Every finding on record at Gridley Post Acute

Based on interview and record review, the facility failed to provide nursing services in accordance with professional standards of quality for two of six sampled residents (Resident 1, Resident 3).Licensed nursing staff did not adequately assess and monitor Resident 1 after the onset of new pain and emerging signs of clinical decline. The lack of timely nursing assessment and intervention resulted in a delay in transferring Resident 1 to the hospital, where Resident 1 was subsequently treated for sepsis (life-threatening systemic infection) and diverticulitis (inflammation of the gut lining that causes severe pain).Licensed nursing staff did not change Resident 3's Peripherally Inserted Central Catheter (PICC - a long, thin tube that is inserted into a vein in the arm. The tube travels up the vein until it reaches a large vein near the heart. It is used when someone needs medicines, fluids, or nutrition for a long time) line dressing according to facility policy and accepted standards of care. This had the potential to compromise catheter integrity and increase the risk of catheter-related complications, including infection, which could result in the resident's health status.Findings:A review of the facility's undated document titled Resident Examination and Assessment indicated that the procedure's purpose is to examine and assess the resident for any abnormalities in health status. The document states that a pain assessment requires a physical examination including the description of pain, its location, duration, severity, aggravating and relieving factors, and the impact of pain on activities, mood, sleep, and appetite, as well as current pain medications and treatments. It further specifies that the following information must be recorded in the resident's medical record: the date and time the procedure was performed; the name and title of the individual performing the procedure; all assessment data obtained; how the resident tolerated the procedure; if the resident refused, the reason and interventions taken; and the signature and title of the person documenting the information.A review of the facility's document titled Registered Nurse (RN) job description, revised May 2022, indicated that RNs are responsible for monitoring residents for acute changes in condition-such as confusion, fever, breathing difficulties, increased pain, urinary issues, loss of appetite, constipation, diarrhea, vision or hearing changes, general malaise, or decreased range of motion-and for conducting assessments and notifying the provider when needed.A review of Resident 1's admission record, indicated that Resident 1 was admitted on [DATE] with diagnoses including high blood pressure, a history of falling, and adult failure to thrive (a condition involving significant weight loss, poor nutrition, decreased physical activity, and social withdrawal.) Resident 1 was her own health care decision maker.During a concurrent interview and record review on 7/23/26 at 11:46 p.m. with RN A, Resident 1's nursing progress notes and the May 2026 medication administration record were reviewed. RN A confirmed that Resident 1 developed abdominal pain on 6/23/26 at 2:45 p.m. and was administered Hydrocodone Acetaminophen (Norco) 5 325 mg. RN A acknowledged that no documentation was completed regarding Resident 1's pain assessment or pain level before or after the administration of Norco. RN A further confirmed that Resident 1 continued to experience pain, had one episode of vomiting, requested transfer to the hospital, and departed the facility at 5:05 p.m. the same day. RN A also verified that the medication administration record for 6/23/26 did not contain any entry indicating that Norco had been administered to Resident 1.During a concurrent interview and record review on 7/23/26 at 12:17 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 1 reported abdominal pain at 2:45 p.m., experienced green-colored vomiting, and was administered a Norco as ordered; the record further indicated that Resident 1 requested transfer to the hospital and departed the facility at 5:05 pm for evaluation. During a subsequent interview and record review on 7/31/26 at 10:25 am, the DON stated that documentation of Resident 1's pain should have been entered in the nursing progress notes, confirmed that ongoing assessments were required, and indicated RN A should have utilized a pain scale and completed a full gastrointestinal assessment, including bowel sound evaluation and palpation for abdominal tenderness or abnormalities.A review of the facility's undated policy titled Peripheral Intravenous (IV - inside a vein) Dressing Changes (the sterile process of removing a soiled, loose, or old protective covering over an IV site), indicated that the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. The policy states that the dressing needs to be changed if it becomes damp, loosened or visibly soiled and at least every 5 to 7 days. Change dressing and perform site care if signs and symptoms of site infection are present.A review of the facility's document titled Registered Nurse (RN) job description, revised May 2022, indicated that RNs would Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care.A review of Resident 3's admission record, indicated that Resident 3 was admitted on [DATE] with diagnoses including urinary tract