Every finding on record at Granada Rehabilitation & Wellness Center, LP

Based on observation interviews and record review, the facility failed to ensure the required daily patient census and direct care service hours per patient day information was posted for 7/02/26 for a facility census of 83. Observation revealed the facility continued to display a daily patient census and direct care service hours per patient day form dated 6/30/26, rather than the current day's required posting.The facility's failure to post the required daily patient census and direct care service hours per patient day information prevented residents, residents' representatives, staff, and members of the public from having access to current staffing information as required by law.During an observation on 7/02/26 at 9:22 a.m. of the facility's designated staffing information posting location in the front lobby area across from the administrator's office in a display cabinet behind glass, revealed the posted daily patient census and direct care service hours per patient day form was dated 6/30/26. The required posting reflecting the facility's census and direct care service hours for 7/02/26 was not displayed.During an interview on 7/02/26 at 10:10 a.m., the director of nursing (DON) confirmed the required daily census and direct care service hours per patient day (HPPD) form for 7/02/26 was not posted in the facility at 9:22 a.m. and that the only form displayed was dated 6/30/26. The DON acknowledged the form must be updated daily and that the posted information was not current.During an interview on 7/02/26, at 3:44 p.m., the administrator (ADM) confirmed the required daily census and direct care service hours per patient day (HPPD) form for 7/02/26, was not posted in the facility at 9:22 a.m. on 7/02/26, and that the only form displayed at that time was dated 6/30/26. The ADM acknowledged the form must be updated daily and that the posted information was not current.During a review of the facility's policy and procedure titled, Nursing Department - Staffing, Scheduling & Postings revised July, 2018, indicated, Nurse Staffing Postings . The Facility will post the following information on a daily basis. Facility name. The current date . The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. a. Registered Nurses . b. Licensed Practical Nurses or Licensed Vocational Nurses. c. Certified Nurse Aides. d. Resident Census. B. Posting requirements. The Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. Data must be posted as follows . a. Clear and readable format. b. In a prominent place readily accessible to residents and visitors.

Based on interview and record review, the facility failed to ensure nursing services met professional standards for one (1) of six (6) sampled residents (Resident 2) when complete neurological assessments (subjective and objective data collected through interview and detailed physical examination of the central nervous system [brain, spinal cord] and the peripheral nervous system [other body nerves] was not documented following a head injury.This failure had the potential to delay identification of neurological changes indicative of brain injury or other clinical decline. Cross reference F726).A review of Resident 2's Face Sheet (a facility demographic), dated 6/10/26, indicated he was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety, and unsteadiness on feet.A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/16/26, indicated he had mild cognitive impairment (involves noticeable declines in memory, language, or thinking skills, but are not severe enough to disrupt daily life).A review of facility Progress Notes, dated 6/07/26 at 1:16 p.m., indicated Resident 2 had a verbal and physical altercation with his roommate on the previous day and had a lasting headache after being struck on the right temple. The Progress Note further indicated Alert charting was initiated and neuros continued Q4 hrs [every four hours] d/t [due to] complaints of headache. VS [vital signs] and neuros are wnl [within normal limits].During a concurrent interview and record review on 6/24/26 at 3:50 p.m., the Assistant Director of Nursing stated Resident 2's medical chart contained no flowsheets or documentation showing the components of a complete neurological assessment following Resident 2's head injury. The ADON stated documentation such as neuros wnl or neuros at baseline was acceptable and the facility had no neurological assessment policy, procedure, or protocol. When asked how the facility measured competency of performing neurological checks, the DON stated, nurses should know how to do this, and there were no such competencies given by the Director of Staff Development. During an interview on 6/24/26 at 4 p.m. with Licensed Nurse 1 (LN 1), she stated to complete a neurological check she would, check the pupils, check hand grip, take vital signs, look if there is any change in consciousness, and assess for pain.During an interview on 6/24/26 at 4:05 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated that to complete a thorough neurological check she would, take vital signs, assess how [residents] respond and are talking, check pupil size and range of motion of extremities. When asked to explain more about what to look for in the pupils, LN 2 stated look to see if they [residents' pupils] are the dilated or pinpoint.A review of the American Association of Neuroscience Nurses guidance literature titled, Neurological Assessment of the Adult hospitalized Patient, dated 2021, indicated neurological assessments could be challenging for nurses. The report advised, using a standardized approach can help the nurse identify changes that may affect outcomes. A list of assessment components help guide the nurse, creating structure around the identification of neurological changes in the patient. Reflecting those components in the EHR [Electronic Health Record, a secure, digital version of a patient's medical chart] allows the nurse to document findings consistently. A standardized approach can assist with rapid identification of neurological changes so interventions can be initiated promptly.

Based on observation, interview, and record review, the facility failed to protect one of six sampled residents (Resident 2) from abuse when Resident 2 was struck by Resident 3 during an physical altercation on 6/06/26.This failure resulted in Resident 2 being struck on the right temple and suffering a lingering headache.A review of Resident 2's Face Sheet (a facility demographic), dated 6/10/26, indicated he was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety, and unsteadiness on feet.A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/16/26, indicated he had mild cognitive impairment (involves noticeable declines in memory, language, or thinking skills, but are not severe enough to disrupt daily life).A review of Resident 3's Face Sheet, dated 6/10/26, indicated he was admitted to the facility 9/8/25 with diagnoses of congestive heart failure (occurs when the heart muscle becomes too stiff or weak to pump blood efficiently), malnutrition (a serious condition resulting from deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients) and muscle weakness.A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had mild problems with memory, orientation, and decision-making.A review of Resident 3's Psychology Progress Note, dated 6/04/26, indicated Resident 3 was diagnosed with adjustment disorder with depressed mood (an emotional or behavioral reaction to a specific, identifiable life stressor that begins within three months of the event), as evidenced by a reported emotional and behavioral response to medical conditions, functional limitations, increased need for assistance, and rehab placement. This response appears to be causing marked distress that is out of proportion to the severity and intensity of the stressor and is causing significant impairment in social functioning.A review of Resident 3's nursing Progress Notes, dated 6/06/26 at 9:31 p.m., indicated Resident 3's roommate (Resident 2) was watching a war movie on the television, which upset Resident 3. After a verbal exchange, Resident 3 hit Resident 2 on the head several times. Staff responded and separated the residents. A review of Resident 2's nursing Progress Notes, dated 6/07/26 at 1:16 p.m. indicated Resident 2 was immediately assessed following the physical altercation on 6/06/26, and although there was no visible bruising or bleeding, Resident 2 had an elevated blood pressure reading of 159/101 (normal blood pressure reading is 120/80 or less) and complained of headache which lasted until the next day. Resident 2 was given pain medication for discomfort.During an interview on 6/24/26 with the Administrator (ADM) and the Assistant Director of Nursing (ADON), the ADM expressed surprise that this incident would result in a deficiency, but acknowledged that the assault against Resident 2 actually occurred.A review of facility Policy and Procedure (P & P) titled, Abuse Prevention and Management, dated 5/30/24, indicated Prevention.the facility identifies, corrects and intervenes in situations of in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

Based on interview and record review, the facility failed to notify the state mental health authority (Department of Health Care Services [California agency responsible for overseeing the state's required screenings to identify individuals with serious mental illness]) for two (2) of six (6) sampled residents (Resident 3 and Resident 5), who had significant changes in mental health status.This failure had the potential to result in residents not receiving appropriate mental health services based on their most current clinical needs1. A review of Resident 3's Face Sheet (facility demographic) indicated he was admitted to the facility 9/08/25 with diagnosis of congestive heart failure (CHF, occurs when the heart muscle becomes too stiff or weak to pump blood efficiently), malnutrition (when the body does not receive the proper balance of nutrients and calories required to maintain healthy tissues and organ function), and muscle weakness.A review of Resident 3's Notice of PASRR Level 1 (Preadmission Screening and Resident Review, a federally required screening to identify if an individual seeking admission to a Medicaid-certified nursing facility has or may have, a serious mental illness, intellectual disability, or developmental disability) Screening Results, dated 9/01/25, indicated Resident 5 did not require a Level 2 Screening (this evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed) due to Negative for SMI [serious mental illness].A review of Resident 3's Psychology Intake Note, dated 2/17/26, indicated, [Resident 3] reportedly began to experience mood symptoms (i.e., depressed mood, diminished interest, guilt, decreased energy, poor concentration, poor appetite, anhedonia [the inability to experience pleasure or a profound loss of interest in activities you once enjoyed], and insomnia [a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or getting restful sleep]) around the date of admission., and was officially diagnosed with adjustment disorder with depressed mood (an emotional or behavioral reaction to a specific, identifiable life stressor that begins within three months of the event).A review of Resident 3's Psychology Progress Notes, dated 5/17/26, indicated [Resident 3] demonstrated a disorganized thought process today and was very tangential (a communication disorder where a speaker starts on a topic, drifts into unrelated side trails, and never returns to the original point) and repetitive.A review of Resident 3's Nursing Progress Notes, dated 6/06/26 at 9:35 p.m., indicated Resident 3 became upset and agitated when his roommate was watching a war movie in their shared bedroom. Resident 3 then physically attacked his roommate.A review of Resident 3's medical record indicated that the facility did not document notification to the state mental health authority regarding Resident 3's significant change in mental health status.2. A review of Resident 5's Face Sheet, dated 6/24/26, indicated she was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a general term for brain dysfunction caused by chemical imbalances or systemic illnesses in the body, rather than a direct physical injury or structural disease in the brain itself) and cognitive communication deficit (an impairment caused by disrupted brain function, rather than a primary speech or language issue).A review of Resident 5's Notice of PASRR Level 1 Screening Results, dated 6/16/25, indicated Resident 5 did not require a Level 2 Screening due to Negative for SMI.A review of Resident 5's Care Plan Report, initiated 7/17/25, indicated, Focus:.[Resident 5] is having adjustment issues to admission affecting mood. The resident is at risk for altered psychological well-being manifested by little interest/pleasure in doing things.Intervention: Document behavior problems and assess need for behavior management program.A review of Resident 5's Psychology Progress Note, dated 5/19/26, indicated she was diagnosed with adjustment disorder with anxiety (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior).A review of Resident 3's medical record indicated that the facility did not document notification to the state mental health authority regarding Resident 3's significant change in mental health status.During an interview on 6/24/26 at 2:44 p.m., the Medical Records Director stated she was responsible for ensuring PASRR processes were completed. She stated the MDS Nurse (Minimum Data Set Nurse, evaluates, monitors and documents the clinical needs of long-term care residents) and nursing staff were responsible for notifying her when residents experienced significant mental health changes requiring renewed PASRR referral, but she had not received notification regarding Resident 3 or Resident 5. She stated this process was important to ensure residents are placed appropriately and to protect all residents in the facility.A review of facility Policy and Procedure (P & P) titled, admission Screening Resident Review (PASRR), dated 2022, indicated, Purpose: To ensure that all residents are screened for mental illness and intellectual disability (ID) or a related condition (RC).

The facility failed to ensure a sufficient number of dietary staff were maintained to carry out required Food and Nutrition Services functions when dietary staff responsible for cleaning and sanitation were reassigned to cover vacant food preparation roles. This failure resulted in insufficient staffing to complete essential duties and placed a census of 78 residents who ate food from the kitchen at risk for potential foodborne illnesses.Findings:During a concurrent observation and interview with the Certified Dietary Manager (CDM) in the kitchen on 4/21/26 at 8:09 a.m., the facility stove was noted to have large amounts of grease and food debris built up around and beneath all burners. The backsplash behind the grill of the stove was stained with grease. The CDM stated she was an interim traveler CDM until the current CDM In Training (CDMIT) was able to resume classes to become certified. The CDMIT was pulled to work as a cook until the position could be filled. The CDM stated the kitchen was short staffed and had been employed by the facility for three months. During an interview in the dietary office on 4/22/26 at 10:35 a.m., the CDM stated the dietary staffing was short and the full-time cook was on leave, the morning cook resigned, a diet aide is out on leave, and the morning diet aide just went out on medical leave for 3 months. The CDM stated these vacancies had affected tasks such as cleaning and sanitation to be pushed to the bottom of the list of priorities. During an observation in the kitchen on 4/22/26 at 11:33 a.m., the side of the facility oven had accumulated food debris, with several rust-colored stains and areas of white residue of unknown origin. The space between the back of the oven and the wall had significant dust buildup. The facility toaster had a large amount of dust accumulated in the upper vents above the serving tray.A review of the facility's policy titled Dietary Department-General, dated 6/1/14, indicated the purpose of the policy was, To ensure that the dietary department has the requisite organization to meet the nutritional needs of residents. The primary objectives of the dietary department include.maintenance of standards for standards of sanitation and safety.

Based on observation, interview and record review, the kitchen and maintenance staff failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:Dietary staff did not apply hair restraints properly;Expired food and drink were found in the refrigerator;Moldy strawberries were found in the refrigerator and moldy onions found in a bin in the dry storage area;The stovetop was encrusted with hardened black residue, the backsplash was stained with grease, the side of the oven was encrusted with white and rust-colored residue and the toaster had accumulated amounts of dust in the upper vents above the serving tray. The space between the back of the stovetop, oven and wall had clumps of dust adhering to the wall, pipe and floor; and,Ice buildup was found on the inner gasket of the freezer door.These failures posed a risk for foodborne illness for a census of 78 residents.1. During an observation in the kitchen on 4/22/26 at 10:35 a.m., the [NAME] In Training (CIT) and [NAME] 2 wore hair restraints which did not fully cover the back of their heads, exposing hair.During an interview in the dietary office on 4/23/26 at 8:38 a.m., the Certified Dietary Manager (CDM) stated she was unaware the hair nets were not entirely covering the hair for the CIT or [NAME] 2. The CDM stated their high bun hairstyle was causing the hair restraint to pull up, exposing their hair.A review of the facility's policy titled Dietary Department Infection Control for Dietary Employees, dated 3/25/26, indicated, Personal cleanliness is required in sanitary food preparation.cover hair.with an effective hair restraint.while in any kitchen and food storage areas.A review of the Food and Drug Administration (FDA, a federal agency responsible for oversight and regulation of products that directly affect public health and safety) Food Code 2022 2-402.11 (A) indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.2. During a concurrent interview and observation in the kitchen on 4/21/26 at 8:09 a.m., the refrigerator contained a bag of shredded carrots with a use by date of 4/18/26 and a bag of parsley was observed with a use by date of 4/1/26. The CDM stated both items should have been thrown out. In a separate refrigerator, a pitcher labeled punch was marked with a use by date of 4/19/26. The CDM stated the punch should not be used and should also be thrown out.During an interview in the dietary office on 4/23/26 at 8:38 a.m., the CDM stated the facility did not have a policy regarding expired food. The CDM further stated the expectation was for all expired food and drink to be discarded as it was considered unsafe to consume.3. During a concurrent interview and observation in the kitchen on 4/21/26, at 8:11 a.m., packaged strawberries were observed in the refrigerator covered with white mold. The CDM stated she would not use those and they should be discarded.During a concurrent interview and observation in the dry storage room on 4/21/26 at 8:23 a.m., a bin containing onions was observed. A few of the onions had gray/black mold present. The CDM stated the onions should have been discarded.A review of the facility's policy titled Food Storage and Handling, dated 6/4/24, indicated, Fresh vegetables should be checked and sorted for ripeness.rotate vegetables so that the oldest produce is used first.A review of the FDA Food Code 2022 3-701.11 indicated, Food that is unsafe.shall be discarded.4. During a concurrent observation and interview in the kitchen on 4/21/26 at 8:09 a.m., the stovetop was observed to have greasy, hardened black residue around and in all burners. The CDM stated the stovetop was in use constantly throughout the day and was scheduled to be cleaned once per week. The backsplash to the stove was observed to be stained with grease. The lateral side of the oven was observed to be encrusted with white and rust-colored residue. During an interview in the dietary office on 4/22/26 at 10:35 a.m., the CDM stated the kitchen had experienced a staffing shortage, which had affected the cleaning and sanitation tasks.During a concurrent observation and interview in the kitchen on 4/22/26 at 11:33 a.m., the upper vents of the toaster, located above the serving tray, were observed to have an accumulation of dust. The gap between the oven, stovetop and wall contained clumps of dust and debris adhered to the wall, surrounding pipe and floor below. The CDM confirmed these observations at the time they were identified.A review of the facility's policy titled Conventional (Gas)-Operation and Cleaning, dated 7/13/23, indicated, Sanitation of Equipment.Remove spills, spillovers, and burned food deposits from the oven as soon as practicable.Daily tasks: wipe the cool oven exterior and knobs with a warm detergent solution.A review of the FDA Food Code 2022, Section 4-601.11 indicated, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (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.5. During a concurrent observation and interview in the kitchen on 4/21/26, 8:15 a.m., the freezer door was observed to have ice buildup on the left side gasket. The CDM stated the ice accumulated when the door did not maintain an appropriate seal when the door was shut, which could potentially affect proper temperature control.During an interview in the facility hallway on 4/23/26 at 8:20 a.m., the Maintenance Director (MND) stated the gasket on the affected freezer had gone bad and needed replacement. The MND further stated he did not routinely schedule inspections of the kitchen equipment.A review of the facility's policy titled Maintenance Service, dated 1/1/12, indicated, The Maintenance Department maintains all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the.equipment in a safe and operable manner at all times. The Director of Maintenance is responsible for developing and maintaining a schedule to assure that the.equipment are maintained in a safe and operable manner.A review of the 2022 Food Code 4-501.11(A) indicated, Equipment shall be maintained in a state of repair and condition that meets the requirements. (B) Equipment components such as doors, seals shall be kept intact, tight and adjusted in accordance with manufacturer's specifications.

Based on observation and interview, the licensed nurse failed to ensure that resident information was protected during a medication pass when Licensed Nurse 3 (LN 3) did not lock the computer screen after preparing medication for three residents (Resident 1, Resident 11, and Resident 29) of 23 sampled residents.This failure decreased the facility's potential to protect residents' personal information from the public.Findings:During a medication pass observation with LN 3 on 4/22/26 at 11:52 a.m., 11:55 a.m., and 11:59 a.m. with, LN 3 closed the laptop lid halfway down and did not lock the screen after preparing medications. Visitors were observed walking past the laptop with the screen partially visible.During an interview with LN 3 on 4/22/26 at 12:10 p.m., LN 3 confirmed she did not lock the computer screen or log out of the resident chart. LN 3 further stated it was possible for someone to see the resident information if they lifted the laptop screen.During an interview with the Assistant Director of Nursing (ADON) on 4/23/26 at 2:24 p.m., the ADON stated she expected LN 3 to protect resident privacy by either turning the med cart to face the residents' room or use the lock screen.A review of the facility's policy and procedure titled, Electronic Protected Health Information Security, revised December 2012, indicated, Resident medical records will be maintained in a manner that protects the electronic protected health information from unauthorized use and access.monitors should face away from public view.

