume 100% of breakfast, 75% of lunch, 50% of dinner and 100% of after noon snack, Determine food preferences" and to "Give food that is easily swallowed." Review of the Speech Video Swallow Study done 1/16/14 indicated Resident 1's aspiration (breathing in food or fluid into lung) risk as moderate. The Speech Diet recommendations were for the National Dysphagia Diet (NDD) II-Ground, Liquids-Nectar thick. In the summary a recommendation indicated NDD II (moist with extra gravy). Review of the Speech Language Pathologist (SLP - a specialist who evaluates and treats patients with speech, language, cognitive-communication and swallowing disorders in individuals of all ages, from infants to the elderly) treatment note, dated 1/31/14, revealed the resident had a coughing/choking event: "Arranged for 1:1 (one to one) assistance w/ (with) meals." The SLP recommendations for Resident 1, dated 5/28/14, indicated, "In order to facilitate safety with oral intake, caregivers will assist patient in use of rate moderation (encourage resident to eat slower), bolus size modification (smaller bites), alternation of liquid/solids, second dry swallow (swallowing without food in mouth)...in order to decrease risk of choking and aspiration." Under, "Caregiver goals: Keep him from choking to death." Review of the SLP treatment note dated 6/2/14 revealed, "Pt seen @ (at) dining room ....and dining room CNAs (Certified Nursing Assistants) present for training. Upon arrival, tray had dry chopped meat w(with)/no gravy and dry rice. Removed immediately and replaced w/(with) correct diet order." The SLP note for 6/6/14 indicated, "Pt needed consistent cues to take small/single sips and go at a slow rate." A treatment note, dated 6/10/14, confirmed "Instructed caregivers SSP (Swallow/Strategies/Positions: to facilitate safety and efficiency, it is recommended the patient to use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions)...to improve safety w/ (with) oral intake, focused on the following-rate and bolus size modifications, alternation of consistencies, cough/re-swallow, single sips, double swallows and frequent breaks." And on 6/9/14, "Educated staff on SSP and supervision needed to prevent choking and decrease risk of aspiration w/ verbalized understanding demonstrated." A comprehensive review was done on the SLP notes and on 1/3/14, 1/10/14, and 2/6/14, the SLP noted either wrong food consistency or wrong liquid consistency on the resident's diet tray. Review of the facility Incident reports indicated Resident 1 experienced choking events on food that was not indicated on a mechanical soft, ground meat diet or per the food preference form completed on admission by the Dietary Manager. On 5/27/14, Resident 1 choked on cake which caused him to become "limp and cyanotic (skin turned blue from lack of oxygen)" and then on 6/21/14 Resident 1 choked on a dinner roll which caused him to become distressed and cyanotic. " Review of the Facility Reported Event, dated 8/23/14, revealed that Resident 1 "...began choking at 12:15 PM," 911 was called and the Resident 1 was transported to the emergency department. Review of the Pre-hospital Care Report, dated 8/23/14, completed by the ambulance crew who responded to the 911 call, indicated the Field Clinical Impression as "Respiratory and cardiac arrest secondary to foreign body obstruction." The "Comments" section included, at 12:31, "Rice was suctioned form (sic) airway revealing a large foreign body obstructing pt airway." And at 12:32, "A large piece of chicken approximately the sized (sic) of a fifty cent piece (30.6 millimeter or 1.2 inches) was removed form (sic) airway." The Call Summary indicated, "PT was found unresponsive, pulseless and apneic (not breathing) while lying on the floor...staff indicated he started chocking (sic) while eating lunch...Pt was found to have a large piece of chicken completely blocking his airway. After removal of foreign body and pt ventilated no improvement was noted and DNR (Do not resuscitate) was followed." Review of the emergency department reports, dated 8/23/14, in History of Present Illness, indicated "...They (EMT) were able to suction out the rice and remove the piece of chicken from his esophagus (airway) in the ambulance." Resident 1 was pronounced dead at the emergency department at 12:48 p.m. During an interview on 9/2/14 at 1 p.m., the SLP stated she had trained the family and the CNA's to encourage the resident to sit up when eating, slow down between bites, take smaller bites, and to swallow between bites. During an interview with Licensed