infection (UTI), liver disease and acute kidney injury (AKI).A review of Resident 3's physician orders, dated 6/29/26, for PICC line dressing care - Change the transparent dressing on admission, then weekly and as needed, every day shift every 7 days.; for PICC line monitoring - Assess the left upper arm PICC site every shift for signs of infection or infiltration.A review of Resident 3's clinical nursing record obtained from the local infusion center, dated 7/20/26, indicated that the infusion center RN assessed Resident 3's PICC dressing and observed multiple layers of tape over the original dressing dated 6/27/26. The note further stated that the RN contacted the facility to discuss PICC line care and recommended that Resident 3 go to the emergency room for assessment and a dressing change.During an interview with Resident 3 on 7/31/26 at 11:10 am, Resident 3 stated that the staff were not changing the PICC line dressing as often as they should have been. Resident 3 reported becoming aware of this during a visit to the local infusion center, where a nurse informed her that the PICC dressing should be changed weekly and monitored regularly.During an interview with the DON on 7/31/26 at 11:21 am, the DON acknowledged receiving a call from the local infusion center regarding Resident 3's PICC line dressing. The DON stated, They told me it was old; I can't recall the date they mentioned on the dressing. The DON confirmed that the dressing changes for Resident 3 were not performed as required.During an interview with the Charge Nurse (CN) at the local infusion center on 8/4/26 at 1:10 pm, the CN reported that when Resident 3 arrived for treatment on 7/20/26, the date on the PICC line dressing was dated 6/27/26 and could not be used due to its condition. Resident 3 was subsequently sent to the local emergency department to have the PICC line evaluated and redressed. CN confirmed that her staff contacted the DON at the facility where Resident 3 resides and informed the DON of their assessment.

Based on interview and record review, the facility failed to honor the food preferences for one of five sampled residents (Residents 1).This failure had the potential to result in Resident 1 not eating, placing Resident 1 at risk for nutritional deficiencies and unintended weight loss.A review of the facility's undated policy titled, Resident Food Preferences, indicated, If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.A review of Resident 1's admission Record, indicated that she was admitted on [DATE] with diagnoses of high blood pressure, history of falling, and adult failure to thrive (a multifactorial syndrome where a person experiences a combination of significant weight loss, poor nutrition, decrease physical activity and social withdrawal. Resident 1 was her own health care decision maker.During an interview on 7/22/26 at 12:37 pm, with Resident 1, Resident 1 stated she had an allergy to eggs and reported that she was served eggs multiple times despite informing facility staff of her allergy. Resident 1 stated she was unsure why she continued to receive eggs even after she had spoken with staff on several occasions.A review of Resident 1's food preference activity log indicated on 5/27/26 at 10:35 am, egg was added as an allergy and at 10:38 am breakfast, lunch and dinner notepad changed allergies to eggs and egg yolk.During a concurrent interview and record review on 7/23/26 at 10:43 am, with the Dietary Manager (DM), when reviewing Resident 1's food preference activity log, DM confirmed that Resident 1 had eggs listed as an allergy on 5/27/26, egg allergy was then removed on 6/4/26 and on 6/23/26 the log indicated Resident 1's preference for no eggs for breakfast. The DM confirmed that Resident 1 continued to receive eggs during the period following the removal of eggs as an allergy and prior to documentation on 6/23/36 indicating Resident 1's preference for no eggs at breakfast. When asked whether Residents 1's documented food preferences were being honored during this period, the Dietary Manager stated no.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS - the resident assessment tool) for one of four sampled residents (Resident 3). The facility did not correctly identify the presence of a peripherally inserted central catheter (PICC - a central venous access device used for the administration of long term intravenous medications.)This failure resulted in an inaccurate resident assessment and had the potential to lead to inappropriate care planning and adverse health outcomes for Resident 3.Findings:A review of MDS Assessment Coordinator Policy Statement, last revised 11/2019, indicated that each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by identifying each section completed.A review of Resident 3's MDS readmission assessment, dated 7/7/26, indicated that under section O, Special Treatments, Procedures, and Programs, intravenous therapy (IV), , which includes administration through a PICC line, was not marked, despite Resident 3 receiving IV medication via a PICC line during the assessment period.During a concurrent interview and record review with the MDS Coordinator on 7/31/26 at 12:13 pm, Resident 3's MDS was reviewed. The MDS Coordinator confirmed that the IV section had not been marked to reflect the presence of the PICC line. The MDS Coordinator acknowledged that it should have been marked.