Based on observation, interview, and record review, the licensed nurses failed to remove the following from one of two medication carts:One unlabeled bottle of eye drops,Two inhalers without open dates, andThree loose pills.In addition, one expired insulin (medication used to treat diabetes) pen was found in one of two medication storage room fridges.These failures decreased the facility's potential to safely administer medications and prevent drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use).Findings:During a concurrent observation and interview with Licensed Nurse 2 (LN 2) on [DATE] at 11:23 a.m. during a medication cart inspection, LN 2 confirmed that:One bottle of [brand name] contact lens drops was found without a resident identifier,Two budesonide (medication to treat breathing problems) inhalers were found without open dates, andThree loose pills were found in Side Two Top medication cart.LN 2 stated medications needed a resident label, otherwise it could be given to the wrong resident, and medications needed to have open dates because some medications have time frames and it could be expired. LN 2 further stated having loose pills in the cart could lead to missed medication doses or could possibly be taken by staff.During a concurrent observation and interview with LN 2 on [DATE] at 11:56 a.m., LN 2 confirmed that a long-acting insulin pen with an expiry date of [DATE] was found in the Side Two medication fridge. LN 2 stated expired medication may have a reduced or negative effect if given to a resident.During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:24 p.m., the ADON stated she expected: all medication to have open dates to ensure meds were used at the appropriate time and not become outdated; all prescribed meds have resident names to ensure the correct medication is given to the correct person; and, expected expired meds were removed, because they could have a negative effect if given to a resident.A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], indicated, All medications dispensed by the pharmacy are stored in the container with the pharmacy label.Outdated medications are immediately removed from inventory.Medication storage areas are kept clean and free of clutter.

Based on observation, interview and record review, the nursing, therapy, and maintenance staff failed to ensure infection prevention and control practices were implemented for a census of 78 residents when:Staff did not wear Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for residents three residents (Resident 25, Resident 40, and Resident 96) on Enhanced Barrier Precautions (EBP- to reduce transmission of multidrug-resistant organisms in nursing homes. EBP involves gown and glove use during high-contact resident care activities such as transferring and changing bed linen); and,12 rooms were observed without proper infection precaution signage or easily accessible PPE supply containers; and,Staff failed to maintain a clean oxygen concentrator for Resident 46.These failures decreased the facility's potential to prevent the spread an infection amongst residents and decreased the facility's potential to prevent bacteria and debris from directly entering Resident 46's lungs, placing her at risk for an infection.1. A review of Resident 25's face sheet indicated admission to the facility in March 2026 with a diagnosis of a unspecified elevated white blood count (which can be indicative of infection). During an observation on 4/23/26 at 10:22 a.m. Certified Nursing Assistant 1 (CNA 1) was inside Resident 25's room changing the bed linens without wearing a gown or gloves. A sign was posted right outside Resident 25's room which indicated, Enhanced Barrier Precautions.Everyone Must.Wear gloves and a gown for the following High-Contact Resident Care Activities.Changing Linens. A review of Resident 40's face sheet indicated admission to the facility in March 2026 with an elevated white blood count, u, and an open wound of the right back wall of the thorax (chest region). An observation on 4/23/2026 at 10:26 a.m., CNA 2 was transferring Resident 40 to a wheelchair without wearing a gown or gloves. A sign was posted right outside Resident 40's room which indicated, Enhanced Barrier Precautions.Everyone Must.Wear gloves and a gown for the following High-Contact Resident Care Activities.Transferring. In an interview with CNA 2 on 4/23/2026 at 11:41 a.m., CNA 2 stated, The precautions are for me and the residents. It's for our safety. If we are cleaning the patient, I wear it. I haven't used it for transferring because she is all clean. I'm just noticing this sign now. I usually just use PPE if [I am] cleaning a resident. I have learned my lesson. I will now use it during transfer as well. In an observation on 4/23/26 at 11:45 a.m., a Physical Therapist and an Occupational Therapist was assisting Resident 40 with ambulation (walking) in Resident 40's room and transferred Resident 40 to a wheelchair to go to the Physical Therapy room. Neither staff members were wearing PPE despite signage in front of Resident 40's door and above the Resident 40's bed. In an interview with the Certified Occupational Therapist Assistant (COTA) on 4/23/2026 at 12:04 p.m., the COTA stated, Barrier precautions means you gown up. Oh, I never noticed that [EBP sign]. No one has ever told me. Why doesn't she not have a container in here? [the PPE container was located under resident belongings in the far corner of the room] I'm really bad about reading signs, and I've never noticed anyone else wearing PPE in this room. I know she has a wound VAC [vacuum-assisted closure, a medical device used to accelerate the healing of large, chronic, or severe wounds], and she's been here awhile. No one else wears it in [this room]. In an interview with CNA 1 on 4/23/2026 at 1:25 p.m., CNA 1 stated, I wear PPE in the evenings and the mornings, and when doing patient care. I didn't wear PPE earlier because I was making a bed that was already cleaned. There was no food or soilage, so I felt the bed was in clean condition. This is my policy with all residents, and wear PPE if the sheets are soiled. If they appear clean; I usually put gloves on, this one time was unusual, I wasn't wearing them. CNA 1 further stated, We use PPE to protect ourselves and the patients from the spread of bacteria or disease. A review of a Resident 96 Face sheet, indicated Resident 96 was admitted to the facility in April 2026 with diagnoses which included bacteremia (bacteria in the bloodstream) and methicillin-resistant staphylococcus aureus (MRSA- a type of bacteria that is resistant to several antibiotics). During an observation and interview with the Speech Language Pathologist (SLP) and CNA 3 on 4/22/26 at 3:25 p.m., the SLP and CNA 3 were seen transferring Resident 96 to bed without wearing any gowns. Signage outside the room indicated Resident 96 was on EBP. Both the SLP and CNA 3 confirmed they were not wearing gowns and stated not wearing a gown could spread infection. A review of Resident 96's Care Plan Report, dated 4/19/26, indicated, Resident is on EBP related to a history of MRSA.[staff were expected to] Implement EBP to prevent the spread of infections. 2. On 4/23/26 beginning at 10:15 a.m., 12 rooms were observed for infection control signage and PPE storage. One room had no infection control precaution signage posted; Two rooms had no PPE supplies present outside of the room; 11 rooms had the PPE supplies stored deep inside the room; and, the PPE supplies in three of the 11 rooms were not easily noticeable. In an interview with the Infection Preventionist Nurse (IP) on 4/23/26 at 9:13 a.m., the IP stated, My expectation is that everyone wears PPE in rooms with precautions. If they don't, disease can spread to the worker and other residents. In an interview with the Director of Staff Development (DSD) on 4/23/26 at 4:30 p.m., the DSD stated, Our last infection control in-services were on 4/10/26 and 4/20/26; and the Blood borne pathogens in-service was on 4/13/26 and 4/17/26. We also did competencies on Hand Hygiene and Donning and Doffing PPE. The DSD further stated, It is my expectation that all staff put on their gown and gloves when they are providing care to an EBP resident in their room. A review of the facility's policy titled, Enhanced Barrier Precautions, revised 10/15/24, indicated, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs [multi-drug resistant organisms].Dressing, Bathing/showering, Transferring within the resident room, Providing hygiene, Changing linens, Changing briefs or assisting with toileting.Wound care: any skin opening requiring a dressing.Per the CDC [Centers for Disease Control], this generally includes residents with chronic wounds.Examples of chronic wounds include.Pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers.Post the appropriate Enhanced Barrier Precautions sign on the resident's room door to inform caregivers of the appropriate tasks requiring the use of PPE.To facilitate compliance with EBP.Make PPE, including gowns and gloves, available outside of the resident room. 3. A review of Resident 46's face sheet indicated admission to the facility on 2/21/25 with diagnoses of Acute and Chronic Respiratory Failure with Hypoxia (a serious condition in which the respiratory system fails to provide enough oxygen to the blood to support vital organ function) and Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD- an irreversible disease which restricts airflow, making it difficult to breathe. An acute case involves worsening symptoms usually triggered by respiratory infections or pollutants). A review of Resident 46's physician orders dated 1/7/26 indicated, Oxygen at 2 L [liters, a unit of measure] via NC [nasal cannula- a flexible device used to deliver oxygen through the nose] to keep O2 Sat [oxygen saturation-measures the amount of oxygen carrying cells in the blood] every shift. A review of Resident 46's Care Plan dated 1/7/26, indicated Resident 46 required the use of oxygen related to her respiratory failure and COPD. Resident 46's goal was to be compliant with oxygen therapy and to maintain unlabored breathing and a patent airway. To reach this goal, staff were expected to change humidifier and oxygen tubing, monitor for signs of hypoxia (the body's tissues do not receive enough oxygen to function properly) and to observe oxygen precautions. During an observation in Resident 46's room on 4/21/26 at 9:36 a.m., an oxygen concentrator (a medical device that pulls air from the surrounding environment, filters out impurities and delivers medical-grade oxygen to residents with a respiratory condition) was located near Resident 46's bed. The oxygen concentrator was noted to have visible dust and debris on the overall outside of the concentrator. The external filter contained a visible accumulation of dust, lint and debris. During an interview in Resident 46's room on 4/21/26 at 2:21 p.m., Licensed Nurse 1 (LN 1) stated housekeeping or maintenance staff was responsible for ensuring the oxygen concentrators were kept clean. LN 1 further stated the oxygen concentrator should not have been in the condition it was observed to be in. During an interview in the Maintenance Director's (MND) office on 4/21/26 at 2:25 p.m., the MND stated a third-party vendor visits the facility monthly to clean, repair and replace the filters on the oxygen concentrators, if needed. The MND further stated there was no documentation received for work completed by the third-party vendor. During an interview in the hallway on 4/21/26 at 2:28 p.m., the Housekeeping Supervisor (HS) stated housekeeping did not clean the oxygen concentrators. The HS further stated he believed nursing was responsible for cleaning the outside of the oxygen concentrators and the third-party vendor cleans them during their monthly visits. During an interview in the Assistant Director of Nursing (ADON) office on 4/21/26 at 2:34 p.m., the ADON stated nursing staff should be cleaning the outside of the oxygen concentrators, and the third-party vendor changed the internal filters and troubleshoots functional problems. The Surveyor and the ADON walked to Resident 46's room. The Surveyor turned the oxygen contractor around to show ADON dirty outside filter, she stated Oh no! This is not good for the resident. During a phone interview on 4/21/26 at 3:16 p.m., the Regional Manager of the third-party vendor (REV) stated Resident 46's oxygen concentrator was last serviced by their staff in July 2025. During that visit, the machine was checked for operation and function. The REV further stated they were responsible for internal cleanliness only. During an interview in the Infection Preventionist (IP) office on 4/23/26 at 9 a.m., the IP stated Oh, that's bad when shown the picture of Resident 46's oxygen concentrator outside filter. The IP stated the resident would not get the prescribed amount of oxygen with that much dust buildup and dust carried various bacteria and other spores which could further compromise Resident 46. The IP further stated she was disappointed and the system must change. A review of the facility's policy titled Infectious Disease Management, dated 5/4/23, indicated the facility, will use appropriate infection control.and prevention measures for the prevention.of infectious diseases. A review of the facility's policy titled Cleaning and Disinfection of Resident Care Equipment, dated 1/1/12, indicated, Resident care equipment.is cleaned and disinfected according to current CDC recommendations.The following are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care.semi-critical items consist of items that come in contact with mucous membranes (moist, thin sheets of tissue that line body organs exposed to the external environment) (e.g., respiratory therapy equipment). Such devices are free from microorganisms. A review of [Brand Name] 10 L Oxygen Concentrator Instruction Guide, dated March 2023, indicated the company recommended cleaning intervals for the outer cabinet and the filter door vents to be seven days.

Based on interview and record review, the facility's admissions or social service staff failed to ensure residents were asked about their Advanced Directives (a legal document indicating resident preference on end-of-life treatment decisions), for one resident (Resident 20) of eight sampled residents when there was no documented evidence in Resident 20's medical record that a discussion was had about an Advanced Directive.This failure decreased the facility's potential to ensure Resident 20's wishes were carried out during an emergency.Findings:A review of Resident 20's admission record indicated the resident was admitted in February 2026 with a diagnosis of cellulitis (a common, potentially serious bacterial infection affecting the deep layers of skin and underlying tissue) of the buttocks. This document also indicated Resident 20 had a Public Guardian (a court-appointed official or agency that acts as the decision-maker for individuals unable to care for themselves) as their Responsible Party (RP, a person who is appointed as the decision-maker for a resident who is no longer able to make decisions for themselves [usually a family member or friend]).A review of Resident 20's medical record on 4/20/26 indicated Resident 20 was conserved on 3/19/25. A review of Resident 20's progress notes showed no documented evidence that admissions or social service staff had a conversation with Resident 20's RP regarding an Advanced Directive.A review of Resident 20's admissions agreement signed on 4/2/26 indicated the section titled Advanced Directive was left blank and none of the questions in the section were reviewed or asked of Resident 20's RP.In an interview with the Medical Records Director (MRD) on 4/22/26 at 10:10 a.m., the MRD stated Resident 20 did not have any Advance Directive paperwork because he was in the process of getting conserved. During an interview on 4/22/26 at 12:03 p.m., with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (IDON), both stated all residents or their RPs were expected to be asked about Advanced Directives and life-sustaining treatment wishes upon admission to the facility. In an interview with Resident 20's RP on 4/23/26 at 4:23 p.m. the RP confirmed Resident 20's conservatorship commenced on 3/19/26. The RP stated they were unaware Resident 20 did not have an Advanced Directive and they wanted Resident 20 to have one.In a subsequent interview with the MDR on 4/24/26 at 8:22 a.m., the MDR stated, We do not have advanced directive paperwork for [Resident #20].A review of the facility's policy titled, Advance Directive, dated 2/25/2024, indicated, Upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care.and the right to formulate advance directives.During the Social Service Assessment process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive.If the resident does not have an Advance Directive and additional information is requested, the Social Service Director or Designee may provide the resident with a copy of the Advance Directive form for their review.An Advance Directive is defined as a resident's written preference regarding treatment options.

Based on interview and record review, the licensed nurses and social service staff failed to provide written summaries of resident baseline care plans to communicate the initial goals of care for two residents (Resident 8 and Resident 14) of three sampled residents.This failure decreased the facility's potential to safeguard against adverse events right after admission to the facility by ensuring continuity of care and communication of residents' care needs.Findings:A review of Resident 8's Face Sheet, indicated admission to the facility in February 2026 with diagnoses of age-related osteoporosis (a chronic bone disease characterized by a weakened bone structure and high fracture risk), muscle weakness, a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the right heel, and repeated falls. The face sheet also indicated Resident 8 was her own Responsible Party (a person designated as the decision-maker).A review of Resident 8's Baseline Care Plan, indicated Resident 8 was her own RP yet she did not sign the document; however, the baseline care plan was signed by the Assistant Director of Nursing (ADON), Social Service Director (SSD), and Director of Rehabilitation (DOR) on 2/27/26.A review of Resident 14's Face Sheet, indicated admission to the facility in March 2026 with diagnoses of polyosteoarthritis (generalized osteoarthritis, a common degenerative wear-and-tear joint disease caused by the gradual breakdown of cartilage, leading to pain, stiffness, and reduced mobility which can affect multiple joints and be characterized by pain, stiffness, and swelling), hypoxemia (lower-than-normal levels of oxygen in the blood), and muscle weakness.A review of Resident 14's Baseline Care Plan, indicated Resident 14 was her own RP yet she did not sign the document; however, the baseline care plan was signed by the ADON, the SSD, and the DOR on 3/18/26.During an interview on 4/23/26 at 10:09 a.m., Resident 14 stated she did not receive a copy of her baseline care plan summary.During a concurrent interview and record review on 4/23/26 at 12:37 p.m., the ADON read the facility's policy regarding base line care plans and stated, The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to.During an interview on 4/23/26 at 2:33 p.m., Resident 8 stated she never received a copy of her baseline care plan summary.A review of the facility's policy and procedure titled, Person-Centered Care Planning, dated 5/22/25, indicated, Baseline Care Plan Summary.The facility must provide the resident and their representative with a summary of the baseline care plan that includes.Initial goals of the resident.A summary of the resident medications and dietary instructions.Any service and treatments provided to the resident.