Vocational Nurse 1 on 9/2/14 at 3:10 p.m., she stated she checked the lunch trays on 8/23/14. She stated she saw a "layered enchilada" cut in pieces on Resident 1's tray. An interview was conducted on 9/5/14 at 2 p.m. with the DM, she described how the chicken quesadilla was made. She said the frozen, precooked chicken pieces were thawed, heated and placed in food processor to be chopped "fine". The processed chicken was then placed in the oven until lunch. The cook placed a tortilla on a plate, put cheese and then the ground chicken on it, then folded the tortilla over the filling. Review of the lunch menu for 8/23/14 indicated Chicken Quesadilla, Spanish rice, and seasoned black beans. During an interview on 9/19/14 at 12:17 p.m., CNA 1 stated on 8/23/14 she was in the West dining room passing lunch trays alone. She stated that usually there were at least two CNA's in the dining room during meals but the other CNA was called out to care for a resident. CNA 1 said she, "...served Resident 1 his meal, then went back to get the lunch tray for another resident at the same table." She heard a noise and looked at Resident 1, who looked "scared." She asked if he needed the choking maneuver and he nodded his head. She called for help and attempted to help the resident. During an interview with the Coroner on 9/19/14 at 9:15 a.m., he stated the ambulance crew removed a large piece of chicken from the patient's airway. He examined the piece of chicken, took pictures, and described it as a "single piece of chicken... not chopped... approximately the size of a quarter or 50 cent piece size." In his professional opinion Resident 1's death was consistent with choking due to a large piece of chicken in the airway. Review of the Certificate of Death, issued 9/19/2014, indicated the, "IMMEDIATE CAUSE" of death for Resident 1 as, "AIRWAY OBSTRUCTION" and "FOOD BOLUS." Under the description of how the injury occurred indicated, "CHOKED ON A PIECE OF FOOD."

Based on observation, interview and record review, the facility failed to provide adequate supervision for toileting needs to prevent falls for 1 of 2 sampled residents (Resident 1) when: Resident 1 had six unwitnessed falls between 9/11/13 through 6/29/14. This failure resulted in a fall with fracture on 6/29/14 and an overall significant functional decline for Resident 1. Findings: According to a"Face Sheet" the facility admitted Resident 1 with multiple [DIAGNOSES REDACTED]. According to a Minimum Data Set (an assessment tool) dated 3/18/14 and 6/11/14, Resident 1 had short-term and long-term memory problems. The two MDSs also reflected Resident 1 had urinary incontinence (involuntary loss of urine), was not on any urinary toileting program and required one staff limited physical assistance to move on and off the toilet. A review of an at risk for falls care plan with "Problem Onset: 7/1/13" under goal and target date indicated, Resident 1 would have no falls through the next review. There was no documented target date. Under the care plan approaches the plan indicated, "If required, Encourage use of eye wear...Assist with transfers and ambulation, as needed." A review of the initial admission MDS, dated [DATE], indicated Resident 1 was occasionally incontinent of bladder and she needed supervision and set up for toilet use. According to the same MDS, no trial toileting program had been attempted since urinary incontinence was noted. A review of Department Notes, dated 9/11/13 at 3:42 a.m., indicated Resident 1 had an unwitnessed (no one present) fall in her room, "...CNA (Certified Nursing Assistant) responded to residents room and found her on the floor next to her bed...resident stated that she was coming back from the bathroom and slipped...urine was found dribbled from bed into bathroom..." The note further indicated Resident 1 was not wearing an incontinent brief. An undated, unsigned "Fall Risk Evaluation" (FRE) verified by the MDS Coordinator (MDS 1) on 8/8/14 at 2:35 pm, indicated it was completed after Resident 1 fell on [DATE]. The evaluation indicated Resident 1 scored 10 (an indication of higher risk for falls). Further review indicated, "Score-10 or More Must Be Care-Planned." The FRE also indicated Resident 1 needed assistance with bowel and bladder elimination and had loss of balance while standing. Under history of falls for the past 3 months was marked as, "None." An undated "Interdisciplinary Resident Care Plan-Falls", under potential for fall/entrapment/other injury listed multiple problems including, "Impaired mobility...Poor judgement/safety awareness, Vision impairment...Repetitive Physical motion...