Based on observation, interview and record review the facility failed to ensure smoking occurred only in designated areas, and that proper safety equipment (ashtrays and fire extinguishers) were available for use for one of two sampled residents (Resident 2).This deficient practice had the potential to place all residents at risk for smoking related accidents and hazards.Findings:A review of an undated facility policy titled Smoking Policy - Residents indicated that smoking is permitted only in designated resident smoking areas. The policy further states that the facility may impose smoking restrictions at any time if it determines a resident cannot smoke safely. Additionally, the policy specifies that the facility reserves the right to confiscate smoking items found in violation of the smoking policies.A review of Resident 2's admission record indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, high blood pressure and chronic obstructive pulmonary disease (a long-term lung condition where airways and air sacs are damaged, making it hard to move air in and out of the lungs). Resident 2 was his own health care decision maker.A review of Resident 2's smoking assessment, dated 6/11/26 at 11:11 am, indicated that Resident 2 was able to hold a cigarette without assistance and could safely extinguish a cigarette. A review of Resident 2's care plan with the initiated date of 6/11/26, indicated that Resident 2 had been assessed as an independent smoker.During an observation on 7/22/26 at 9:03 am, Resident 2 was observed outside on the east side of the facility, where a concrete walkway is bordered by rocks and mulch next to the facility's building. Seated in his wheelchair, Resident 2 removed a pack of cigarettes and a lighter from his shirt pocket and lit a cigarette. While smoking, Resident 2 did not have a smoking apron on, and there were no visible cigarette receptacles (a designated cigarette butt disposal container) available in the area. After finishing the cigarette, Resident 2 flicked the still lit butt into the surrounding rocks, which contained dry grasses. During an observation on 7/23/26 at 9:27 am, multiple cigarette butts were observed scattered throughout the dirt, rocks, and mulch along both sides of the walkway on the east side of the facility's building, leading toward the area where Resident 2 had been sitting. During a concurrent interview and record review on 7/23/26 at 9:43 am, with the Administrator (Admin), Resident 2's clinical record was reviewed. When asked how independent residents are monitored when smoking, the Admin stated that independent residents are not monitored when smoking once they sign themselves out of the facility. When discussing the east side of the facility's building, the Admin acknowledged being aware that Resident 2 had been smoking in a non designated area and stated that staff and maintenance attempt to monitor that area and redirect residents to appropriate smoking locations. The Admin confirmed there was no designated smoking area outside of the facility property for independent smokers and that the only designated outdoor smoking area was located on the west side of the facility. The Admin further acknowledged that there were no appropriate cigarette receptacles available on the east side of the facility, despite residents being known to smoke there. At the time of the interview, the Admin confirmed that no smoking restrictions had been imposed and Resident 2's smoking privileges had not been modifiedDuring an interview on 7/31/26 at 1:19 pm with the Admin, the Admin confirmed he reviewed the smoking policy with Resident 2 multiple times. The Admin confirmed that no smoking restrictions or privilege changes had been implemented for Resident 2.