Based on interview and record review, Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) failed to provide urinary catheter care for one resident (Resident 1) out of three sampled residents when Resident 1 developed a facility acquired mucosal membrane skin injury (damage to the skin and/or underlying soft tissue caused by pressure from a medical device used for therapeutic purposes) and urinary tract infection (UTI- an infection of the bladder/urinary tract) from an indwelling urinary catheter (flexible tube remaining in the bladder to continuously drain urine into an external bag).This failure resulted in Resident 1 sustaining a laceration which measured 1.3 centimeters (cm-a unit of measure) long and 0.5 cm wide to Resident 1's urinary meatus (the external opening of the penis) and a severe infection with Pseudomonas Aeruginosa (a serious, often antibiotic-resistant bacteria that causes UTI).Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (a common, noncancerous enlargement of the prostate gland in men which causes difficulty urinating) and diabetes mellitus (a chronic disorder which results in the body's inability to use food energy efficiently and causes wounds to heal slowly). A review of Resident 1's care plan, dated 12/18/25, indicated Resident 1 had an indwelling urinary catheter due to his diagnosis of BPH with lower urinary tract symptoms. Resident 1's goal was to be free from catheter related trauma. Staff were expected to Monitor/ document [Resident 1] for pain/discomfort due to [the urinary catheter and].Monitor/record/report to MD [physician] for s/sx [signs and symptoms] [of a] UTI: pain, burning.A review of Resident 1's order recap report indicated Resident 1 had the following orders in place:-Starting on 1/4/26, staff were expected to insert an indwelling urinary catheter inserted for urinary retention (inability to drain the bladder); and,-Starting on 1/4/26, staff were expected to provide urinary catheter care to Resident 1.A review of Resident 1's Medication Administration Record (MAR), dated January 2026, indicated LNs conducted urinary catheter care for Resident 1 during the day, evening, and night shifts from 1/13/26 through 1/19/26.A review of Resident 1's skin check assessment dated [DATE] at 10:30 a.m. indicated Resident 1 did not have any skin concerns on his genitals.A review of Resident 1's shower sheets, dated 1/14/26 through 1/18/26 indicated CNAs did not find any skin changes on Resident 1 and LNs reviewed and verified what was documented on the shower sheets.A review of Resident 1's Occupational Therapist (OT) progress note dated 1/19/26 indicated, Therapist noted drainage from catheter site and requested wound nurse to assess the area for possible infection. Therapist assisted the wound nurse initially with initiation of pericare, however a second nurse assisted with a more complete assessment of [Resident 1's] needs .[Resident 1] was agreeable to OT session however [Resident 1] required assessment by nursing for possible infection at catheter site.Toileting hygiene= Dependent.Shower/bathe self= Not applicable.Lower body dressing [i.e. putting on underwear or putting on pants]= Dependent.Personal hygiene= Dependent.A review of Resident 1's progress note dated 1/19/26 at 12:01 p.m., indicated, .Treatment RN [Registered Nurse] was notified by [Occupational] therapy of a possible ureteral infection.[Resident 1's] urethra [the tube connecting the bladder to the outside of the body allowing for excretion of urine] is split down the middle, approx. [approximately] 1/ 2 - inch thickness, with purulent [containing pus (a thick, milky, white-yellow to brown fluid that accumulates at the site of infection] green and yellow exudate [discharge] inside the urethra, and climbing down the [urinary] catheter tube. [Resident 1] states 'this thing needs to come out. It hurts. It's been like this for a while.'A review of Resident 1's progress note dated 1/19/26 at 12:11 p.m. indicated, Resident has pain in the area when moving or providing catheter care.A review of Resident 1's skin check assessment dated [DATE] at 12:18 p.m., indicated Resident 1 had a new facility acquired skin issue which involved a laceration located on Resident 1's urethra on his penis. The assessment described the wound as having erythema (redness of the skin or mucosal membrane) and edema (swelling) with increased exudate. The wound measured 1.5 cm in length and 0.5 cm wide, and Resident 1 described the pain as sharp. A review of Resident 1's progress note dated 1/19/26 at 1:44 p.m. indicated, MD [physician] ordered UA [urinalysis- a common diagnostic test that analyzes urine to detect infections] & C&S [culture and sensitivity- a test used to identify the specific bacteria causing an infection].to be sent out today.A review of Resident 1's UA and C&S test results dated 1/22/26 indicated the bacteria known as pseudomonas aeruginosa was causing Resident 1's urine to: appear turbid (significantly cloudy); test 3+ positive for white blood cell esterase (an enzyme released by WBC as it fights off bacteria. 3+ indicates the highest amount the test can detect); test positive for blood; test positive for nitrites (a specific marker for UTI); and many bacteria which were all considered to be abnormal.A review of Resident 1's hospital emergency department (ED) note dated 1/23/26 indicated, .Physical Exam.GU [genitourinary- anatomy of the genitals and urinary system] Indwelling [urinary] catheter in place.chronic pressure wounds present. Pus around meatus. Enlarged testicles with swelling, erythema, and tenderness to palpation [touch].positive for large UTI.Final diagnoses [in ED].Urinary tract infection associated with indwelling urethral catheter.During an interview in the facility hallway on 2/11/26 at 1:31 p.m., the Treatment Nurse (TN) stated both the LNs and CNAs were responsible for providing catheter care for residents. The TN stated catheter care was a part of nurses' daily routine of perineal (small area of the body between the anus and the external genitalia) care. The LNs were responsible for following up with the physician for anything concerning.During an interview at the Side 1 nurses' station on 2/11/26 at 1:44 p.m., LN 1 stated CNA staff were responsible for providing catheter care to residents every two hours or sooner if needed. LN 1 further stated CNAs were supposed to report any concerns or if something is not looking right to the LN staff for follow up. LN 1 also stated catheter care was documented in the resident's electronic medical record (EMR).During an interview in the facility conference room on 2/11/26 at 2:14 p.m., the OT stated she was working on transferring Resident 1 from the bed to his wheelchair. The OT stated she pulled up his pants when he yelled, Ow, that hurts! The OT thought she pulled on Resident 1's catheter tubing, which she observed was not secured to his thigh. The OT stated when she looked at his catheter, she found a large smear of yellowish drainage on his pants as well as the tip of his penis. The OT stated the opening on the penis appeared split and she was surprised no one caught this before me. The OT stated she immediately reported her finding to Resident 1's primary nurse.During an interview in the Director of Nursing (DON) office on 2/11/26 at 3:20 p.m., the DON stated the CNA staff were responsible for catheter care, which included cleaning around the meatus. The DON stated CNAs had catheter care listed on the competency checklist which was completed upon hire and assessed annually. The DON confirmed there was no documented evidence in Resident 1's EMR that CNAs conducted or provided catheter care for Resident 1. During a phone interview on 2/24/26 at 8:41 a.m., the DON stated the facility used catheter leg straps to secure and stabilize the catheter tubing. The DON added the leg straps were available for staff to implement on residents with an indwelling catheter. The DON stated the use of a leg strap did not have a specific location to be documented aside from a nurse's progress note. The DON acknowledged she did not find evidence of the placement or use of a leg strap to secure Resident 1's urinary catheter in Resident 1's EMR. During a phone interview on 2/25/26 at 8:29 a.m., the physician (MD) stated Resident 1 likely had small increments of tearing of his meatus over a period of time but stated, It should have caught someone's attention at some point. The MD further stated she was concerned that the infection was not detected by nursing staff, considering foley care was ordered to be provided every shift. The MD stated an infected wound would begin pus formation, on average, between one or two days following bacterial exposure. The MD confirmed Resident 1's pressure injury to his penis and subsequent UTI did not happen in a matter of hours as it was evidenced by the amount of exudate from the tip of Resident 1's penis and the lack of blood from a new wound.During an interview on 2/25/26 at 12:39 p.m., the DON stated catheter care was validated upon hire and annually thereafter with the Director of Staff Development. A review of facility's policy titled Indwelling Catheter-Insertion, Maintenance, and Discontinued of, dated 8/19/25, did not indicate how catheter care was expected to be completed.A review of the facility's policy titled Indwelling Catheter-Insertion, Maintenance, and Discontinued of dated 8/19/25, indicated, Secure the catheter to the patient's thigh using a securement device or tape.A review of the facility's policy titled Indwelling Catheter dated 8/19/25 indicated, Purpose.To provide safe, appropriate, current guidance for the use of indwelling catheters for clinical use.A review of an undated Centers for Disease Control and Prevention's (CDC- the leading national public health agency in the United States) presentation titled Indwelling Urinary Catheter Insertion and Maintenance indicated, Interventions to Prevent CAUTI [catheter associated UTI].Properly secure catheters to prevent movement and urethral traction.Meatal Cleaning.Assess the patient for any pain or discomfort.Inspect the meatus for redness, irritation and drainage.Assess the catheter where it enters the meatus for encrusted material and drainage.Clean the meatus during daily bathing.Ensure the tubing does not go in and out of the urethra during cleaning.Consider the use of checklists.If the patient must have an indwelling urinary catheter, pay attention to maintenance practices.A review of facility policy titled Pressure Injury Prevention, dated 7/31/24, indicated Implement interventions.monitoring.medical tubes and catheters. Staff will observe for any signs of potential or active pressure injury daily.

Based on interviews and record reviews, the facility failed to ensure a baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was completed timely, for two out of two sampled residents (Resident 1 and Resident 2), when neither BCPs were completed within 48 hours of admission and Resident 1's BCP did not address her Pressure Ulcers (PUs, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for nearly one month after admission.These failures had the potential to result in newly admitted residents receiving unsafe care and put Resident 1 at an increased risk for further skin breakdown and worsening of PUs.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 1/7/2026 with a diagnosis of Dementia (a progressive state of decline in mental abilities) and stage 2 PU (partial-thickness loss of skin, presenting as a shallow open sore on the tailbone) on both sides of their buttocks.A review of Resident 1's BCP indicated Resident 1 was admitted to the facility with stage 2 PU on 1/7/26 but the BCP was not completed until 2/5/26.A review of Resident 2's face sheet indicated an admission date of 2/2/2026 with a diagnosis of Dementia and muscle weakness.A review of Resident 2's BCP indicated Resident 2 was admitted to the facility on [DATE] but the BCP was not completed until 2/5/26.During a concurrent interview and record review on 2/5/26 at 11:17 a.m. with the Director of Nursing (DON), Resident 1's and Resident 2's BCPs, both completed on 2/5/26, were reviewed. The DON stated the facility's policy was to ensure the BCP was completed within 48 hours of admission. The DON confirmed the BCP was important to provide an overview of short term safe and appropriate care and not completing a BCP within 48 hours of admission increased the risk of unsafe care for the newly admitted resident. The DON confirmed neither Resident 1 or Resident 2's BCPs were completed within 48 hours of admission. The DON also confirmed the facility had submitted a Plan of Correction (POC, document submitted by facility detailing how they will fix deficiencies found during an inspection) that indicated the facility would ensure that specifically skin care plans would be developed and implemented within 24 hours of a resident's admission. The DON explained, a skin care plan was to provide guidance for care to prevent skin injury and/or to promote wound healing. The DON stated if there was no skin care plan, the resident could be at risk for skin breakdown and/or wound worsening. The DON confirmed Resident 1's skin care plan/care plan for the PU was not initiated until 2/5/26.A review of the facility's policy and procedure (P&P) titled Person-Centered Care Planning, revised 4/24/25, it indicated .the baseline care plan will be developed and implemented, using the necessary combination of prob specific care plans to promote continuity of care and communication among facility staff, increase resident's safety, and safeguard against adverse events, within 48 [hours] of resident's admission.

Based on observation, interviews and record reviews, the facility failed to ensure professional standards of quality were provided, for one out of two sampled residents (Resident 3), when:1. Resident 3 administered a nebulizer (a machine that turns liquid medication into a fine mist that is inhaled into the lungs through a mouthpiece or mask) treatment herself without physician order or assessment for self-medication administration,2.LN B inaccurately documented in Resident 3's Electronic Medication Administration Record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) polyethylene glycol (a laxative/stool softener use to treat occasional constipation [stool that is hard, dry, or difficult and painful to pass]) had been given.These failures could lead to Resident 3 receiving incorrect dosing of medication, worsening of condition and lead to incorrect treatment decisions.Findings:A review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 11/2025 with a diagnosis Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing).A review of Resident 3's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/20/25, with a score of 12 indicating Resident 3 had moderate cognitive impairment (some memory issues, confusion). A review of Resident 3's EMAR dated 2/5/26 indicated Resident 3 received a 9:00 a.m. dose of:Ipratropium-Albuterol (medications to treat COPD) inhalation solution for shortness of breath (difficult breathing) and wheezing (a high-pitched sound made when breathing is restricted in the lungs), andpolyethylene glycol for constipation.During an interview on 2/5/26 at 9:39 a.m., Resident 3 stated for her 9 a.m. medication administration, she was in her room without staff present and giving herself a nebulizer treatment as she always had done. Resident 3 added, but today she did not finish the nebulizer treatment because when the nurse returned and turned off the nebulizer machine, Resident 3 saw there was still medication left in the nebulizer cup (part of nebulizer machine that holds the liquid medication). Resident 3 also stated she had not received her laxative yet, which would have been mixed with water in a disposable cup. Resident 3 stated she felt the nurse today was in a rush which made Resident 3 feel anxious (a state of worry, nervousness, or unease).During a concurrent observation and interview on 2/5/26 at 9:46 a.m., with Licensed Nurse (LN) B and Resident 3, in Resident 3's room. LN B verified Resident 3 had administered the nebulizer treatment to herself and acknowledged Resident 3 did not have an order to self-administer the nebulizer treatment. LN B explained a physician's order and a self-medication administration assessment, to ensure resident safety, was necessary to be completed before a resident was to self-administer a medication. LN B verified the nebulizer cup removed from Resident 3 still had greater than 1 ml of medication left in it. Resident 3 stated she had not received her polyethylene glycol/laxative yet either. LN B told Resident 3 the polyethylene glycol had been administered this morning. Resident 3 pointed to the trash can on the right side of her bed and said look there, if you really gave it to me, show me the cup where you had mixed the med. LN B checked and verified there was no cup in the trash can and then stated she remembered that she had not given Resident 3 the laxative after all.During a concurrent interview and record review on 2/5/26 at 9:59 a.m., with LN B, Resident 3's EMAR for 2/5/25 was reviewed. LN B verified Resident 3's EMAR dated 2/5/25 showed polyethylene glycol was documented as administered to Resident 3. LN B acknowledged she had not followed the facility policy when she documented giving Resident 3 the polyethylene glycol when she had not actually given it to Resident 3.During a concurrent interview and record review on 2/5/26 at 11:17 a.m., with the Director of Nursing (DON), Resident 3's POS for 2/2025 was reviewed. The DON verified Resident 3 did not have an order to self-administer medications. The DON also verified there was no self-administer medication assessment completed for Resident 3. The DON stated to ensure resident safety, it was the facility's policy that a self-medication administration assessment needed to be completed, and a physician order be obtained prior to allowing residents to self-administer medications. The DON stated it was the facility's policy to document the administration of a medication on the EMAR after it was administered to the resident. The DON stated if a nurse had documented a medication was administered when it was not, it could lead to loss of trust, misleading clinical decisions and could put residents' safety at risk.A review of the facility's policy and procedure (P&P) titled NP80 Medication-Self Administration, revised 7/31/25, the P&P indicated .the LN completes the self-administration of medication assessment which evaluates the resident. a physician's written order is required before a resident begins self-administration.A review of the facility's policy and procedure (P&P) titled NP76 Medication- Administration, revised 6/26/25, the P&P indicated .Right Documentation: immediately document after administration.

Based on interview and record review, the facility failed to implement their abuse policy for one resident (Resident 1) of nine sampled residents when licensed nurses did not document an assessment, a Change of Condition (COC), notification of the incident to the physician (MD), and 72-hour monitoring for Resident 1 immediately after an alleged abuse incident.This failure decreased the facility's potential to ensure Resident 1's needs were met after his involvement in an altercation.Findings:A review of Resident 1's admission record indicated he was admitted in September 2025 with a diagnosis of chronic systolic (congestive) heart failure (CHF - a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), hypertensive heart disease (heart failure due to high blood pressure), and muscle weakness (generalized). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/22/25, indicated Resident 1 had no memory impairment.A review of Resident 1's Health Status Note dated 12/25/25 at 7:49 p.m. written by Licensed Nurse 1 (LN 1) stated Resident 1 was in an altercation with his roommate and he will be on alert charting and monitored for any changes or concerns. In an interview on 1/29/26 at 2:06 p.m., the Director of Nursing (DON) confirmed she was aware of the allegation of abuse that occurred on 12/25/25. The DON stated she expected nurses to have charted a Change of Condition (COC) in the resident's chart, documented when the MD and family were notified, updated the residents' care plan and monitor the residents for 72 hours after the alleged abuse incident. The DON also stated she expected the Social Services Director (SSD) to follow-up with the resident and document what occurred during the conversation.A review of Resident 1's late charted COC which was effective 12/25/25 at 11:34 a.m. but was written on 12/26/25 at 3:37 p.m. by the DON indicated the MD was notified and recommended nursing staff monitor the Resident a day after the incident occurred. In an interview on 2/4/26 at 9:29 a.m., the DON stated, I wrote the note [COC]. I wrote it because I realized it hadn't been done and needed to be [in order] to trigger the alerts.A review of Resident 1's progress notes with effective dates of 12/27/25 and 12/28/25 were all documented between 48-72 hours late on 12/30/25. These notes included behavior monitoring 72 hours after the alleged abuse incident.In a concurrent interview and record review on 1/29/26 at 2:25 p.m., the DON confirmed the 72-hour checks were incomplete and the assessments were not written to the expected standard. The DON also confirmed there were no documented assessments of the residents immediately after the altercation.In an interview on 1/29/26 at 3:20 p.m. the Director of Staff Development (DSD- a person who is responsible for training staff) stated she had trained the nurses to chart assessments, COC, and 72-hour checks immediately after a resident was identified as being a victim of an abuse allegation.A review of the facility's undated Change of Condition lesson plan indicated Licensed Nurses were to document the following: date, time and pertinent details of the incident in the nursing notes, the time and how the Attending physician was contacted and if there were any new orders, the time the family or responsible person was contacted, update the care plan and document each shift for at least 72 hours on the status of the resident.A review of the facility's policy titled Abuse Prevention and Management, revised 5/30/24, indicated, .the resident will be assessed by the licensed nurse for any physical injuries or emotional distress. Notify the physician and provide treatment as ordered. Notify the responsible party of the incident and results of assessment findings.