(under) Goals, 1. Resident will have no falls through next review... (under) Approaches (included)...3. Assist with transfers 6. Assist resident to the rest room and with peri-care/incontinent cares as needed. 13. Enc.(encourage) use of eye wear..." The care plan also included a hand written note dated 9/12/13, "... (problem) unwitnessed fall w/head injury." No new interventions were documented on this care plan. Department Notes, dated 9/12/13 at 11:40 p.m., indicated Resident 1 had an unwitnessed fall, "...Cna's heard someone yell help...into pts(patients) bathroom to find her on the floor lying...assessment. Pt has...hematoma (collection of blood under the scalp as a result of trauma) to R(right) forehead, skin tear to right elbow and small sd (skin discoloration) to R ankle." According to a FRE, dated 9/16/13, Resident 1 scored 13 an indication of higher risk for falls and under gait and balance, "Loss of Balance While Standing (and) Decreased Muscular Coordination", were marked. Under history of falls past 3 months was marked as, "1 to 2 Times" and visual impairment marked as ,"No." Under bowel and bladder elimination, "elimination with assistance" was marked. According to a "Fall Trending Investigation Report" (FIR) dated 9/16/13 Resident 1 had 2 falls in last 30 days and location of fall was marked,"Bathroom". Under protective measures prior to fall indicated, "...Frequent Observation." Under measures taken after fall to reduce risk of a repeat fall included,..."Frequent Observation." The FIR hand written information indicated, "staff to assist (with) mobility, toileting..." There was no documented evidence a specific plan to address toileting unassisted was developed. A review of an MDS, dated [DATE], indicated Resident 1 was frequently incontinent of bladder and required limited assistance of one staff for toilet use. According to the MDS, no urinary toileting program was currently being used to manage the incontinence. Department Notes, dated 10/3/13 at 8:42 p.m., indicated Resident 1 had an unwitnessed fall in her room, "...CNA alerted me (nurse) that res (resident) was found on the floor...assessment...Res stated she hit her head..." A hand written "Interdisciplinary Resident Care Plan" dated 10/3/13, documented under problem, "Unwitnessed fall...Res (Resident) states hit her head on wall." Under the goals indicated zero falls with target date documented as 10/6/13. The FRE, dated 10/3/13, indicated Resident 1 scored 8 and under gait and balance, "Loss of Balance While Standing", was marked. Under history of falls past 3 months was marked as, "1 to 2 Times" and visual impairment marked as ,"No." The FIR dated 10/7/13 indicated Resident 1 had 2 falls in the last 30 days and the fall location was not marked. Under protective measures prior to fall indicated, "...Frequent Observation." Under measures taken after fall to reduce risk of a repeat fall included,..."Frequent Observation...Frequent Opportunities for Toileting." The FIR hand written information indicated, "staff to assist (with) toileting and dressing..." There was no documented evidence new interventions were developed as a result of this 3rd fall. Department Notes, dated 4/22/14, at 2:27 a.m., indicated Resident 1 had an unwitnessed (no-one present) fall in her room."...(Two CNAs )...heard res (resident) call for help. CNA informed RN res found on (floor) in res room....assess. Res found sitting upright in between beds w/a (with a) puddle of urine...Stated she was going to the bathrm (sic). Res not wearing socks..." A FRE, dated 4/22/14, indicated Resident 1 scored 9 and under bowel and bladder elimination, "Independent and Continent", was marked. Under gait and balance, "Loss of Balance While Standing", was marked. Under history of falls past 3 months was marked as "1 to 2 Times" and visual impairment was marked as "No." There was no documented evidence interventions to provide needed supervision were implemented to prevent the fall. Department Notes, dated 5/15/14 at 11:37 p.m., indicated Resident 1 had an unwitnessed fall in her room, "...CNA'S heard a thump in Resident's room...resident was lying on the floor at the end of her bed on her back...asked what happened? She stated, "I couldn't tell you."...