Based on interview, and facility record review, the facility did not ensure an allegation of verbal abuse involving one resident (Resident 1) was reported to the California Department of Public Health (the Department) within the required timeframe of the incident.This failure delayed the Department from investigating the allegation of abuse to ensure resident safety.Findings:A review of Resident 1's admission record indicated admission to the facility on 9/27/25 with a diagnosis that included, Developmental Delay (occurs when a child reaches milestones in physical, cognitive, communication, social-emotional, or adaptive skills later than typically expected), Rheumatoid Arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the joint lining , causing pain, swelling, stiffness, warmth, fatigue, and potential joint damage), Major Depressive Disorder (a serious mood disorder causing persistent sadness, loss of interest, and impacts how you feel, think, and act), and Anxiety Disorder (mental health conditions marked by excessive, persistent worry and fear about everyday situations, significantly interfering with life). A review of Resident 1's minimum data set (MDS, an assessment tool) dated 12/16/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool that helps determine an individual's memory and orientation) score of 13 (indicates cognitively intact or normal thinking and memory).During an interview on 1/8/26 at 12:17 p.m., Resident 1 stated a Certified Nursing Assistant (CNA) said to her he wanted to clean her vagina. Resident 1 stated it disturbed her that the facility had male CNAs, and she did not feel comfortable having a male CNA clean her and wanted to keep her dignity.During an interview with the Administrator (ADM) and Director of Nursing (DON) on 1/8/26 at 3p.m., the ADM stated Resident 1 reported the event to the Nurse Supervisor the evening of 12/6/25, who then notified her and the DON of the incident. The DON stated she called the incident to the Department the evening of 12/6/25 however, the DON and Administrator were unable to provide documented evidence that the event was reported to CDPH on 12/6/25.A review of SOC 341 (a form used by mandated reporters to document and report allegations of suspected abuse) indicated that CDPH, Ombudsman, and Law enforcement were notified of the alleged abuse on 12/7/25.During a review of the facility's policy titled, Abuse Prevention and Management, revised 5/30/24, indicated, Notification of Outside Agencies for All Allegations of Abuse.The administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on interviews and record reviews, the facility failed to provide services for one resident (Resident 1) when licensed nurses did not provide care for Resident 1's surgical drains (tubes placed in the body after surgery to remove excess blood, pus, or other fluids from a wound or cavity, preventing buildup that could slow healing or cause infections) upon admission to the facility.This failure resulted in Resident 1 having to be readmitted to the hospital for care of a preventable infection.Findings:A review of Resident 1's undated hospital referral form titled [NAME] [Artificial Intelligence Discharge Agent, a software platform used to streamline a patient 's discharge process to skilled nursing facilities] Facesheet indicated Resident 1 had a drain located on the right lateral flank (the side area of the body between the last rib and the hip bone) and another on the right medial upper quadrant (the central part of the upper abdomen) surgically placed on 10/5/25 after surgeons drained a liver abscess (a painful, pus-filled pocket which forms when the immune system walls off an infection which results in a collection of dead white blood cells, germs, and dead tissue).A review of Resident 1's admission record indicated admission to the facility on [DATE] with diagnoses which included abscess of liver, peritoneal abscess (a localized collection of pus and infected fluid within the abdominal cavity (peritoneum) and encounter for change or removal of drains.A review of Resident 1's hospital transfer orders dated 10/8/25, indicated, .Operations/Major Procedures.IR [Interventional Radiology, a medical specialty that uses imaging (i.e. x-ray) to guide minimally invasive procedures] guided drain placement x [times] 2.Drain Management: Per Nursing Protocol.A review of Resident 1's Hospitalist Discharge Summary dated 10/8/25, indicated Hospital Physician 1 (HP 1) provided instructions on how nurses were expected to care for Resident 1's drains, Nursing drain care per IR instructions (flush [to inject a solution into the drain or tube to prevent blockages] both drains with 10 cc [cubic centimeter, a unit of measurement] NS [Normal Saline- is a salt and water solution used to clean wounds] every 8 hours until discontinuation [of drains].Cleared by general surgery to be discharged to skilled nursing facility [SNF, the facility] for.wound/drain management.A review of Resident 1's progress note dated 10/8/25 at 6:08 p.m. indicated, .New admit has 2 JP drains to RUQ [right upper quadrant of abdomen] above other surgical incisions, which require packing.A review of Resident 1's progress note dated 10/8/25 at 6:45 p.m. indicated, [Resident 1] with a diagnosis of hepatic abscess [a pus-filled pocket that forms in the liver caused by an infection which requires prompt treatment to prevent serious complications], currently with two JP [Jackson Pratt, a type of surgical device with a tube and squeezable bulb used to remove fluid from surgical site] drains in place on right side.A review of Resident 1's care plan focused on his intraabdominal abscess initiated on 10/8/25 did not include any mention of Resident 1's surgical drains nor any interventions regarding care of his surgical drains.A review of Resident 1's facility physician's (Attending Physician 3) assessment note dated 10/10/25 indicated, .[Resident 1 is] now status post drain placement for bile [fluid made by the liver to help digest fats] leak and intra-abdominal fluid collection.The patient is being managed for multiple post-surgical complications and chronic conditions. He remains.appropriate for skilled nursing.care. Ongoing monitoring and medical management are required for his abscess.and surgical wounds.Monitor JP drain output and wound healing.A review of Resident 1's progress note dated 10/13/25 at 6:50 p.m. indicated, Resident noted with small drainage from his Uresil [NAME]-Close(R) suction drainage. Notified [physician] and [physician] say [sic] no need for transfer to hospital. Continue to monitor and have tx [treatment] nurse consult with wound doctor.A review of Resident 1's after visit summary from a follow-up visit with the surgeon dated 10/14/25 indicated, Starting today, please flush both of [Resident 1's] drains once a day. To do this, swab the sideport [an opening in a drain that allows for a connection to an additional line or provides an exit point from the side rather than the bottom] with alcohol, attach a saline flush [a pre-filled syringe of normal saline injected through a line to clear it, to prevent blockages and keep the line open], apply the clips so that half of the saline flush goes into the body, and then half goes into the drain. Make sure that the drain bellows [a flexible, ridged tube used to create gentle, constant vacuum to draw blood, pus, or other fluids from surgical sites, preventing buildup and infection] are always maintained compressed.A review of Resident 1's physician's order dated 10/24/25 indicated, Continue to flush both drains daily. Ensure drains are functioning properly.A review of Resident 1's care plan focused on his need for enhanced barrier precautions (an infection control measure to prevent the spread of multidrug-resistant organisms) related to his surgical wound initiated on 10/28/25 indicated the following intervention, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. This care plan did not indicate person-centered care for Resident 1's specific Uresil [NAME]-Close(R) surgical drains.A review of Resident 1's encounter note with the surgical center dated 10/31/25 indicated, [Resident 1] states nursing at SNF have not been flushing drains.Medial drain appears to be clogged with thick exudative [a mass of cells and fluid that has seeped out of blood vessels or an organ] output, bag full of tan exudative output and clearly has not been emptied in several days.Medical assistant was asked to call nursing staff at [the facility] prior to [Resident 1's] arrival to determine the nursing care.[Resident 1] is receiving. When asked what wound care they are providing to the drains, they stated that they changed wound dressing daily and did not outwardly state that they were flushing drains until they were asked about it directly.[Resident 1] states nursing have not been flushing his drains . It is clear that [Resident 1] is not receiving appropriate wound care at [the facility] and despite multiple instructions to flush drains twice daily, this is not being done.The more medial drain on the right upper quadrant appeared to be clogged.Drain bag was nearly full with tan exudative output, indicating that this drain had not been cared for for at least several days.At this point in time, it appears [Resident 1] is not receiving adequate care at [the facility].A review of Resident 1's physician's order dated 10/31/25 indicated, Drain must be flushed twice daily. This is necessary for his drain to function properly. It is clear from his past visits this is not being done. FLUSH DRAIN TWICE DAILY! Change dressings on drain sites and wounds daily.A review of Resident 1's encounter note with the surgical center dated 11/2/25 indicated, .I remain very concerned about the care of this fragile patient. He had a significant closed space infection [a painful infection trapped in a body compartment with unyielding walls] requiring invasive interventions in this hospital after surgery by the on-call surgeon. When I saw him for urgent evaluation a few weeks ago, it was clear that time that his drains were not being flushed which is critical for maintenance of these.drains, despite discharge instructions to his nursing facility saying they needed to be flushed. I wrote very specific instructions on paper which were sent to [the facility] at that time for daily flushing, because an indwelling drain [a soft, flexible tube left inside the body to continuously drain fluids from an area], that is not functioning will just cause increasing pain, allow persistent close space infection, and delay his care.It is extremely disappointing to learn that despite my clear instructions during my visit, that daily nursing care by his nursing facility is not happening. This was a primary intervention for him, and a primary reason for him to remain in the supervised setting.A review of Resident 1's facility progress note dated 11/6/25 at 12:40 p.m. indicated, Resident returned from follow-up appointment; will be sent to hospital dur to intra-abdominal abscess.A review of Resident 1's hospital history and physical dated 11/6/25 at 7:55 p.m. indicated, Assessment & Plan.failure to flush this drain which has been documented repeatedly at [the facility] has resulted in close space infection which is now eroded through his abdominal wall and is freely in communication with an abdominal wound and his previous drain site.This was opened up partially in the clinic today, and I am admitting him for adequate care.A review of Resident 1's facility Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 10/8/25 through 11/6/25 was reviewed on 11/25/25 and indicated no documented evidence Resident 1's drain output measurements were not being monitored by the licensed nurses. During a concurrent interview and record review on 11/25/25 at 3:25 p.m., the Director of Nursing (DON) stated the Administrator (ADM) and the Assistant Director of Nursing (ADON) were responsible for calling the hospital for new admissions to see if their needs could be met at this facility. The DON was asked to review Resident 1's TAR dated October 2025 and was asked why there was no documentation to show Resident 1's drains were being flushed between 10/8/25 and 10/14/25. The DON stated the order from the hospital for drain management indicated per nursing protocol and our facility did not have a nursing protocol for drain management. The DON stated, the nurse called the doctor to get an order for drain management. The DON was asked to provide documented evidence of the nurse's call for drain management orders but was unable to provide any. The DON was also asked if any nurses notified Attending Physician 3 there were no orders for drain management of Resident 1's drains. The DON stated the Attending Physician 3 signed off on the hospital transfer orders which suggested the Attending Physician 3 was aware since she signed the orders. The DON was asked to provide any policies and procedures regarding nursing drain management and care. A policy for titled Jackson Pratt Drain was provided which indicated guidance on nursing care for these specific drains.During an interview on 12/16/25 at 10:58 p.m., the Hospital Physician 1 stated the admitting facility received his Skilled/Intermediate Nursing Facility Transfer Orders and Hospitalist Discharge Summary notes. Hospital Physician 1 stated it was his expectation the facility would follow under item #4 on the Hospitalist Discharge Summary which indicated the instructions for flushing Resident 1's drains (flush both drains with 10cc NS every 8 hours until discontinuation).During an interview on 12/17/25 at 2:48 p.m., the DON stated she was aware Resident 1 was going to be admitted to the facility with drains because she saw the referral sent to the facility by the hospital. The DON stated nurses should be documenting drain output. The DON acknowledged there was no documentation to indicate nurses were monitoring Resident 1's drain output from 10/8/25 to 11/6/25. The DON acknowledged both a JP drain and the type of drain Resident 1 had served the same purpose. The DON also acknowledged a care plan had not been initiated for management of Resident 1's drains. The DON stated nurses had not called the physician to obtain orders for management of Resident 1's drains upon admission.During an interview on 12/18/25 at 9:26 a.m., Hospital Physician 4 stated he expected the facility staff to follow the instructions for flushing the Resident 1's drains. Hospital Physician 4 stated he observed Resident 1's drains were blocked and neglected during Resident 1's follow-up appointments. Hospital Physician 4 stated there were multiple orders to flush Resident 1's drains but it was not being done at the nursing facility. Physician 4 described Resident 1's drain collection bag had an accordion bellow (an accordion-shaped bulb) that needed to be compressed to promote negative pressure to draw out the fluid but clarified that it would not work if the drains were not being flushed.A review of the facility's Facility Assessment, dated August 2025-July2026, indicated, Another core competency is to work together cooperatively, recognizing that the power of our combined efforts exceeds what we can accomplish individually.This is demonstrated when our team of caregivers provides personalized, highly sophisticated health care.Licensed nurses provide skilled services including wound care.clinical assessments.Prior to admit we would do some research into the diagnosis or condition to see if we can meet the person's needs. Things to consider include.staff competency and/or ability to train competency.We would involved our medical director.as needed.Competencies that are necessary to provide the level and types of support and care needed for our residents.Person-centered care- This should include but not be limited to person-centered care planning.Measurements-.recording intake and output.Resident assessment and examinations- admission assessment, skin assessment.A review of a facility policy and procedure titled Jackson Pratt Drain, dated 9/19/19, indicated, To guide licensed nurse in the provision of safe, competent, and ethical care in the procedure of caring for and emptying Jackson Pratt drains.Emptying.Empty contents into measuring container; note amount and appearance of drainage.Fully compress the collection reservoir with one hand, then replace the spout plug with the other hand.Compress the reservoir by squeezing blub flat, replacing plug while compressed.The collection reservoir should remain compressed, if not; repeat procedure and notify physician.Fasten below the level of the wound to promote drainage.Documentation: Appearance of site.Appearance of drainage.Output.Physician notified of any problems.A review of an undated [NAME]-Close(R) patient and nursing information guide indicated, Dual anti-reflux valves prevent liquids and air from backing up into the catheter or wound drain.To ensure continuous flow, attach the bag to the patient gown or bedding below the level of the drainage site.To re-activate the system, compress the bellows. The fluid in the bellows will be discharged into the bag and the suction will be re-established.Although the graduation marks on the bag are approximations only, approximate volumes collected can be recorded on the white 'write-on' area on the bag. When recording these approximations, first empty bellow contents into the bag.

Based on observation, interview, and record review, the facility nursing staff failed to follow professional standards when one licensed nurse gave a dose of one of four sampled residents, Resident 1's, prescription medications to a staff member who was experiencing symptoms of anxiety. This failure resulted in the potential misuse of Resident 1's medication when the nurse, who was entrusted with full access to the medication cart, gave the medication to someone to whom it was not prescribed, and resulted in the loss of a dose of Resident 1's medication when the dose was thrown away.During an observation on 8/6/25 at 9:45 a.m., two medication carts were parked next to the nurses' station. Two security cameras were noted mounted on the ceiling pointed at the nurses' station.During an interview on 8/6/25 at 11:29 a.m., Licensed Staff B stated nurses were not allowed to give medications to staff from the medication cart because the medications belonged to the residents, staff did not have a doctor's order for the medications, and the nurses did not know whether the staff members might have any side effects to the medications.During a phone interview on 8/6/25 at 1:44 p.m., Unlicensed Staff A verified a nurse gave her a medication from the medication cart for anxiety. Unlicensed Staff A stated the nurse was Licensed Staff B. Unlicensed Staff A stated she told Licensed Staff B that she was having anxiety and Licensed Staff B told her, I can give you something for that and Licensed Staff B reached into the medication cart and pulled out a medication. Unlicensed Staff A stated she took the medication from Licensed Staff B and threw it away in the hopper (a sink with a flushing mechanism designed for safe and hygienic disposal of clinical waste like the contents of bedpans) because she did not know what it was going to do to her.During an interview on 8/6/25 at 2 p.m. with Administrator and Assistant Director of Nursing (ADON), Administrator stated that she was sitting in her office watching the security cameras when she saw Licensed Staff B hand Unlicensed Staff A a pill cup at the Station 1 cart. Administrator stated she told ADON what she saw and asked ADON to go investigate. ADON stated she approached Licensed Staff B and Unlicensed Staff A at the medication cart and asked them to explain what was happening. ADON stated Licensed Staff B told her Unlicensed Staff A was not feeling good, so she gave her a dose of propranolol (a prescription medication for high blood pressure, chest pain, and irregular heart beat). ADON stated Licensed Staff B pulled a bubble pack of propranolol out of the medication cart to show ADON what she had given to Unlicensed Staff A. ADON stated she told Licensed Staff B that at no time should she give medications to staff off the cart. Administrator stated Licensed Staff B was written up (disciplinary action) for giving the medication to Unlicensed Staff A.During an interview on 8/6/25 at 2:25 p.m., Licensed Staff B verified she gave propranolol from the medication cart to a staff member who was having anxiety. During an observation and concurrent interview on 8/6/25 at 2:40 p.m., ADON opened the drawer to one of the medication carts at Station 1 and pulled out a bubble pack of propranolol 40 mg (milligrams) tablets labeled for Resident 1. ADON stated the tablet of propranolol that Licensed Staff B gave to Unlicensed Staff A belonged to Resident 1.Review of Resident 1's facesheet indicated an admission date of 11/11/19. Review of Resident 1's physician orders revealed an order dated 11/12/24 for propranolol 40 mg one tablet by mouth three times a day for hypertension (high blood pressure).Review of facility job description LVN (licensed vocational nurse) Staff Nurse, not dated, indicated, Prepares/administers medications as ordered by the physician and within the legal scope of practice.Review of facility policy and procedure Medication - Administration, last revised 1/1/2012, indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner.

Based on interview and record review, the facility failed to develop and implement a fall risk care plan to meet the medical, nursing, mental, and psychosocial needs for one (Resident 1) of three sampled residents. This deficient practice resulted in Resident 1 experiencing injury and pain secondary to an unwitnessed fall on 4/26/25. Findings: A review of Resident 1's, Admission Record, dated 5/7/25, showed Resident 1 was initially admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) affecting the right side, morbid obesity (a complex chronic disease in which you have a body mass index [BMI] of 40 or higher, with normal range for adults considered to be between 18.5 and 24.9), muscle weakness, dementia (a general term for a group of symptoms that affect thinking, memory, and other cognitive [relating to, being, or involving conscious intellectual activity-such as thinking, reasoning, or remembering] abilities. It's not a single disease, but rather a collection of conditions that can damage brain cells, leading to a decline in mental function), dysarthria (a motor speech disorder caused by weakness or lack of control of the muscles involved in speech production), long term use of anticoagulants (medications that stop blood from clotting too easily), and a history of falling. A review of Resident 1 ' s, Minimum Data Set Section C (MDS-a standardized assessment tool used in long-term care facilities to evaluate residents' health status, functional capabilities, and other relevant information), dated 4/7/25, indicated Resident 1 had a BIMS (Brief Interview for Mental Status - used to identify delirium [a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's surroundings] and needed supports in patients living in skilled nursing facilities and long-term care facilities) score of 9, indicating Resident 1 had moderate cognitive impairment (MCI-cognitive deficits that significantly impact daily life. Individuals with moderate MCI experience difficulties with memory, language, judgment, and problem-solving, often requiring assistance with household tasks and finances. They may become confused about where they are or what is happening and struggle with both routine and complex tasks). A review of Resident 1 ' s, MDS - GG, dated 4/7/25, indicated Resident 1 was partially dependent (not completely reliant on others for basic needs like bathing, dressing, or eating, but may need help with some day-to-day activities) on facility staff for self-care, indoor mobility (the ability to move or to be moved. It can describe a person's capacity to walk, move around, or change body position) and functional cognition (how an individual utilizes and integrates his or her thinking and processing skills to accomplish everyday activities in clinical and community living environments), and experienced one-sided impairment of the upper and lower limbs. Resident 1 was reported to be wheelchair dependent. A review of Resident 1 ' s, After Visit Summary, dated 3/31/25, indicated Resident 1 was transferred to the facility after a 13-day acute hospitalization due to pre-syncope (the sensation of feeling like you are about to faint, but without actually losing consciousness), and a fall at home. A review of Resident 1 ' s, Fall Risk Evaluation , dated 3/31/25, indicated due to past fall history, incontinence (involuntary leakage of urine or stool), diseases, recent hospitalization and multiple medications, Resident 1 was a high fall risk. A review of Resident 1 ' s, SBAR (Situation, Background, Assessment, Recommendation- a structured communication framework used in healthcare, particularly nursing, to facilitate clear and concise information sharing about a patient's condition or situation) Communication Form and Progress Note, dated 4/26/25, indicated Resident 1 was heard yelling for help, and was found on the floor of his bedroom. Resident 1 displayed new onset pain evidenced by moaning, groaning and facial grimacing, and was sent out to acute care hospital via 911 ambulance. A review of Resident 1 ' s, After Visit Summary, dated 4/26/25, indicated Resident 1 visited the acute hospital emergency room (AH ER) after falling and was diagnosed with a closed (where the skin is not broken) rib fracture of the left side. A review of fax correspondence from Granada Rehabilitation and Wellness Center to CDPH (California Department of Public Health), dated 4/28/25, reported Resident 1 complained of unrelieved pain one day after returning from AH ER, after administration of ordered lidocaine patch (a medication patch applied to the skin that numbs a specific area of the body, blocking pain signals going to the brain) and Tylenol (generic name acetaminophen- effective for mild to moderate pain, such as headaches, muscle aches, backaches, and toothaches). The facility reported this to Resident 1 ' s physician, who ordered Resident 1 receive a stronger pain medication (Toradol-generic name ketorolac, which treats short-term moderate to severe pain. It works by decreasing swelling) for five days. During a concurrent observation and interview on 5/8/25 at 9:58 a.m., with Resident 1 in his bedroom, Resident 1 was lying in bed on his right side, stating he was in severe pain, while groaning and grimacing. Resident 1 was pointing and grabbing at his left side. Licensed Vocational Nurse 1 (LVN 1) was alerted of Resident 1 ' s condition. LVN 1 responded by assessing and administering ordered pain medication to Resident 1. During a concurrent observation and interview on 5/8/25 at 11:26 a.m. with Resident 1, Resident 1 was still in bed, laying quietly with his CPAP ([continuous positive airway pressure] machine that treats sleep apnea [a potentially serious sleep disorder in which breathing repeatedly stops and starts]. It keeps airways open during sleep and delivers oxygen through a mask). Resident 1 stated he was more comfortable now, and he was trying to rest before lunch, and did not want to talk. During an interview on 5/8/25 at 12:15 p.m., with LVN 1, LVN 1 stated fall risk care plans were usually initiated by nursing management when a resident was first admitted . LVN 1 stated any licensed nurse should initiate a care plan for a new condition, or if a care plan was otherwise needed. LVN 1 stated a nursing care plan was necessary to guide nurses in possible interventions and precautions for actual and potential problems. During an interview on 5/8/25 at 1:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 1 ' s physician had ordered Tramadol (a centrally acting analgesic [pain medication that reduces pain signals to the brain] used to treat moderate to moderately severe pain in adults) to better manage Resident 1 ' s ongoing pain. During a concurrent interview and record review on 5/8/25 at 2:40 p.m., with the Director of Nursing (DON), the DON stated the facility did not initiate a fall risk nursing care plan for Resident 1 prior to his unwitnessed fall on 4/26/25. Review of nursing care plans showed a fall risk care plan for this resident was not developed until 4/28/25. The DON stated this should not have happened, and a nursing care plan was a roadmap, of care interventions for the care and safety of residents of the facility. During a review of facility P & P titled, Fall Management Program, dated 3/13/21, the P & P indicated, As part of the admission assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident ' s care plan .the Interdisciplinary Treatment Team (involves healthcare professionals from various disciplines working together to provide complete care for residents. These teams aim to improve outcomes through collaboration, open communication, and shared decision-making) will initiate, review and update the Resident ' s fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall as needed.

Based on interview, record review, and facility policy review, the facility failed to ensure they referred the resident to the appropriate state-designated authority for a Level II preadmission and resident review (PASARR) when the resident was diagnoses with a new mental illness diagnosis for 1 (Resident #11) of 1 sampled resident reviewed for PASARR. Findings included: A facility policy titled, P-NP04 Pre-Admission Screening Resident Review, revised 09/01/2023, revealed, 5. The facility MDS [Minimum Data Set] Coordinator will be responsible to access and ensure updates to the [PASARR] are completed per MDS guidelines. An Admission Record indicated the facility admitted Resident #11 on 05/05/2011. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction, ataxia, protein-calorie malnutrition, and unspecified mental disorder due to known physiological condition. Per the Admission Record, the resident received a diagnosis of bipolar disorder on 11/20/2015 and schizoaffective disorder on 11/23/2018. Resident #11's medical record revealed no evidence to indicate a PASARR evaluation was completed when the resident received a new mental illness diagnosis of bipolar disorder on 11/20/2015 or schizoaffective disorder on 11/23/2018. During an interview on 07/30/2024 at 12;12 PM, the Social Services Director (SSD) stated she worked at the facility for [AGE] years and never did anything related to a PASARR. Per the SSD, the only PASARR the facility had for Resident #11 was one completed in 2011 when the resident admitted to the facility. During an interview on 07/30/2024 at 2:16 PM, the Director of Nursing (DON) stated the only PASARR the facility had for Resident #11 was dated 05/05/2011. The DON stated she was not aware another PASARR should be completed with a new mental illness diagnosis. The DON stated the PASARRs are done by the Assistant DON, who was not in the facility during the survey. During a follow-up interview on 08/02/2024 at 9:23 AM, the DON stated the facility would do another PASARR in the future for residents with additional mental health issues and submit them to the state. The DON stated this should have been done for Resident #11. During an interview on 08/02/2204 at 10:50 AM, the Administrator stated she expected staff to complete another PASARR with a resident received a new mental illness diagnosis.

Based on interview, record review, and policy review, the facility did not ensure that Resident 1 was free from significant medication error when Resident 1 received [MEDICATION(S)] ER ([MEDICATION(S)] [MEDICATION(S)] extended release), a narcotic medication, on 8/6/2021, which was not ordered by the physician. Resident 1 had an adverse reaction to the medication and required hospitalization in the acute care facility for ten days. Resident 1 was admitted to the intensive care unit (ICU), where she received an intravenous (given into the vein) medication to reverse the effects of the narcotic medication, and an intravenous medication to maintain her blood pressure. Findings: Resident 1 was admitted to the Skilled Nursing Facility on 5/13/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Minimum Data Set (MDS), dated [DATE], indicated Resident 1 had clear speech, was understood when she spoke, and was able to understand when spoken to. Resident 1's Brief Interview for Mental Status (BIMS) indicated a score of 3/15. (The MDS is an assessment tool to determine the functional status, mood, and medical conditions of Nursing Home residents. The BIMS is an assessment tool to determine a resident's attention, orientation, and ability to recall information. A score of 3 out of 15 possible correct answers to questions indicates severe cognitive impairment). During an interview on 8/12/2021 at 10 a.m., the Director of Nurses (DON) stated Resident 1 had tested positive for Covid-19 virus and was in quarantine in the Red Zone of the facility on 8/6/2021. The DON stated Resident 1 received a narcotic medication ordered for Resident 1's roommate, Resident 2. The DON stated the narcotic was administered in the morning but Licensed Nurse A did not realize the error until early afternoon when Resident 1 was confused and lethargic. During an interview on 8/19/2021 at 3 p.m., Licensed Nurse A stated she had not worked with the residents before and had not worked with any resident in a Red Zone of the facility before. Licensed Nurse A stated she did not check Resident 1's identification armband and did not check Resident 1's roommate's identification armband before administering the narcotic to Resident 1. Licensed Nurse A stated she called out the name of Resident 1's roommate (Resident 2) and Resident 1 responded. Licensed Nurse A stated Resident 1's roommate did not respond when Resident 1's roommate's name was called. Licensed Nurse A stated she did not remember if the residents' pictures were available in the Medication Administration Records (MAR). Licensed Nurse A stated she notified the Assistant Director of Nurses (ADON) when she realized she gave Resident 1 a narcotic, [MEDICATION(S)] ER 30 mg, which was ordered for Resident 1's roommate (Resident 2). ([MEDICATION(S)] ER is a brand of long-acting [MEDICATION(S)], intended for management of severe pain. The side effects include respiratory depression and low blood pressure). During an interview on 8/18/2021 at 4 p.m., the DON stated Licensed Nurse A had recently received her Licensed Vocational Nurse license (LVN) but had worked as a Certified Nurse Assistant at the facility while studying to become an LVN. The DON stated the MARs had photos of the residents, and all residents had armbands for identification, but some residents removed their armbands. The DON stated Resident 1 was not be able to identify her own medication but Resident 1's roommate was able to identify her own medication. The DON stated Licensed Nurse A notified the ADON, who notified the DON at 1:45 p.m., that a narcotic had been given to the incorrect resident. The DON stated the expectation was the Licensed Nurse would give the correct medicine at the correct time to the correct resident by the correct route. During a review of documents on 8/12/2021, the census sheet for 8/6/2021, indicated Licensed Nurse A was the Licensed Nurse for Side 1, which had three residents in quarantine, in the Red Zone, due to testing positive for Covid-19 virus and 30 residents in the Yellow Zone, who were negative for the virus. During a review of records on 8/12/2021, Licensed Nurse A's notes indicated a set of vital signs (Blood pressure, pulse, temperature) on Resident 1 at 12:30 p.m., due to increased lethargy and again at 1 p.m. Both sets of vital signs and oxygenation levels were within normal range. The note indicated the physician was notified and gave the order to send Resident 1 to the Emergency Department for further observation. During a review of medical records on 8/12/2021, Resident 1's MAR (Medication Administration Record) did not indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of medical records on 8/12/2021, the MAR for Resident 1's roommate, Resident 2, indicated [MEDICATION(S)] ER 30 mg was administered by Licensed Nurse A at 8 a.m. on 8/6/2021. During a review of documents on 8/12/2021, the document titled, Corrective Action Memo, dated 8/8/2021, by the DON, about Licensed Nurse A, indicated the [MEDICATION(S)] was given out of the correct time parameters for medication administration. The document indicated Licensed Nurse A admitted the medication was removed from inventory at 10 a.m. The MAR for Resident 1's roommate indicated the correct time for administration of [MEDICATION(S)] ER 30 mg was 8 a.m. During a review of the medical records for Resident 1, from the acute care hospital, on 10/14/21, the Emergency Department Report, dated 8/6/21 at 2:23 p.m., indicated .patient was accidentally given a dose of [MEDICATION(S)] 30 mg this morning at 1000. Per EMS, patient was accidentally administered her roommate's dose of long acting [MEDICATION(S)] 30 mg.Patient was provided with [MEDICATION(S)] (medicine that rapidly reverses an opioid overdose). 0.4 mg (milligram) en route prior to arrival. Resident 1 was, somewhat somnolent and confused but was able to communicate with the medical staff, when she arrived at the Emergency Department. Resident 1 became increasingly difficult to arouse and required an intravenous medication, [MEDICATION(S)], to [MEDICATION(S)] the effects of the narcotic medication, and an intravenous medication, [MEDICATION(S)] (medication used to treat life-threatening low blood pressure ([CONDITION(S)])), to maintain her blood pressure. Resident 1 was admitted to the Intensive Care Unit (ICU) at 5:44 p.m. An acute care record titled, History and Physical, dated 8/7/21, revealed Resident 1, had an iatrogenic complication from the wrong medication administration re: [MEDICATION(S)] 30 mg. She developed [CONDITION(S)] (low blood pressure) and obtundation (reduced level of alertness or consciousness) . During a review of facility policies on 8/12/21, the policy titled, Medication Administration, not dated, indicated the Licensed Nurses had to verify the resident's identity before administering medications and also maintain a resident's right to the correct medication, at the right time, in the right amount, and by the right route.