(Resident 1's)...right shoe was next to her right foot..." A FRE, dated 5/15/14, indicated Resident 1 had falls 1 to 2 times past 3 months, was independent and continent for bowel and bladder and had loss of balance while standing. According to Department Notes, dated 5/17/14 at 1:49 p.m., Resident 1 was noted with discomfort to left groin and on 5/17/14 at 8:59 p.m., documented as having complained of left, "hip soreness upon waking up from a nap around 5 pm..." There was no documented evidence of new or additional care plan interventions for this fall. According to Department Notes, dated 6/29/14 at 7:26 p.m., Resident 1 had an unwitnessed fall in the bathroom located in the family room, " ...At 1545 (3:45 p.m.) res (resident) had taken herself to the bathrm (sic) in the family room. CNA heard a loud noise and a yell for help, CNA... went to the bathrm (sic) opened door and found res on the floor on her right side, head toward the door, and feet towards the toilet...brief (incontinent brief) wet...Assessment...pain in her right elbow and hip...unable to move her right leg, stating she couldn't move it and it hurt...Assisted to bed with three staff members...1645 (4:45 p.m.) Amb (ambulance) here and transported...BP (blood pressure) 180/102 at time of fall..." A review of the hospital documents provided by the facility regarding Resident 1, reflected the following: The "history and physical examination [REDACTED]. Patient complained of right hip pain and was refusing to ambulate...IMPRESSION:... Right femoral neck fracture (broken upper thigh bone), pathologic...secondary to a fall..." Further review indicated, "General Diagnostic" (page 3 of 3) under findings/impression indicated, "Acute displaced subcapital fracture (loss of bone alignment at fracture site) of the right femoral neck (long bone running through the thigh near the hip) ..." Resident 1's "Discharge Summary" dated 7/5/14, under course of hospitalization indicated, "...Patient underwent a right hip hemiarthroplasty (operation to treat fracture) on 6/29..." According to the intake report received by California Department of Public Health (CDPH) from the facility on 7/1/14, Resident 1 was found on the floor in the rest room off the family room and had sustained a right hip fracture. The report indicated, "Upon assessment the resident's elbow was bruised and range of motion on upper extremities...Resident could move her left leg but not her right leg; the right leg was slightly shorter...Her brief was wet; the resident normally toilets herself." The report further indicated staff were involved with another resident when Resident 1 fell . "... The resident, when she returns from the hospital, will be put on a scheduled toilet plan." A review of Resident 1's Department Notes (nurses notes) after her stay at the hospital, dated 7/5/14 and timed at 11:24 p.m., indicated, " ... Resident transported by ambulance...Resident is lethargic...Resident has a dressing to right hip...Resident requires x 3 (assistance by 3 staff) extensive assist when repositioning and peri-care is being provided...Resident c/o (complain of) pain 8/10 (severe pain)..." A FRE, dated 7/5/14, indicated Resident 1 was non-ambulatory and, "Independent Incontinent", was marked under bowel and bladder elimination. The FRE also indicated Resident 1 had 1 to 2 falls past 3 months and had no visual impairment. Resident 1 scored 15 on the FRE indicating a higher risk for falls, "Score 10 or More Must Be Care-Planned." During an observation on 7/9/14, at 9:50 a.m., Resident 1 was observed lying in bed. Her family was at the bedside. When Resident 1 was asked what happened, she stated, "Sometimes it hurts when I move." Resident 1 further stated, "Happened so fast. I don't know what happened...I forget things you know." Resident 1 was not wearing eye glasses and the family was observed searching for them in her closet. A review of the most recent re-admission MDS, dated [DATE], indicated a significant decline in activities of daily living namely bed mobility, transfer, and toilet use and, was totally dependent on staff to complete these activities. Resident 1 was non-ambulatory and required extensive assistance of one person in locomotion (wheel chair locomotion). The MDS also indicated Resident 1 was always incontinent of bowel and bladder and that no toileting program had been attempted. Indicators of pain or possible pain e.g. that hurts, ouch, stop were observed daily. Review of the record indicated Resident 1 was initially assessed for Physical Therapy (PT) on 7/7/14 and Occupational Therapy (OT) on 7/8/14. According to the PT assessment, dated 7/7/14, Resident 1 was referred to them due to, "New onset of decrease in strength...reduced functional activity tolerance...reduced ability to safely ambulate and increased need for assistance from others." PT documented the prior level