Based on interview and clinical record review, the facility failed to meet professional standards of quality for 1 of 2 sampled residents (Residents 1) when: 1. A licensed nurse did not follow the rights of medication administration (There are eight rights of medication administration, including the right patient, the right medication, the right dose, the right time, the right route .) and gave Resident 1 a medication, [MEDICATION NAME] (used to treat pain and addition to narcotic pain relievers), which was not prescribed to her by a physician and 2. Resident 1's vital signs ((VS) clinical measurements, specifically pulse rate, respiration rate, blood pressure, and temperature, that indicate the state of a resident's essential body functions) were not monitored closely following the administration of the wrong medication. This failure led to Resident 1 requiring hospitalization in the Intensive Care Unit (ICU) due to altered level of consciousness (a disruption in how the brain works that causes a change in behavior), [MEDICAL CONDITION] (rapid heart rate), aspiration pneumonia (inhale of food into your lungs), hypotensive (low blood pressure) ., which led to Resident 1's family decided to withdrawal care, and all medication infusions were stopped, resulting in her death. Findings: 1. A review of Resident 1's Face Sheet, Initial Visit: History and Physical, dated [DATE], and history and physical examination [REDACTED]. It is a group of lung diseases that makes it difficulty breathing), [MEDICAL CONDITION] exacerbation (symptoms flared up) due to right sided pneumonia (an infection that inflames the air sacs in one or both lungs), [MEDICAL CONDITION] (fluttery heartbeat because your blood is not moving well through the heart), high blood pressure, etc. Resident 1 was transferred from the acute care facility for physical deconditioning (Prolonged bed rest and inactivity can cause a decline in function of one's body parts and systems). Resident 1 was receiving physical therapy to regain her strength following her hospitalization . A review of Resident 1's Baseline Care Plan, dated [DATE] and Baseline Assessment, dated [DATE] indicated Resident 1 was alert, oriented to person, place and time, able to make needs known, able to follow simple command and able to understand others. Resident 1's VS were normal. A review of Resident 1's Change of Condition, dated [DATE], indicated Resident 1 was administered the wrong medication, [MEDICATION NAME] 8 milligrams (mg) - 2 mg film on [DATE] at 12 p.m. A review of an Interdisciplinary Team (IDT) Conference Review, dated [DATE], indicated on [DATE] at 12 p.m., Licensed Staff B notified the DON (Director of Nursing) she had administered the wrong medication, [MEDICATION NAME], to Resident 1. The NP (Nurse Practitioner), contracted under Resident 1's physician was in the facility, and was asked to assess Resident 1. The IDT review revealed the NP indicated to both Licensed Staff B and the DON: 1. There should be no concern other than Resident 1 being in a transient (short lived) sedation (state of calm or sleep) and 2. Monitor Resident 1. During an interview on [DATE] at 2:50 p.m., Administrative Staff A stated Resident 1 did get the wrong medication, [MEDICATION NAME], and Licensed Staff B could not explain why she gave Resident 1 [MEDICATION NAME]. Administrative Staff A stated the resident who was supposed to receive [MEDICATION NAME] was in the room next door to Resident 1 and the medication was to be given at 2 p.m., but was given to Resident 1 at 12 p.m. During a concurrent interview and record review on [DATE] at 5::05 p.m., Licensed Staff B stated she did give Resident 1 the wrong medication ([MEDICATION NAME]). Licensed Staff B stated she panicked due to she knew she was late giving Resident 1 her 10 a.m. dose of [MEDICATION NAME] (antifungal medication given to treat yeast infection of the mouth and throat), which was stored in the narcotics drawer and pulled [MEDICATION NAME] from the narcotics drawer without looking at Resident 1's MAR and gave Resident 1 the wrong medication, [MEDICATION NAME]. A review of Disposition of Controlled Drugs: Tabs/Caps Controlled Substances Inventory for [MEDICATION NAME] 8 milligrams (mg) - 2 mg film indicated the medication was to be given to another resident, who was in a neighboring room at 2 p.m. Licensed Staff B stated Resident 1 was up in a chair in her room when she was given the wrong medication, [MEDICATION NAME] at 12 p.m., but at 2 p.m., Resident 1 was placed in her bed because she had become drowsy and wanted to take a nap. During an interview on [DATE] at 4:25 p.m., the DON stated that during her interview with Licensed Staff B, Licensed Staff B explained she did not look at Resident 1's MAR while she was preparing Resident 1's medication. The DON stated Licensed Staff B did not follow Nursing Standards of Practice for administering a medication. Licensed Staff B did not check the medication label against the entry on the MAR, being sure that the name, route, dose, and time matched, which led to her administering the wrong medication, [MEDICATION NAME], to Resident 1. The facility policy/procedure titled, Medication - Administration, revised [DATE], indicated: 1. The Licensed Nurse will verify the resident's identity before administering the medication, 2. Nursing Staff will keep in mind the seven rights of administering medication: The right medication, the right amount, the right resident, the right time, the right route . According to Lippincott's Nursing Center, which referenced the Nursing 2012 Drug Handbook, Lippincott Williams & Wilkins: Philadelphia, PA (2012), there are eight rights of medication administration, including the right patient, the right medication, the right dose, the right time, the right route . (http://www.nursingcenter.com/ncblog/may-,[DATE]-rights-of-medication-administration). 2. During a concurrent interview and record review on [DATE] at 5::05 p.m., Resident 1's clinical record titled, Change of Condition dated [DATE] at 12 p.m., indicated Resident 1's VS at time Licensed Staff B administered the wrong medication, [MEDICATION NAME], to Resident 1 were: blood pressure (BP) ,[DATE] (Normal BP: ,[DATE]), pulse 82 (average for an [AGE] year-old female was 72 beats/minutes (min)), and 18 breaths/min (normal rate at rest is 12 to 18 breathes per min). A review of Residents 1's clinical record titled, Resident Baseline Evaluation, dated [DATE], indicated Resident 1's BP was ,[DATE], pulse 92 beats/min, and respirations were 16 breathes/min. Licensed Staff B stated she had reported giving Resident 1 the wrong medication, [MEDICATION NAME], to the nurse who was assigned to care for Resident 1 on the PM shift (2:,[DATE] p.m.) of [DATE], and explained to her Resident 1 needed to be monitored closely. When Licensed Staff B was asked when the PM nurse should have taken Resident 1's VS, Licensed Staff B stated near the start of the PM Shift, around 4 p.m. A review of Resident 1's MAR, dated [DATE], indicated Resident 1's medications were held at 6 p.m., 8 p.m. and 10 p.m., due to she was somnolent (drowsy). A review of Resident 1's Licensed Nurses Notes, dated [DATE] at 10 p.m., indicated Resident 1's VS were taken at 10 p.m., not 4 p.m. BP was ,[DATE], pulse 60 beats/min, respirations 10 breathes/min and saturation level ((Sat Level) measurement of oxygen in the blood) at room air was 91% (Normal level for a healthy adult on room air is ,[DATE]%). Resident 1 was aroused to verbal stimuli, but quickly fell back to sleep. Resident 1's medications were held for safety due to Resident 1 had difficulty swallowing. There was no other documentation on the PM Shift of [DATE] to indicate she was being monitored or if Resident 1's physician or the NP were notified regarding Resident 1's abnormal respirations of 10 breaths/min and saturation level of 91%. During a concurrent interview and record review on [DATE] at 4:25 p.m. and [DATE] at 1:32 p.m., the DON stated she would have been concerned about Resident 1's abnormal respirations of 10 breathes/min and saturation level of 91%. The DON stated she would have called Resident 1's physician if she was the nurse caring for her, and she would have been checking Resident 1's VS more frequently. The DON stated when a resident had a Change of Condition, the resident's VS were taken at least once a shift (every 8 hours). The DON stated the PM nurse should have made sure Resident 1's VS were taken within the first 2 hours of the PM Shift (by 5 p.m.). During a concurrent interview and record review on [DATE] at 3:30 p.m., the NP stated she entered the facility on [DATE], starting around ,[DATE]:15 p.m., to make rounds on other residents, not Resident 1, when the DON informed her Resident 1 had received the wrong medication, [MEDICATION NAME]. The NP stated she checked on Resident 1. The NP stated when she assessed Resident 1, she was up in her chair watching television and she had just finished lunch. The NP stated Resident 1 was alert and answered questions appropriately. Resident 1's History of Present Illness, dated [DATE], indicated Resident 1 was breathing at room air and was not in any distress. NP stated she told Licensed Staff B to monitor Resident 1 closely. When asked what she meant by monitor resident closely, she stated to her professional standards would be to take VS at least every 4 hours, not every 8 hours. When the NP was asked about Resident 1's VS, on [DATE] at 10 p.m., (BP ,[DATE], pulse 60 beats/min, respirations 10 breathes/min and saturation level 91% on room air), she stated the PM nurse should have called Resident 1's physician due to her abnormal VS, and because Resident 1 was very sedated; the nurses should have been taking Resident 1's VS more often than every 8 hours. The NP stated she had not received a call from a nurse until the following morning ([DATE]) around 6 a.m. about Resident 1's abnormal VS/Sat Level. The NP stated she ordered for Resident 1 to be transferred to the acute care facility right away to be evaluated. The NP stated she had told nursing staff and the DON to monitor Resident 1 closely. During a concurrent interview and record review on [DATE] at 7:26 p.m., Licensed Nurse E stated she was working the Night Shift on [DATE]. Licensed Staff E stated the PM nurse, who gave her report at the change of shift, stated Resident 1 had been given the wrong medication, [MEDICATION NAME], on the AM Shift, but was doing well. Licensed Staff E stated the PM nurse did not inform her of Resident 1's abnormal VS (BP was ,[DATE], pulse 60 beats/min, respirations 10 breathes/min and saturation level at room air was 91%) taken on [DATE] at 10 p.m. Licensed Staff E stated she could not understand why Resident 1's physician was not notified about the abnormal VS or why Resident 1's VS were taken so late on the PM Shift (10 p.m.). Licensed Staff E stated if she had been made aware of Resident 1's VS, she would have called her physician right away. Licensed Staff E stated she checked on Resident 1 twice during the Night Shift, the first time Resident 1 appeared asleep. Licensed Staff E stated she did not take Resident 1's VS at that time. Licensed Staff E stated if she had been told to monitor Resident 1 closely, she would have taken her VS every 2 hours, but the PM nurse did not inform her Resident 1 needed to be monitored closely. There was no documentation indicating Licensed Staff E and CNAs were monitoring Resident 1 after 10 p.m. on [DATE] until [DATE] at 5:58 a.m. Licensed Staff E stated when she went to pass her early morning medications on [DATE], she checked on Resident 1 for the second time and noticed she had a brown substance (like pudding) on the side of her mouth, she was not responding, she was struggling for air and Resident 1's VS were abnormal. A review of Resident 1's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated [DATE] at 5:58 a.m., indicated Resident 1's VS were: BP ,[DATE], pulse ranged from 64 to 166 beats/min, respiration 10 breathes/min, Sat Level was 89% on room air, and she had signs of aspiration (inhaling of food into the airway). Licensed Staff E had notified the NP, who ordered Resident 1 to be sent to the acute care facility's ED (Emergency Department) for evaluation. Resident 1 was placed on 2 Liters of O2 (oxygen) and Sat Level was 97%. According to Lexidrugs. [MEDICATION NAME] U.S. Brand Name for Buprenorphine and Naloxene. https://online.lexi.com/lco/action/search?q=[MEDICATION NAME]&t=name&va=subox. Accessed [DATE], 1. Special populations: Elderly: Use with caution in elderly patients; may be more sensitive to adverse effects (e.g., life-threatening respiratory depression), 2. Disease-related concerns: Respiratory disease: Use with caution and monitor for respiratory depression in patients with significant [MEDICAL CONDITION], 3. Other side effects include severe dizziness, passing out, difficulty breathing, slow breathing, shallow breathing, severe fatigue, change in balance, slow movements, difficulty focusing . The facility job description titled, Charge Nurse, undated, indicated: A licensed professional nurse was directly under the supervision of the DON. The Charge Nurse is responsible for staff assignment and provides overall supervision of resident care activities. General Duties and responsibilities include: 1. Prepare and administer medications as ordered by the physician, 2. Chart licensed nurses' notes in an informative and descriptive manner that reflects the care provides as well as the resident's response to the care, 3. Verify the identification of the resident before administering medication or treatment . A review of Resident 1's Emergency Department (ED) Summary Report, triaged dated [DATE] at 6:25 a.m., ED Report, dated [DATE], and History and Physical, dated [DATE], indicated when the Emergency Medical Care (EMC) arrived at the facility, they were informed Resident 1 had been given [MEDICATION NAME] by mistake on [DATE] at approximately 2 p.m., EMS observed a dried substance with the appearance of dried blood on Resident 1's lips and was informed the substance was pudding. Resident 1 was noted to open her eyes in response to voice, but no verbal response was noted, and her O2 Sat Level on 2 Liters O2 was 88% on the way to the ED. Resident 1 arrived at the acute care facility ED on [DATE] at 6:13 a.m. by ambulance. Resident 1's VS on [DATE] at 6:25 a.m. were: BP ,[DATE], pulse 165, respirations 24, and O2 Sat Level on 15 Liters per non-rebreather mask (a device used to assist in delivering a higher concentration of oxygen) was 93 %. Resident 1 would open her eyes to speech, but verbal response was incomprehensible and she had an altered mental status. Resident 1 was admitted to the ICU (Intensive Care Unit) on [DATE] at 8:40 a.m. Resident 1's EKG (electrocardiogram is a test that measures the electrical activity of the heartbeat) indicated Resident 1 had [MEDICAL CONDITION] ventricular (irregular heart beat) with [MEDICAL CONDITION](rapid heartbeat), her chest X-ray indicated she had a right lung pneumonia (infection in the air sacs of the lungs), and abnormal lung sounds. A review of Resident 1's Cardiology Consultation, dated [DATE] and Intensivist Progress Note, dated [DATE], indicated Resident 1 had a pneumonia due to inhalation of food and vomit, acute on chronic congested heart failure (acute means sudden heart failure: is the inability of the heart to pump enough blood to serve the body's needs with symptoms that include shortness of breath), altered mental status, [DIAGNOSES REDACTED] (heart's mitral valve does not close tightly, which allows blood to flow backward into the heart) upon admission to the acute care facility. A review of Shift Event Report, dated [DATE] at 2:30 p.m., indicated Resident 1 continued to be non-responsive to treatments, as evidence by continued hemodynamic (related to the flow of blood within the organs and tissues of the body) instability with cardiac support by intravenous (administered into the vein) [MEDICATION NAME] (medication given to treat low blood pressure and heart rate), [MEDICATION NAME] (medication given to increase blood pressure) and [MEDICATION NAME] (given to treat low blood pressure, [MEDICAL CONDITION],,,). Following a meeting between the physician and Resident 1's family (in person), the family decided to withdrawal care and all medication infusions were stopped. With Resident 1's family by her bedside on [DATE] at 2:30 p.m., Resident 1 expired and physician called time of death in the presence of Resident 1's family. A review of the Controlled Document (Coroner's Report), dated [DATE], indicated after the Deputy Coroner reviewed Resident 1's medical records from the care facility and the acute care facility and talked to the Physician, the Deputy Coroner determined Resident 1's causes of death as follows: Asystolic [MEDICAL CONDITION] (the heart stopped beating), Cardiogenic Shock (the heart cannot pump enough blood to meet the body's needs), Septic Shock (A widespread infection causing organ failure and dangerously low blood pressure), and Right Lung Pneumonia due to Resident 1 was accidentally administered the wrong medication, [MEDICATION NAME], which caused her death. The report revealed these [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to provide adequate care and/or services to prevent a pressure ulcer (wound that occurs as a result of prolonged pressure on a specific area of the body. This usually occurs when individuals stay in one position for a long period of time. Commonly known as bed sore.) from developing for one of five sampled residents (Resident 82) when: 1) nursing staff did not follow the facility's weekly skin checks to assess Resident 82's skin; 2) nursing staff did not assist Resident 82 in changing her wet undergarment/clothing in a timely manner; 3) facility staff did not specify pressure redistributing devices (work by reducing or redistributing pressure, friction or shear forces; devices include high-specification mattresses, pressure redistribution cushions .) and 4) facility staff did not follow the professional standard of practice, which the facility used to stage the pressure ulcer. These failures resulted in Resident 82 developing a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) in the coccyx/sacrum (located below the sacrum is the tail end of your spine, called the coccyx or tailbone) area. These failures also resulted in the potential for further worsening of the pressure ulcer. Findings: Resident 82's face sheet (admission record), indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/20/17, indicated Resident 82's BIMS (brief interview for mental status) score was 15, which indicated Resident 82 was cognitively intact (intellectual activity: such as thinking, reasoning, or remembering). The MDS revealed Resident 82's weight was 103 pounds with a height 63 inches. The MDS indicated Resident 82 required extensive assistance with one person assist for activities of daily living including bed mobility, toilet use, personal hygiene and bathing. The treatment nurses notes, dated 12/13/17, at 1 p.m., revealed Resident 82 had a blanchable redness area in the coccyx and sacrum area. Resident 82's skin care plan initiated on 12/13/17, indicated Resident 82 was at risk for skin break or ulcer formation related to multiple problems including impaired mobility, incontinence (lack of control over urination or bowel movement), [MEDICAL CONDITION] (condition in which you do not have enough healthy red blood cells to carry adequate oxygen to the body's tissues), and thin and fragile skin. The approaches included providing pressure redistributing devices (device used to prevent pressure ulcer) and assess for effectiveness and cleaning resident's skin after each episode of incontinence. The care plan did not specify what kind of pressure redistributing devices or when to provide the device, nor did address how to evaluate the effectiveness. During a concurrent observation and interview on 1/30/18, at 9:17 a.m., Resident 82 was in bed and awake. Resident 82 stated she often wet herself with urine before she could press the call light for assistance because she could not control her bladder. Resident 82 stated sometimes she had to wait for a long time but did not know exactly how long. Resident 82 stated she had to wait and sit on the wet undergarment/clothing (wet with urine) that made her feel wet and cold. Resident 82 also stated the staff did not like it when Resident 82 wet the undergarment/clothing. Resident 82 stated the staff said something liked why don't you call earlier, why don't you call before you go. Resident 82 stated sometimes the staff said something more, but she could not hear them. Resident 82 stated they (staff) looked and sounded mad and they don't like it. Resident 82 stated the staff's responses made Resident 82 feel bad. Resident 82's Treatment Administration Record, dated (MONTH) (YEAR), indicated weekly skin checks, which were scheduled on 12/13/17, 12/20/17, and 12/27/17. The skin checks under 12/20/17 was blank with no staff initial for the skin assessment. The treatment administration record did not indicate a skin check performed for two weeks, from 12/14/17 to 12/26/17. The treatment administration record also indicated a treatment Apply barrier cream to coccyx/sacrum reddened area every day and as needed for 14 days from 12/13/17-12/27/17. The treatment under 12/20/17 was blank with no staff initial for the treatment. The Treatment Nurses Notes, dated 12/28/17, at 2:45 p.m., indicated Resident 82 had Full thickness tissue loss, based of ulcer covered (with) 90% slough (dead tissue) to sacrum/coccyx noted measuring 2.5 cm x 1.7 cm x 0.2 cm (2.5 centimeter length x 1.7 centimeter width x 0.2 centimeter depth), scant serous (watery clear) drainage. Requested Santyl (ointment for treating ulcers) for UTD (unstageable, full thickness tissue loss covered by slough) wound (and) LAL mattress (Low Air Loss Mattress, which has tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float) from (physician) . The weekly pressure ulcer progress report indicated an UTD pressure ulcer from 12/28/17 with size 2.5 cm x 1.7 cm x 0.2 cm and 90% slough to 1/30/18 with size 2.5 cm x 0.8 cm x 0.4 cm and 20% slough/80% granular. The report also indicated the UTD pressure ulcer had 20% slough/80% granular continuously for three assessments on 1/17/18, 1/22/18, and 1/30/18. During a concurrent record review and interview on 2/2/18, at 9:25 a.m., Licensed Staff J (who was a treatment nurse) stated Resident 82's pressure ulcer in the coccyx/sacrum area was at least stage III. Licensed Staff J stated she wrote UTD because the pressure ulcer started with UTD covered with slough. Licensed Staff J stated she kept documenting it as UTD because if they documented stage III, they could not change it to stage II if it were down to stage II (partial thickness loss of dermis without slough). Licensed Staff J stated the treatment nurse described the pressure ulcer, the doctor diagnosed with [REDACTED]. Licensed Staff J stated staff should change the resident right away. When reviewed the treatment sheet where staff did not initial or sign for weekly skin assessment, Licensed Staff J stated she did not know if they did the skin assessment. During an interview after the observation for dressing change on 2/2/18, at 10:03 a.m., Licensed Staff J stated Resident 82's pressure ulcer in the coccyx/sacrum area had approximately 10% slough in the bottom of the wound, other area was granular. Licensed Staff J stated the pressure ulcer was stage III because of full thickness tissue loss and having granular tissue. Licensed Staff J reviewed the skin care plan dated 12/13/17 and stated the care plan did not specify pressure redistributing devices. Licensed Staff J stated the LAL mattress was provided after she noticed the pressure ulcer on 12/28/17. Licensed Staff J stated Resident 82 had a Roho cushion for the wheelchair (cushion in the wheelchair provides skin protection and positioning) but did not know when the cushion was started. During an interview on 2/2/18, at 10:55 a.m., Physician K stated she did not examine Resident 82's wound in the coccyx at all. Physician K stated the treatment nurse usually staged the pressure ulcer because the treatment nurse had more experience with the wound. Physician K stated it was not necessary for the doctor to diagnose/stage the pressure ulcer. Physician K stated she gave the treatment order when the treatment nurse notified Physician K of the pressure ulcer information. When mentioned that the wound had full thickness tissue loss with some slough, or the nurse described as 20% slough and 80% granular, Physician K stated the pressure ulcer was stage III. During a concurrent interview and record review on 2/2/18, at 11:34 a.m., the DON (director of nursing) reviewed the skin care plan initiated on 12/13/17 and stated the skin care plan did not specify pressure redistributing devices. The DON stated air mattress could be one redistributing device, but it was not provided until the pressure ulcer was developed. The DON stated Resident 82 had a Roho cushion in the wheelchair but the Roho cushion did not help much on the pressure ulcer because Resident 82 was sitting on it. The DON stated because Resident 82 was bony so put the Roho cushion to prevent pressure ulcer on other areas. When mentioned about long wait time for the call light answering and Resident 82 sitting on her wet undergarment/clothing with urine for a long time, the DON stated staff should assist the resident when the call light was on. The DON stated sitting in the urine could cause skin breakdown. The pressure ulcer staging guide by the National Pressure Ulcer Advisory Panel, dated 2007, which was used by the facility, indicated stage III pressure ulcer involved full thickness tissue loss. Subcutaneous fat (fatty tissue lying directly under the skin layers) may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Un-stageable involved full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Stage II involved partial thickness loss of dermis without slough. Upon request for policy and procedure regarding pressure ulcer, the facility provided a policy and procedure titled Pressure Injury Management - Fundamentals, revised (MONTH) (YEAR), indicated the cause of pressure injury included bony prominences (sticks out or protrudes) with high risk area coccyx/sacrum and maceration (when skin remains moist from sweat, urine and feces it becomes irritated and reddened and susceptible to breakdown). Contributing factors include but not limited to underweight, [MEDICAL CONDITION], and chronic incontinence. Preventive Equipment include but not limited to pressure reducing/relieving mattress, pressure relieving cushions when in chair, pillows and wedges.

Based on interview and record review, the facility failed to ensure resident safety when staff did not implement adequate supervision and assistance for one unsampled resident (Resident 236) who had poor safety awareness and a history of falls. This failure contributed to Resident 236 falling and needing to be transferred to the Emergency Department (ED) because she refractured her left hip. Findings: Review of Resident 236's, Consultation Report, dated 11/8/17, History and Physical Report, dated 11/8/17, and Operative Report, dated 11/9/17 (all from the acute care facility), indicated Resident 236 used a wheelchair most of the time, had thought the chair was behind her while doing a yoga class, causing her to miss the chair, landing on her buttocks, which resulted in a left [MEDICAL CONDITION] and a left hip repair on 11/9/17. Resident 236 had other [DIAGNOSES REDACTED]. Review of Resident 236's, Transfer Summary, from the acute care facility, dated 11/13/17, indicated Resident 236's hearing was fair, she needed a walker (an assistive device, which helped with stability to help prevent loss of balance and falls) when walking, and she was at risk for falls. Review of Resident 236's, Admission Face Sheet, dated 11/13/17, indicated Resident 236's [DIAGNOSES REDACTED]. Review of, Plan of Care - Physical Therapy, dated 11/14/17, indicated Resident 236 had decreased wheelchair mobility, decreased safety awareness, and impaired balance and walking. Falls: Fall 1 Review of, Skilled Nurses Notes, dated 11/19 through 11/20/17, indicated Resident 236 was confused (not being able to think clearly or quickly, feeling disorientated, and struggling to pay attention, make decisions or remember things) periodically. The, Skilled Nurses Notes, dated nights, 11/20/17, indicated Resident 236 had an unwitnessed fall due to she refused to use the call light, got up to use the bedside commode (portable bedside toilet) on her own, and when trying to transfer herself back to bed, had told the nurse she slipped and ended up falling on her buttocks. Resident 236's, Therapy Post Fall Screen, dated 11/20/17, and Interdisciplinary Team (IDT: person-centered team of people who help to make decisions regarding a resident's plan of care) Conference Record, dated 11/20/17, and a request to Resident 236's physician, dated 11/20/17, indicated Resident 236 had fallen on 11/20/17 at 12:45 a.m., because she was confused about remembering to use her call light at night and did not remember to wait for assistance to use the commode. There was a request for Resident 236's physician to order a speech evaluation and treat for cognitive decline, which the physician approved. There was no indication of Resident 236 being monitored more closely due to her increased cognitive decline. Resident 236's room was located at the very end of the hall, furthest room away from the nurses' station. Resident 236's commode remained next to her bedside, and she continued to get up to the commode without assistance. Review of, Resident/Family/Responsible Party Educational Assessment, dated 11/20/18, Resident/Family/Responsible Party Interdisciplinary Teaching Flow Sheet, dated 11/20/17, and, Licensed Nurses Notes, dated 11/20/17, indicated Resident 236 had intermittent confusion, was impulsive, very confused about how to use the call light, got tangled up in the call light while in bed, had to be re-educated by the night staff often, did not think she needed assistance, and for safety, Resident 236 needed to wait for staff to be transferred to the commode. Resident 236's, Resident Care Plan for falls, dated 11/15/17, indicated she was at risk for falls, had an actual fall, limited mobility, poor balance, and needed glasses due to vision deficit. Fall risk interventions included orienting her to the environment each time changes were made, keep call light within reach, keep bed in low position, remind her to wear glasses, and encourage use of assistive device (wheelchair and bedside commode) with assistance. Resident Care Plan for visual impairment, dated 11/15/17, indicated Resident 236 had poor vision due to [MEDICAL CONDITION], could only see large print, and needed glasses. Review of Resident 236's, Resident Care Plan, for falls, dated 11/20/17, indicated Resident 236 had mild intermittent confusion since admission (11/13/17), had unsteady gait, forgot to call/wait for assistance for transfer, engaged in independent transfer/walking despite explanation of risk, and had a history of [REDACTED]. There was no documentation regarding a staff member offering Resident 236 the bedpan or taking her to the bathroom every hour. During a concurrent interview and record review on 1/31/18 at 11:30 a.m., the Director of Nursing (DON) stated Resident 236 was confused, overestimated her own abilities, and that was the reason why her family member stated she could not take Resident 236 home, not safe, not cooperative. When asked if Resident 236's family was notified of Resident 236's fall, which occurred on 11/20/17, the DON said, No, because Resident 236 was her own responsible party. The DON stated the facility would not call a family member if the resident was his/her own responsible party. The DON stated Resident 236 had the capacity to make her own decisions. Review of Resident 236's, Resident Care Plan for noncompliance, dated 11/20/17, indicated offering assistance for all transfers. Resident 236's, Licensed Nurses Notes, dated 11/20/17 at 8 a.m., indicated the night shift made rounds on residents every two hours. The facility indicated Resident 236 was her own responsible party. There was no indication how staff was going to ensure Resident 236, who was confused, did not get up on her own to use the commode, which was still located near Resident 236's bed, but now positioned at the foot of her bed. Resident 236's Admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 11/20/17, indicated Resident 236's BIM (Brief Interview of Mental Status) was 9 (moderately cognitively impaired), and she needed one-person physical assistance with walking, dressing, toilet use and personal hygiene. During an interview on 11/27/17 at 11:50 A.M., Physical Therapist L stated she worked with Resident 236 in the rehabilitation room; was very familiar with Resident 236's ability to walk and transfer. Physical Therapist L stated Resident 236 needed moderate assistance and she should not have been up on her own. Physical Therapist L stated when Resident 236 first started physical therapy on 11/14/17, she could follow directions well, but before the two falls (11/20/17 and 11/21/17) she was becoming more confused. Physical Therapist L stated Resident 236 was not full weight bearing (amount of weight a person puts on the leg where surgery has been performed), she needed cueing, and walked approximately 10 feet using the walker with assistance. Physical Therapist L stated Resident 236 should not have been up on her own because she was unsteady and was becoming more confused. Physical Therapist L stated Resident 236 would often try to transfer herself without assistance because her commode was near her bedside. Physical Therapist L said, Maybe if the staff had removed the commode from her room, she would not have tried to transfer herself on her own. Fall 2 Review of Resident 236's, Fall Risk Evaluation, dated 11/16/17, indicated she had a score of 8, and on 11/20/17, her score was 19. A total score of 10 or higher indicated Resident 236 was at, High Risk for potential falls. Review of, IDT Conference Record, SBAR Communication Form (Situation, Background, Appearance, and Review), Post Fall Assessment, and Licensed Nurses Notes, dated 11/21/17, indicated: 1. On 11/21/17 at 6:20 a.m. Resident 236 had tried to get up on her own due to the urgency to urinate and had an unwitnessed fall. Resident 236's CNA (Certified Nursing Assistant) had just left her room when the fall occurred, and Resident 236 still would not remember to use the call light and wait for assistance; 2. Resident 236 was transferred to the ED because her left lower extremity was rotated inward slightly and her ankle was slightly swollen; and 3. Resident 236 was admitted to the acute care facility because she had refractured her left hip. Of note, Resident 236's lab work, dated Tuesday, 11/21/17 at 6:54 a.m., indicated her level of sodium in the blood was abnormally low, 119 mEq/L (Normal range is 132-141 milliequivalents per liter). Sodium is an electrolyte that helps maintain a normal blood pressure. Signs and symptoms of low sodium included confusion. During an interview on 1/31/18 at 11:30 a.m., the DON stated Resident 236 did not have a bed alarm, and her bed was in a low position. The DON stated Resident 236 fell near the commode both times trying to transfer herself either to the commode or back to bed; both unwitnessed. The DON stated Resident 236 needed assistance to the commode even if it was next to the bed, and the bedside commode had not been removed from the bedside yet because the physical therapist (PT) had not completed her evaluation. When the DON was asked, due to the safety of having a commode positioned at her bedside and her frequently attempting to transfer herself to the commode and back to bed unassisted, was the nurse able to reevaluate/reassess and care plan for new approaches, she stated the nurse did care plan for new approaches, such as taking Resident 236 to the bathroom or offering her the bedpan every hour, but according to the DON, the commode was still next to Resident 236's bedside, and Resident 236 was still transferring herself to the commode unassisted. During an interview on 12/26/17 at 3:55 p.m., Confidential X stated she would stay at the facility with Resident 236 all day, up until 10-11 p.m., but was concerned due to the facility not taking fall precautions with Resident 236. Confidential X stated Resident 236's bed was not in a low position, there was no drop pad, and no bed alarm. Confidential X stated Resident 236 would try to use the call light to call for assistance, but often would get the bed controls confused with the call light. Confidential X stated a staff member had informed her after Resident 236's second fall, Resident 236 had fallen a couple of times prior while trying to transfer herself to the commode/bathroom, but no one had informed Confidential X about the previous falls. Confidential X stated if she had been made aware of Resident 236's previous falls, she would have made arrangements for someone to be with Resident 236, 24 hours a day, seven days a week. Confidential X stated Resident 236 was admitted to the acute care facility for one week after falling the second time, due to refracturing her left hip and an abnormal sodium level. Confidential X stated Resident 236 spent two weeks at the acute care facility's rehabilitation unit for strengthening therapy for the left [MEDICAL CONDITION]. During an interview on 2/01/18 at 4:32 p.m., Unlicensed Staff C stated Resident 236 was alert, but had to be reminded often to use the call light; she was not steady and needed assistance to the commode. Unlicensed Staff C stated on 11/21/17, the morning of the second fall, the commode was moved, but to the foot of the bed where Resident 236 was found on the floor. Unlicensed Staff C stated she made rounds every two hours, but for Resident 236 she was told to make rounds every hour. Unlicensed Staff C stated nothing was recorded to show rounds were made on Resident 236 every hour or care planned for hourly rounds. Unlicensed Staff C stated on previous days she would sit down by Resident 236's room at times because her room was the furthest room from the nurses' station; the very end of the hallway. Unlicensed Staff C stated Resident 236 wore pull-ups, did not have a bed alarm or drop pad, but Resident 236's bed was in a low position. Unlicensed Staff C stated Resident 236 refused the bedpan, and transferring Resident 236 to the bathroom was difficult because she needed to be transferred by way of a wheelchair because she was non-weight bearing. Unlicensed Staff C stated on nights she usually was assigned to tend to 21-22 residents. The facility policy/procedure titled, Fall Management Program, revised 11/7/16, indicated: 1. The Licensed Nurse will notify the resident's Attending Physician and responsible party of the fall incident, 2. A resident who sustains multiple falls as defined as more than one fall in a day, week or month, will be considered a high risk to fall and as a result may sustain a major injury, 3. These residents may be identified by a special logo or designation to alert staff to their high risk activity

Based on interview and record review the facility failed to follow nursing professional standards of practice and facility policy when licensed nursing staff withheld the necessary care and services by failing to notify the physician in a timely manner of significant changes of condition on 4/27/16 for Resident 1. Resident 1 required transfer to the emergency room of the local hospital shortly after midnight, on 4/28/16, with agonal breathing (shallow breathing pattern that is often related to [MEDICAL CONDITION] and death), and severe dehydration. Her admission [DIAGNOSES REDACTED]. to infection injures its own tissues and organs). Resident 1 was intubated (a tube inserted into the windpipe), placed on mechanical ventilation, and admitted to the Intensive Care Unit (ICU). Findings: Resident 1's demographic facesheet, dated 4/19/16, indicated she was readmitted to the facility on [DATE] following a hospital stay with [DIAGNOSES REDACTED]. The National Pressure Ulcer Advisory Panel), urinary tract infection, traumatic hemothorax (a collection of blood in the space between the chest wall and the lung, which required 3 chest tubes to drain), acute kidney failure, poorly controlled diabetes and a [MEDICAL CONDITION] following a [MEDICAL CONDITION]. The Stage 4 pressure ulcer was infected with Vancomyocin Resistant [MEDICATION NAME] (VRE). [MEDICATION NAME], a bacteria, can resist and evade several forms of antibiotic therapy, including [MEDICATION NAME], the antibiotic of last resort for resistant infections .[MEDICATION NAME] infections that result in human disease can be fatal, particularly those caused by strains of [MEDICATION NAME]-resistant [MEDICATION NAME] (http://www.niaid.nih.gov/topics/antimicrobialResistance/Examples/vre/Pages/overview.aspx) Physician admission orders [REDACTED]. (A full code means a person will allow all interventions needed to get their heart started. This may include chest compressions and defibrillation to shock the heart out of a life-threatening heart rhythm. Placing a breathing tube in the airway to assist with ventilation and medications to treat the heart are all resuscitation interventions. Not all patients require each step. But if a patient is a full code, it means they are willing to allow any of the above measures. Source: Medical Students Guide to Understanding Code Status, October 2014.) A fax, dated 4/27/16, with no time or date stamp indicating it was sent, from the Registered Dietician to the attending physician, noted that Resident 1 lost 8.6 pounds in one week and the current average intake by mouth was 15% of meals and 95 milliliters (ml) of fluid over the last 21 meals (7 days). Long-term care residents, for example, eat far from 100% of their meals, whereas almost 80% of the total daily fluid comes from fluid intake associated with meals. Patients consuming less than 50% of their meals are at high risk for dehydration. (http://www.medscape.com/viewarticle/ 8_6) Nurses notes, dated 4/27/16 at 4:30 p.m., indicated that while working with physical therapy Resident 1's body became rigid and her eyes rolled back into her head and then Resident 1 vomited approximately 2 cups of brownish-yellow fluid. The vomit was suctioned from the mouth and the oxygen was turned up to 3 liters (L) due a blood oxygen level of 87% (normal is 97 to 100%), this was reported to the Director of Nurses (DON). Nurses notes, dated 4/27/16 at 11:15 p.m. indicated: R (Resident 1) unable to speak, seemed lethargic and not responding at first. Continued to talk to R (Resident 1), she would open her eyes, but not talk. Eventually she started moving her tongue and mouth as if trying to say something. O2 (oxygen) at 88 to 89% via NC (nasal cannula) at 3 LPM (liters per minute) at 8:30 p.m .low grade fever of 99.6 (degrees Fahrenheit). Checked on at 10 p.m., sleeping without shortness of breath, O2 went up to 93% on 3L (liters). Repositioned every 2 hours as needed. Foley (catheter into the bladder) draining amber color urine. Severe dehydration can produce urine the color of amber. (http://www.mayoclinic.org/diseases-conditions/urine-color/basics/symptoms). Intake and urine output was not recorded for 4/27/16 on the Intake and Output record. Nurses notes, dated 4/27/16 at 11:30 p.m., indicated that at the beginning of the 10:30 p.m. to 6:30 a.m. shift a Certified Nursing Assistant (CNA) reported to the nurse that Resident 1 was not responsive. Vital signs noted were: temperature of 101.8 degrees Fahrenheit (normal 97.8 - 99.1 degrees Fahrenheit ), Pulse 118 (normal 60 - 80 ), Respirations 26 (normal 12 - 18), blood pressure of 88/50 and oxygen level 85% on 3 L of oxygen with minimal response to painful stimulus (used to check level of consciousness). The Physician was notified and received orders to transfer to the hospital as an emergency for [MEDICAL CONDITION]. Often, older people are unable to create a higher temperature with infection so very low temperatures and checking the other vital signs plays an important role in following these people for signs of infection. (http://nursinglink.monster.com/training/articles/944-vital-signs-overview-and-effect-of-aging-changes) Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. To be diagnosed with [REDACTED]. [DIAGNOSES REDACTED]. (http://www.mayoclinic.org/diseases-conditions/sepsis/home/ovc- 784) During an interview, on 5/4/16 at 9:30 a.m., Physical Therapy Assistant (PTA) A stated that on 4/27/16 at around 4:30 p.m., Resident 1 had agreed to try to sit on the edge of the bed. When PTA A rolled Resident 1 to one side, Resident 1 stated in a garbled voice, I don't feel so good, and then became rigid and stiff all over and her eyes rolled up in her head. PTA A stated Resident 1 began to vomit, so PTA A called for help and a CNA and Licensed Nurse (LN) B came into the room and took over. During an interview, on 5/3/16 at 5:10 p.m., Licensed Nurse B (LN B) who was assigned to Resident 1 from 2:30 p.m. to 7 p.m. on 4/27/16, stated a CNA reported that Resident 1 went rigid and her eyes rolled back in her head and then started to vomit. LN B stated she suctioned Resident 1's mouth and checked oxygen levels frequently. LN B stated she was concerned that Resident 1 might have aspiration pneumonia (occurs when food, drink, vomit or saliva is inhaled into the lungs) after the vomiting episode. When asked if the physician had been notified of this change in condition, LN B stated No, I did not notify the physician, but in hindsight I guess I should have. I kept checking her oxygen levels and I told the DON. During an interview, on 5/4/16 at 5 p.m., DON stated LN B was instructed to call the physician and report the change in Resident 1's condition, and LN B was told not to send a Fax, but actually call the physician and report the changes. During an interview, on 5/4/16 at 2:50 p.m., LN C, who was assigned to Resident 1 from 7 p.m. to 10:30 p.m. on 4/27/16, stated LN B had reported that Resident 1 had vomited, but did not relay the information about Resident 1's episode of being rigid and with eyes rolled back, prior to the vomiting. Resident 1 was twitching so LN C stated she checked the blood sugar levels which were okay. LN C stated Resident 1 was lethargic and mumbling and the oxygen level was low so the head of the bed was raised and the oxygen was turned up to 3L and the oxygen levels came up to 93% around 9 p.m LN C stated Resident 1 had a low grade fever, but it was not retaken. Resident 1's blood pressure and pulse were not taken, and Resident 1 had dark urine in the Foley with about 300 ml of urine output. LN C agreed, the output was not documented in the record. LN C stated that she did not report the lethargic episode with the inability to speak, the dark urine, twitching or the low grade temperature to the physician. Normal urine output is 70 to 80 ml per hour (80 ml per hour times 8 hours equals 640 ml) during waking hours and 30 to 40 ml per hour while sleeping. http://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter17.pdf During an interview, on 5/4/16 at 6:50 a.m., LN D stated that at the beginning of the night shift on 4/27/16 (10:30 p.m. to 6:30 a.m.) the nursing staff for the evening shift (2:30 p.m. to 10:30 p.m.) were busy, so did not immediately give report to the oncoming shift. LN D stated a CNA, who was checking vital signs at the beginning of the night shift, ran to her and reported that Resident 1 was not responsive. LN D stated she immediately evaluated Resident 1 and the vital signs were not good, so the physician was immediately contacted by telephone and the physician told LN D to send Resident 1 immediately to the hospital for [MEDICAL CONDITION]. LN D stated the ambulance arrived quickly and Resident 1 was transferred to the hospital. Soon after the emergency room called and asked what Resident 1's code status was as they wanted to intubate and send Resident 1 to ICU. LN D stated that the evening shift had only reported that Resident 1 had vomited earlier that evening. During an interview, on 5/4/16 at 9:55 a.m., Resident 1's attending physician stated that due to Resident 1's complex clinical condition, which included the Stage 4 pressure ulcer with VRE, poor nutritional status, poor lungs and heart, that Resident 1 was at high risk for [MEDICAL CONDITION] and repeated hospitalization s and she was not sure that the hospital would be able to remove the mechanical ventilator. Facility policy, titled Change of Condition Notification, dated 1/1/12, indicated: Policy: .The facility will promptly inform the resident, consult with the resident's Attending physician .when the resident endures a significant change of condition .II. Significant Change of Condition related to Attending Physician notification is defined as when the Attending physician must be notified when any sudden and marked adverse change in the resident's condition, which is manifested by signs and symptoms different than the usual, denote a new problem, complication, or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan .III. A Licensed Nurse will notify the resident's Attending Physician .when there is .C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications . Saunders Manual of Nursing Care: Communicating with Physicians: 1 d.(1) Make sure the nurse shares with the physician any information about patient needs and response to treatment .When telephoning physicians about change of condition, do the following: .3. Identify the patient and the diagnosis, 4. State the problem and include: vital signs and level of consciousness; appearance of the patient, response to interventions and any other pertinent data .