of function (PLOF) as independent with bed mobility and transfers and, had no limitation in ambulation distance. This reflected Resident 1 had an overall decline in functional level. According to the OT assessment, dated 7/8/14, Resident 1 was referred to them due to , "...New onset of decrease in strength, decrease in functional mobility, decrease in transfers,reduced ability to safely ambulate...increased need for assistance from others,...Pain..." OT documented the PLOF as minimum assistance with toileting and supervised activities of daily living. This indicated Resident 1 had an overall decline in functional level. Resident 1's remarks as documented by PT and OT included: 7/7/14- 8/3/14: Patient goals, "I just want to be able to get out of bed." During an interview with Certified Nursing Assistant 1 (CNA 1), on 7/9/14, at 10:45 a.m., CNA 1 described Resident 1's prior level of function as, "Patient was very independent needing supervision only." When CNA 1 was asked if resident 1 had any fall prevention devices, CNA 1 stated, "(She has ) not attempted to get out of bed, I guess she should have bed and chair alarm?" When CNA 1 was asked if Resident 1 had a scheduled toileting program or wore vision glasses, she indicated Resident 1 was incontinent of bowel and bladder and was using incontinent briefs. Regarding the eye glasses, CNA 1 stated, "Yes, she wears eye glasses sometimes, they are probably in her drawers." During an interview with CNA 2, on 7/9/14, at 11:50 a.m., CNA 2 was asked how Resident 1 toileting needs were met prior to the 6/29/14 fall and transfer to the other unit. CNA 2 stated, " Sometimes resident wet her...(incontinent briefs) but would get to the bathroom...needed supervision with toileting." Further review of Resident 1's remarks as documented by PT and OT included: 7/11/14: "I'm tired, can I lay down?" 7/14/14: "I really can't tell you how bad it feels." 7/28/14: "My right leg hurts." During a telephone interview with Physical Therapy Assistant 1 (PTA 1), on 8/12/14, at 3:34 p.m., when PTA 1 was asked to describe the progression of Resident 1 in therapy, she indicated she had worked with her only twice and was not sure of her prior level of function. PTA 1 then stated, "I think she was ambulatory about the facility premises." PTA 1 was asked the current ambulation status for Resident 1 and indicated Resident 1 required minimum to moderate assistance walking and only with therapist. During a telephone interview with the Physical Therapist (PT) , on 8/13/14, at 9:45 a.m., he indicated Resident 1 was, "very lethargic...not able to do anything even move in bed", when he first assessed her after readmission on 7/5/14. When PT was asked what Resident 1's PLOF was, he indicated she was independent in ambulation. PT was further asked how Resident 1 was progressing in ambulating and he indicated she ambulated a total of 35 feet on 8/11/14. PT also indicated only therapy is ambulating Resident 1 at this point as she was still unsafe. As per the PT, Resident 1 may in the long-term revert to using a walking cane or front wheel walker. A review of the facility's, "Fall Prevention Program" with a revision date of 5/10 under purpose stipulated, "...To ensure consistency in the implementation of preventive measures to assist with reduction of falls. To evaluate outcomes." A review of the facility's "Bowel & Bladder Continence Program" revised 1/2010, under guidelines stipulated, "Facility residents will receive accurate assessment of bowel and bladder continence for implementation of interventions and programs to restore continence as possible and which promote the highest practicable level of functioning." During a telephone interview with MDS, 1 on 8/15/14, she verified Resident 1 never had a written scheduled assisted toileting plan since admission. MDS 1 also validated Resident 1 was still receiving Physical Therapy and Occupational Therapy.

Based on interview and record review, the facility failed to protect Resident A from physical abuse when Licensed Nurse 1 (LN 1), assisted by Certified Nursing Assistant 2 (CNA 2), forcibly removed dentures from Resident A's mouth. This action caused both physical and mental distress to Resident A. Findings: Review of Resident A's clinical record indicated Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an resident assessment tool), dated 6/21/13, noted that Resident A was alert and had impaired decision-making which required cues and supervision. She was able to make herself understood, but had difficulty understanding staff. Resident A had a history of [REDACTED]. She required maximum assistance with all aspects of care. Review of facility Investigative Report, dated 6/24/13, indicated that on the evening of 6/15/13 at approximately 10 pm, CNA 1 informed LN 1 that Resident A refused to allow him to remove her dentures for oral care. LN 1 told CNA 1 that the dentures had not been cleaned for five days. LN 1, CNA 1, and CNA 2 went into Resident A's room where LN 1 attempted to explain to Resident A the health consequences of not allowing the dentures to be removed. Resident A yelled, " NO." CNA 2 placed Resident A's nightgown over her arms and held her arms down against her chest while LN 1 put her fingers into Resident A's mouth and removed the dentures. Resident A responded by yelling and clenching her teeth trying to keep them from being removed. Review of Nursing Departmental Notes, dated 6/24/13 at 10:03 pm, indicated, "Resident has 3 areas of skin discoloration on both right and left forearms similar in pattern. They are approximately 2" in length and 1" apart. There is one circular greenish yellow skin discoloration on left upper chest approximately 1/2" in width. Resident has a circular reddened area to the left elbow approximately 1" in width. Also there is skin discoloration to the right knee. . ." Review of Care Plan, dated 11/18/11 and updated 6/26/13, indicated, "Resident A can be combative and resistant during personal care. Resident A can also refuse her medication on occasion." Approaches include: "Determine best times of day and preferred caregivers. Assess approaches that work with the resident. For example: giving choices within limits, encouragement of increased self care. . .Provide a calm environment." The facility administrator was interviewed on 7/5/13 at 10 am, about the alleged abuse incident and stated she was made aware of the incident on 6/24/13 by CNA 1. She stated CNA 1 waited to report the incident because he was not sure it was abuse. Record review of abuse allegation documents revealed that LN 1, CNA 1, and CNA 2 were immediately suspended and terminated from the facility on 7/2/13. Resident A was observed on 7/19/13 at 11:30 am, sitting in the Activities Room with several other female residents listening to musical entertainment. She appeared alert and aware of her surroundings. During a concurrent interview with Resident A regarding the abuse incident on 7/19/13 at 11:30 am, she declined to comment. CNA 2 was interviewed on 7/19/13 at 6:30 pm by telephone. She stated she had offered to work the night shift and was familiar with Resident A. She stated that Resident A had not been taking her medication and was often resistive to care. CNA 2 told LN 1 that Resident A had not had her dentures cleaned for five days. She said she accompanied LN 1 and CNA 1 into Resident A's room and was told by LN 1 to hold Resident A's arms down. She did so by placing Resident A's night gown over her arms to keep them from moving. CNA 2 reported that LN 1 tried twice to remove Resident A's dentures and on the second try, put her fingers in Resident A's mouth and lifted the dentures out. During this incident, Resident A was upset and after the dentures were out of Resident A's mouth, CNA 2 stated she realized that forcibly removing them "had not been a good idea." LN 1 was interviewed on 7/19/13 at 6:45 pm by telephone. She stated that CNA 1 had told her Resident A had not had her dentures cleaned for five days and refused to let him remove them. She assessed Resident A's mouth and noticed plaque build up, rotten food, and dried saliva. She said Resident A had a history of [REDACTED]. LN 1 stated she asked Resident A if she could have her dentures to clean and explained the importance of removing and cleaning them. Resident A screamed, "NO." LN 1 stated she then pulled the dentures out of her mouth. She denied asking CNA 2 to hold Resident A's arms down and did not see CNA 2 restraining Resident A. LN 1 stated she was focusing on Resident A. She stated, "In that instance, I thought I was doing what was best for the resident. I realize now it was the wrong thing to do." CNA 1 was interviewed by telephone on 8/1/13 at 12:55 pm. He stated he witnessed the denture removal and did not like what happened. He said he told LN 1 and CNA 2 to "back off" and try the denture cleaning at a later time. He said LN 1 and CNA 2 did not hear him because Resident A was screaming at them. He stated he thought about the incident after it happened and was not sure it was abuse. He then discussed the incident with the social services representative who told the administrator about the abuse