F-000 INNITIAL COMMENTS The following reflects a partial list of findings of the Department of Public Health 6/1/15 - 6/5/15 Representing the California Department of Public Health: # 2258 - Health Facility Evaluator Nurse (HFEN) An A-level State Citation was issued Citation Number: 11-2258- 41 for F314. The facility failed to provide the necessary care and services to ensure that residents who entered the facility without pressure ulcers did not develop them (Resident 11) and to ensure that residents who entered the facility with pressure ulcers received necessary treatment and services to promote healing and prevent infection (Resident 10). For these 2 of 15 sampled residents the facility failed to: 1. Conduct an accurate assessment of Patient 10 on admission and on-going to identify and assess the status of a wound to ensure effective treatment and conduct an adequate assessment for Resident 11 when an excoriation on the resident's buttock was not measured. 2. Develop a comprehensive care plan that addressed resident specific, assessed needs related to an existing pressure soar for Resident 10 and resident centered care planning for the prevention of a pressure ulcer for Resident 11 and ensure the Interdisciplinary Team (IDT) addressed emergent pressure ulcers to avoid possible complications (which include pain, wound and bone infections, and [MEDICAL CONDITION], an infection in the blood) for Resident 10 and to prevent development of an avoidable pressure ulcer and to avoid complications for Resident 11. 3. Ensure appropriate care was provided for Resident 10, when treatment was not initiated at the time of admission and treatment was initiated prior a documented order to ensure physician input/supervision to reduce the risk of complications. These failures resulted in the worsening and infection of an existing pressure ulcer for Resident 10 and the development of an avoidable pressure ulcer for Resident 11, which had the potential for the development of pain, wound and bone infections, and [MEDICAL CONDITION] (infection in the blood). Assessment - Resident 10 Resident 10 was [AGE] years old with [DIAGNOSES REDACTED]. On 4/01/15, Resident 10's Licensed Nurses Notes documented full skin assessment done as per facility guidelines. There was no documentation of the results of the assessment and no indication of a skin irregularity. The first Licensed Nurses Note which addressed the wound on the Resident 10's back was on 4/22/15, (21 days after the resident was admitted ) Faxed M.D.for a referral to wound clinic due to the pressure wound on the back being so close to spine and the depth undetermined. A skin assessment sheet for Resident 10, indicated a pressure ulcer on right side of mid spine, on a pictorial representation. On the back of this sheet was a note, dated 4/01/15, admitted with 2 cm (centimeters) by 3 cm pressure ulcer. Treatment Nurse Notes, dated 4/02/15 documented Resident 10 would receive skin checks weekly, but did not address the existing ulcer. Note, dated 4/03/15, documented, wound on back noted by aid when giving shower it was covered by foam and transparent tape. It is a pressure ulcer.and admission nurse missed seeing it during assessment. The 4/03/15 note was in conflict with the 4/01/15 full skin assessment (which did not indicate the presence of the foam and transparent dressing on Resident 10's spine). No treatment was documented until after this note (2 days after admission). Weekly summaries of 4/01/15-4/04/15, 4/05/15-4/11/15, and 4/11/15-4/18/15 did not indicate any skin breakdown, treatment or preventive measures although a Pressure Ulcer Progress Record indicated the presence of an ulcer on 4/01, 4/09, and 4/16/15. An Interdisciplinary Team Conference Record, dated 4/08/15, did not document any concerns related to skin issues. 2. Care Planning - Resident 10 Resident 10's Care Plan, with a start date of 4/01/15, identified at risk for skin breakdown/ulcer formation. Impaired mobility was selected as a problem from the list of 16 risk factors: admitted with pressure ulcer, which was also on the list was not selected. (The legend for the pressure ulcer assessment tool indicated high risk was a score of 10 thru 12 and a moderate risk as a score of 13-14; the lower the number the higher the risk). Resident 10's care plan indicated a score of 12- a high risk, which was supposed to reflect the score from the pressure ulcer predicting tool. The actual assessment tool, dated 4/01/15, indicated a score of 14. The approaches on that Care Plan were, care and reposition on care rounds, encourage independent turning as applicable and elevate legs to decrease stasis/[MEDICAL CONDITION] (swelling). A Short Term Pressure Ulcer Care Plan, with a start date of 4/10/15 (nine days after admission with an existing ulcer), indicated the presence of the Pressure ulcer. This Care Plan identified the ulcer, additional risk factors and approaches for treatment. The approaches were not resident specific. The approaches included: turning and repositioning as scheduled (no scheduled times were indicated;) encourage use of assistive devices (devices were not identified;) promote good skin care (no specific methods indicated;) and pressure redistributing device -pillow (without direction for its placement/use). The approaches also included administer medication and treatment as ordered with a start date of 4/10/15. 3. Treatment -Resident 10 A review of Resident 10's medical record indicated there was no documentation that the physician was notified of the resident's pressure ulcer on 4/01/15 (the date of admission) or on 4/03/15, when the pressure ulcer was first discovered by staff. The attending physician's initial History and Physical, of 4/04/15, indicated Back non tender, no deformities. There was no documentation that the physician was aware or involved to ensure appropriate treatment was ordered and implemented until 4/14/15. There was no documented treatment of [REDACTED]. The Treatment Administration Record documented treatment, starting 4/03/15, with Santyl and foam dressing. (Santyl is a substance used to breakdown the tissue, which is no longer viable, in a wound). No orders were found from the attending physician for wound treatment until 4/14/15, 11 days later. A wound status update with orders for the Santyl treatment was signed by the physician on 4/13/15 and marked as noted on 4/15/15. Resident 10 was admitted to an acute care facility on 4/22/15 and a wound consultation was done at that time. The discharge summary from the acute care hospital, dated 4/28/15, documented: Decubitus wound (Pressure Ulcer), infection with [MEDICATION NAME] (a class of bacteria) [MEDICAL CONDITION] (Methicllin-Resistant Staphylococcus Aureus). A History and Physical Record, from 5/11/15, indicated sacral decubitus ulcer complicated [MEDICAL CONDITION] bacterium. Licensed Staff E was unable to locate additional information regarding physician notification or additional orders for care. 1. Assessment - Resident 11 A review of Resident 11's medical record indicated the resident was admitted [DATE] with chronic [MEDICAL CONDITION] (inflammation of the lungs). The record indicated the resident was readmitted [DATE] after a 3 day hospital stay for acute [MEDICAL CONDITION]. A review of Licensed Nurses Notes for Resident 11, dated 3/7/15, indicated an area of excoriation (surface injury or abrasion) on the resident's right buttock fold A review of the Treatment Nurses Notes, dated 3/7/15, did not indicate any measurements of the site. 2. Care Planning - Resident 11 Admission 1/21/15: A review of the Licensed Nursing Notes for Resident 11, upon readmission, dated 1/21/15, included a skin assessment which indicated no pressure sores. The facility utilized an assessment tool named Braden Scale for Predicting Pressure ulcer Risk which uses a numerical scale to to indicate a resident's risk for developing pressure sores: Severe Risk = 9 or lower, High Risk = 10-12, Moderate Risk = 13-14, Mild Risk = 15-18. A review of Resident 11's assessment tool, with dates of 1/21/15 and 1/28/15 indicated Resident 11 scored a 12, which was considered a high risk for developing pressure sores. Assessments of 2/18/15 and 3/18/15 indicated the resident's risk factors increased when Resident 11 scored 10. Licensed Nurses Note, dated 2/6/15 indicated the resident was receiving antibiotic medication for an upper respiratory infection. Nurses Note, dated 2/10/15 indicated the resident was having difficulty getting out of bed. Nurses Note, dated 2/13/15, indicated the resident was finished with the course of antibiotics for an upper respiratory infection. Nurses Note, dated 3/11/15 indicated the resident was receiving [MEDICATION NAME], an anti-[MEDICAL CONDITION] medication used to treat symptoms of the flu. Resident 11's Skin Care Plan, with a start date of 7/11/14 and last revised 4/2015, indicated 4 risk factors of impaired mobility, incontinence, history of skin tears/ulcers, and fragile skin. The Problem section indicated the resident's [DIAGNOSES REDACTED]. Nursing interventions, to reduce or remove underlying risk factors, indicated staff were to provide encouragement and assist the resident with repositioning, provide skin care, monitor the skin and provide pressure redistributing devices and assess for effectiveness. The care plan did not indicate the type(s) of pressure reducing devices to be used. The care plan did not indicate that skin checks were to be performed. The care plan did not indicate a turning schedule as to how often the resident needed repositioning to meet her needs. The care plan did not otherwise address nursing strategies of relieving pressure for the buttock/coccyx region of the resident. The care plan did not indicate an education component for the resident to encourage repositioning although Licensed Nursing Notes, dated 2/10/15 indicated the resident hesitant to get out of bed. The interventions were unchanged from 7/11/14 to 4/2015 although the risk factors increased (from 12 to 10,) and the resident experienced a change of condition; - upper respiratory infection. Resident 11, assessed as a high risk for developing pressure ulcers, was not provided with a resident specific skin care plan, resident specific interventions, and the care plan was not revised to reflect the resident's change in health status. The resident developed a pressure ulcer on 3/7/15, 45 days after being readmitted on [DATE]. 2. Care Planning - Resident 11 Admission 3/24/15: A review of an Emergency Department screening assessment, for Resident 11, dated 3/16/15, indicated the hospital received the resident with a pressure ulcer. The resident returned to the skilled nursing facility on 3/24/15. A new care plan was initiated on 3/29/15. A review of Resident 11's assessment tool, with assessment dates of 3/24/15 and 4/6/15 indicated the resident scored a 10, which was considered a high risk for developing pressure ulcers. Resident 11's Non-Pressure Ulcer Weekly Skin and Wound Report, (misnamed as the document was used to document the treatment and status of pressure ulcers,) indicated a 2 (cm) x 2.5 x superficial excoriation of the left buttock on 3/25/15. A second Non-Pressure Ulcer Weekly Skin and Wound Report identified excoriation of the coccyx area on 4/9/15 which was measured as 2 cm x 1.5 cm x superficial. A third, Non-Pressure Ulcer Weekly Skin and Wound Report identified a 3 cm x 4 cm x superficial excoriation of the right buttock fold on 4/9/15. On 6/4/15 at 12:25 p.m. Licensed Staff Q stated the resident's [MEDICATION NAME] (a substance that forms a gel in the presence of water) dressing was changed today. Licensed Staff Q stated the coccyx pressure ulcer was measured as 0.5 cm x 0.3 cm and was not yet closed. Resident 11's Skin Care Plan, with a start date of 3/29/15, indicated 2 out of 16 risk factors for developing pressure ulcers were checked: impaired mobility and fragile skin/dry skin. The Problem section indicated the resident's [DIAGNOSES REDACTED]. The Skin Care Plan, 3/29/15, Nursing interventions, did not indicate the type(s) of pressure reducing devices to be used, skin checks, a turning schedule as to how often the resident needed repositioning to meet her needs, or otherwise address nursing strategies of relieving pressure for the buttock/coccyx region of the resident. The care plan, reviewed 6/29/15 did not indicate an education component for the resident to encourage repositioning although the Wound Status Update document, dated 5/4/15 indicated the resident was not being compliant with laying on side and on 5/15/15, the resident was being non-compliant with repositioning. Nursing interventions were unchanged from the resident's previous admission of 7/11/14 except to refer the resident to a dietary consult, as needed and follow orders for any ordered lab tests. An IDT Conference note, dated 4/08/15, did not address skin issues, although the 3/25/15 Treatment Nurses Note indicated the resident was readmitted with a 2 cm x 2.5 cm x superficial excoriation on the left buttock. An IDT Conference note, dated 4/28/15, one month after the resident's skin breakdown, noted the resident's skin status but did not indicate recommendations for additional nursing interventions or revising the care plan. A review of the facility policy Pressure Ulcer Management, dated 1/1/12, indicated the facility would provide a system for the treatment and management of pressure ulcers. The policy indicated that a Licensed Nurse would perform a skin assessment on admission which included checking for the presence of pressure ulcers. The primary physician was to be notified in order that appropriate treatment be promptly initiated. The responsible party was to be notified. Licensed staff was to care plan for the problem based on recommendations from nursing and other medical professionals. The IDT Team was to document their discussions and their recommendations. Nursing staff was to document the effectiveness of current treatment and update the care plan as necessary. The facility's failure to provide the necessary care and services to prevent the development of pressure ulcers for Resident 11 resulted in the development of an avoidable pressure ulcer and the failure to provide necessary treatment and services to promote healing and prevent infection of an existing pressure ulcer resulted in the worsening of a pressure ulcer which became infected for Resident 10 and required admission and treatment at the acute care hospital. These failures had the potential for the development of pain, wound and bone infections, and [MEDICAL CONDITION] (infection in the blood). These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.

Based on observation, interview, and record review, the facility failed to protect Resident 1 from verbal abuse and physical threats when Licensed Staff C threatened Resident 1's safety. This failure negatively impacted the resident's psychosocial well-being when he became fearful about going down the hallway by himself, likely impacted the sense of safety of other residents who heard the threats and likely continued to cause fear and anxiety to residents who had heard or witnessed the incident and saw that the perpetrator was not removed from resident care immediately following the incident. Findings: Resident 1's face sheet (admission record) indicated that Resident 1 was an [AGE] years old male, who was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 1 on 8/14/14, at 8:50 a.m., the quarterly Minimum Data Set (MDS, an assessment tool), dated 5/8/14, reflected a score of 15 on the Brief Interview for Mental Status, indicating intact thinking and memory. A written statement by Unlicensed Staff F, signed and dated on 8/6/14, indicated that Unlicensed Staff F witnessed the incident: "On 08/05/2014 I was in a Resident's room on Side One when I witnessed Charge Nurse (Licensed Staff C) Say to Resident (Resident 1) ...'If you ever f***ing touch me like that again, I will Break your f***ing Neck. Do you Understand me?' The Resident did respond in anger but I wasn't able to hear his response." The facility's investigation report titled "Summary of incident", dated 8/11/14, indicated that on 8/5/14, at approximately 11 a.m., Resident 1 had exhibited physical aggression towards Licensed Staff C while Licensed Staff C was helping another resident in front of Resident 1's room. The report further indicated that in the afternoon at approximately 3 p.m., Unlicensed Staff F witnessed that Licensed Staff C said to Resident 1 "If you ever F***ing touch me like that again, I will break your f***ing neck. Do you understand me?" The facility investigation resulted in the termination of Licensed Staff C's position. During an interview on 8/13/14, at 3:45 p.m., Administrative Staff A stated that Resident 1 did not get along with Licensed Staff C since January or February, 2014 because Resident 1 believed that his son hired Licensed Staff C to watch him. Administrative Staff A stated that the facility had separated Licensed Staff C and Resident 1; Licensed Staff C did not take care of Resident 1 at all in the last two to three months. Administrative Staff A further stated that on 8/5/14, after Resident 1 punched Licensed Staff C in the morning, she spoke with Licensed Staff C and he went back to work. During an interview on 8/14/14, at 12:50 p.m., Licensed Staff D stated that on 8/5/14, at approximately 11 a.m., Licensed Staff C and another resident were in front of Resident 1's room. Licensed Staff D stated that he did not see the entire incident, but he heard Licensed Staff C said to Resident 1 "Get your hands off me." Licensed Staff D stated that on 8/5/14, Licensed Staff C had the resident assignment which included Resident 1. He stated that Licensed Staff C continued to work with the same assignment after the morning incident. Licensed Staff D further stated that he knew Resident 1 did not get along with Licensed Staff C. When asked the reasons for Licensed Staff C to have the resident assignment including Resident 1, Licensed Staff D stated there was no specific reason but that was Licensed Staff C's primary assignment. Licensed Staff D stated that Licensed Staff C did not have to take care of Resident 1 because Resident 1 did not take any medication and treatment. Review of Resident 1's clinical record revealed that he needed to be assessed for pain and had orders that included pain medication that needed to be given to him as needed if the assessment indicated that he was in pain. During a concurrent observation and interview in a conference room on 8/13/14, at 4:20 p.m., Resident 1 was sitting in a wheelchair and was able to propel himself. Resident 1 stated that on 8/5/14, in the afternoon, near a nurse station, Licensed Staff C said to him included "Next time, if you put your hands on me again, I will break your [***] ing neck." Resident 1 stated that he was fearful and hesitated to go to the hallway by himself following this threat. The facility clinical document titled "Weekly Summary (weekly resident assessment)," dated 7/22/14 and 8/4/14, revealed that Licensed Staff C signed Resident 1's weekly summary forms for completion. Also, the nurse's note dated 7/13/14 at 10 a.m., revealed that Licensed Staff C wrote a note on Resident 1's behavior. During an interview on 8/14/14, at 11:05 a.m., Administrative Staff A was asked "If (Licensed Staff C) did not take care of (Resident 1) at all, how could he write the nurse's note and weekly summary?" Administrative Staff A later verified that Licensed Staff C was writing the weekly summaries and nurses notes for Resident 1 including assessments. Administrative Staff A verified the assignment with staffing personnel and stated that the staffing personnel did not take Licensed Staff C off the resident assignment which included Resident 1. The document titled "Background Screening Report," dated 4/17/13, indicated that Licensed Staff C was convicted for misdemeanor of disturbing the peace - loud/unreasonable noise on 7/19/11. During an interview on 8/14/14, at 11:35 a.m., Administrative Staff A was asked about Licensed Staff C's conviction on the background screen report. Administrative Staff A stated that she did not know about the conviction. She stated if she knew the conviction, she should have investigated the conviction before hiring Licensed Staff C. During an interview on 8/14/14, at 12:25 p.m., Administrative Staff B stated that he knew about Licensed Staff C's conviction on the background screening report and talked to Licensed Staff C. Administrative Staff B stated that he accepted Licensed Staff C's explanation of the conviction and gave Administrative Staff A the information. The facility then decided to hire Licensed Staff C. During a review of Resident 1's clinical record on 8/14/14, at 8:50 a.m., the chart did not contain any nurse's notes, social service notes, and care plan regarding the verbal abuse and threat incident that occurred 8/5/14. During an interview on 8/14/14, at 11:05 a.m., Administrative Staff A reviewed the chart and confirmed that there were no nurse's notes, social service notes or care plan for the incident. She stated that the incident should be care planned and the nurses should document their assessment and monitor Resident 1 for 72 hours. When asked for facility policy and procedure for protecting and monitoring resident after the abuse incident, Administrative Staff A stated the facility had the policy and procedure for protection of the resident. During an interview on 8/14/14, at 11:40 a.m., Social Service Staff E stated she had knowledge about the incident but did not document anything about it in Resident 1's clinical record. The facility policy and procedure titled "Abuse - Prevention Program," dated 1/1/12, indicated "The Facility does not condone any form of resident abuse, neglect and /or mistreatment, and...maintain an environment free from abuse and mistreatment...The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents...The Facility assists or rotates Facility Staff working with difficult or abusive residents..."