Based on observation, staff interview, and document review, the facility failed to provide a functioning assistance device for 1 of 3 sampled residents (Resident A). This failure resulted in a fall and fractured hip, which required surgery for [REDACTED]. Findings: Review of a facility "Face Sheet" indicated Resident A was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 8/15/2010 care plan revealed that Resident A was at risk for falls due to cognitive deficits (problems with memory), poor safety awareness, [DIAGNOSES REDACTED]. The approaches included a pressure alarm at all times while in bed and wheelchair to alert staff if she tried to self-transfer. Review of Resident A's 6/28/2012 Minimal Data Set (MDS-an assessment tool) revealed that she had impaired long and short term memory and moderately impaired decision making ability. Further review of the MDS revealed that Resident A required limited assistance with bathing, transferring, walking in room, dressing, personal hygiene and toilet use. The Resident required staff assistance with balance when walking, turning around, and moving on and off the toilet and for transfers. Review of the 9/2012 physician's orders [REDACTED]. Staff was to monitor the function and placement every shift. This was originally ordered on [DATE]. Review of the 9/15/2012 Fall Risk Evaluation revealed a score of 11, which determined that, with a score of 10 or above, Resident A's fall risk must be care planned (a fall care plan outlined specific interventions to reduce the resident's risk of falls). Review of the 9/24/2012 7:35 a.m. Departmental Notes (nursing notes) revealed that Resident A was found sitting on the floor between her bed and wheel chair. She had attempted to self-transfer. A complete assessment was done with a skin tear was noted on her left upper arm. She was medicated with Vicodin for complaints of pain to the affected site with good relief. Further review of the notes indicated, "...tab alarm (an alarm which is hooked on a gown attached to a box which alarms when pulled out) did not go off when she fell , (Resident A) was able to remove it..." Review of the 9/24/2012 7:38 a.m. note revealed the physician and responsible party were notified. A new order was obtained for the skin tear. Review of the 9/24/2012 facility's Investigation Report revealed that one of the contributing factors was a malfunctioning personal alarm. A disciplinary action was given to staff in the form of a huddle (meeting) to make sure all personal alarms are in place and functioning properly. Departmental Notes for 9/25/2012 at 9:51 a.m. revealed that Resident A was noted to have pain to the touch to her left thigh and knee. Resident was confused but able to communicate pain. She was last medicated for pain at 5:15 a.m. The note indicated "...(Resident A) wincing and touching thigh. (Complains of) pain to upper left leg." The physician was notified at 8:13 a.m. regarding the fall and new complaints of left leg pain. The physician visited at 9:35 a.m. and the Resident was medicated for pain at 9:40 a.m. Review of the 9/25/2012 Physician's Progress Notes revealed that the Resident had a fall and was now complaining of left thigh pain. The notes indicated an x-ray would be done to rule out a fracture. The 9/25/2012 1:03 p.m. Departmental Notes revealed that Resident A was admitted to the acute hospital after the x-ray revealed a left hip fracture. The 9/29/2012 at 7:19 p.m. Departmental Notes documented that Resident A returned to the facility. She had a fracture of the left upper thigh bone which required surgery. The report from the hospital revealed that she had been up in the chair with physical therapy but had not ambulated. On 10/4/2012 at 11:35 a.m. Resident A was observed in bed. She had a non-skid mat at the side of the bed. Registered Nurse 1 (RN 1) was present and she stated that Resident A transferred with Physical Therapy and had the pressure mattress in place. On 10/4/2012 at 12:35 p.m. an interview was conducted with RN 1. She stated that she was not present at the time of the fall but she did the investigation. She stated that Resident A had a tab alarm that was malfunctioning. She stated that if the battery goes out it would beep once or twice. On 10/5/2012 at 10:45 p.m. a telephone interview was conducted with RN 2. She stated that it was 5:30 am and she was doing her medication pass. She stated she was going into Resident A's room when she heard her call out, "help". She stated she found her sitting on the floor and Resident A complained of pain in her left upper arm where she had a skin tear. RN 2 stated she called the physician and did neurological checks. She wondered why the tab alarm did not go off and stated she saw it lying on the bed. It was not attached to the gown. She stated that she checked the alarm at the beginning of the shift and it was working. She stated that Resident A knew how to take if off. On 10/5/2012 at 10:46 p.m. a telephone interview was conducted with Certified Nurses Assistant (CNA) 1. She stated that she had been in Resident A's room 15 or 20 minutes before the fall. She stated she replaced the tab alarm on her gown after she changed her brief. She remembered the alarm going off when she changed her and she stated Resident A could unclip the alarm device from her gown. On 10/19/2012 at 3:45 p.m., a telephone interview was conducted with RN 1. She stated that she had talked with CNA 1 and she told her that Resident A had a pressure mattress on the bed but no box that hangs on the bed that sounds the alarm. She stated that they put a tab alarm on Resident A. On 10/26/2012 at 10:45 p.m., a telephone interview was conducted with RN 2. She stated the pressure mattress did not work and staff had looked in central supply but could not find a box to alarm the mattress. Resident A had only the tab alarm on the night of 9/24/2012, contrary to the physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to protect 1 of 23 sampled residents (4) from accidents when she was left unattended, fell , and sustained a hip fracture. Findings: Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A full MDS (a comprehensive assessment used in nursing facilities), dated 7/30/10, described the resident as having moderately impaired cognitive abilities and long term and short term memory problems. Resident 4 was described as requiring extensive assistance from staff for transfers and hygiene. Review of the clinical record for Resident 4 revealed: -A Huddle (meeting) Attendance Form dated 4/16/10 included under Topics Discussed, "Please do not leave residents unattended in the shower rooms; all residents are at risk for falls and should not be alone." Resident 4's name was on the top right corner of the form. -Fall Risk assessment dated [DATE] which revealed Resident 4 had a score of 19, an asterisk note next to the number included "A score of 10 or more indicates a High Risk for falls." -A Care Plan for Hip Fracture dated 4/26/10 which described the problem/need as, "At risk for fall related to recent history with hip fracture. She is currently taking antidepressant, impaired mobility & confusion related to dementia." Under Goal the care plan included "Resident will have no injuries related to falls through next review." Under the heading Approaches the plan included: "Assist with transfers and ambulation; Assist resident to the restroom and with peri care/incontinent care(cleansing after a bowel movement or urination); and Pressure alarm (a device that sounds an alarm to alert staff when a resident got up unassisted) at all times while in bed to alert staff of attempts to self transfer." Further review of the clinical record for Resident 4 indicated: -A Physician's Order dated 7/6/10 for "Pressure alarm at all times..." -A Nurse's Note dated 7/14/10 at 2:39 p.m. which described Resident 4's fall from the toilet when the CNA "left the bathroom res(ident) attempted to stand using grab bar. She fell and hit right hip, right leg 1/2 inch shorter than left...transport to ER." -A Preliminary X-Ray Report from the ER dated 7/14/10 at 4:39 p.m. which revealed, "Right intertrochanteric (upper portion of the thigh bone) hip fx (fracture)." -A Physician's Progress Note dated 8/9/10 which described the series of 3 hip surgeries Resident 4 had and concluded: "This has all taken a toll on (Resident 4)." During an interview with CNA 1 on 1/6/11 at 7:50 a.m. she stated she took Resident 4 to the toilet on 7/14/10 and removed the alarm to put her on the toilet. CNA 1 stated, "I needed a brief so I pulled the call button but nobody came so I left her for 20-30 seconds to grab a brief and I heard a big crash and she was grabbing her right hip. I was wrong to leave her." Review of the facility policy titled "Fall Prevention Program" revised 5/10, revealed "Purpose...To ensure consistency in the implementation of preventive measures to assist with reduction of falls." During an interview with DON on 1/6/11 at 2:35 a.m. she stated when a resident with an alarm was toileted staff were to "Stay with her." The DON acknowledged CNA 1 had left Resident 4 unattended prior to her fall.