Based on observation, interview and record review, the facility failed to provide necessary mental health services for two of three sampled residents (Resident 1, 2) when:1.Resident 1 did not receive consistent counseling and psychiatric services to meet his mental health need.This resulted in Resident 1 reporting being in a constant state of fear and feeling unsafe in the facility, which had the potential to place Resident 1 at increased risk for self harm and social isolation.2.Resident 2 did not receive psychiatric services to meet his mental health need.This resulted in Resident 2 experiencing increased social isolation and expressing thoughts that they would be better off dead, placing Resident 2 at increased risk for self harm.Findings:A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention, and Monitoring, revised 2/2025, indicated that behavioral interventions are described as individualized, non-drug approaches to care. These interventions are meant to support both the physical and emotional needs of residents, focusing on understanding, preventing, and relieving distress or loss of abilities. The policy also emphasizes the importance of maintaining or improving a resident's mental, physical, or social well-being.1.A review of Resident 1's admission record, indicated that Resident 1 was initially admitted to the facility on [DATE] with diagnoses including depression, paranoid personality disorder (a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious) and mood disorder. Resident 1 was his own health care decision maker.A review of Resident 1's Minimum Data Set (MDS - a resident assessment toll), dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS, assessment of thinking and memory) score of 7, indicating severe impairment in memory and cognitive abilities.A review of Resident 1's care plan, initiated on [DATE] and revised on [DATE], indicated that the resident uses antidepressant medication for statements of sadness. The Care Plan goal stated, The resident will be free from discomfort. Interventions to meet this goal included monitoring, documenting, and reporting changes in mood, behavior, cognition, hallucinations, delusions, social isolation, suicidal thoughts, and withdrawal as needed. The Care Plan for behaviors of paranoia, initiated on [DATE] and revised on [DATE], indicated the goal, The resident will have no evidence of behavioral problems.A review of Resident 1's Preadmission Screening and Resident Review (PASRR, behavioral health and disabilities assessment) Level II (State mental health and disability assessment), dated [DATE], indicated Resident 1 was clinically recommended to receive specialized add on services, including psychotherapy or counseling by a licensed mental health professional, psychiatric consultation and follow up care, diagnostic clarification, medication interventions, and monitoring of mental health conditionsDuring a concurrent observation and interview on [DATE] at 1:10 pm with Resident 1, in Resident 1's room, Resident 1 was tearful and stated that he was in fear of his life on a daily and nightly basis.During an interview on [DATE] at 3:02 pm with Certified Nursing Assistant (CNA) A, CNA A stated, [Resident 1] has always struggled with depression and talked about the suicide of a significant other. CNA A further stated that the facility previously had counselors before the new company assumed ownership. CNA A reported that Resident 1 often excluded themself from social activities and had declined due to depression, including not wanting to eat.During an interview on [DATE] at 3:16 pm with Licensed Nurse (LN) C, LN C stated Resident 1 had progressively declined and experienced constant episodes of paranoia, especially at night.During a concurrent interview and record review on [DATE] at 2:10 pm, with Social Services Designee (SSD), the SSD stated that Resident 1 was often unsatisfied and complained about not receiving enough psychiatric services. The SSD reported that Resident 1 had talked about participating in satanic rituals with a sibling. The SSD stated that a message was left for the crisis line and county behavioral health on [DATE] and acknowledged that follow up should have occurred sooner. The SSD further stated that the facility is responsible for coordinating transportation and services with behavioral health.During an interview on [DATE] at 2:38 pm with the Administrator (Admin), Admin stated that Resident 1 had received counseling until the resident's insurance no longer covered the service. Admin also stated that the current psychiatrist had limited availability and frequently cancelled scheduled appointments. When asked to review the counseling records and the date of the last counseling session, the Admin stated that the facility did not have counseling records.During a concurrent interview and record review on [DATE] at 4:00pm with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. The ADON stated that the facility currently does not have psychiatric services. The ADON reported that the psychiatrist had provided full time services in [DATE]; however, since [DATE], the psychiatrist had not met the residents' needs. The ADON stated that the alternative tele psychiatric provider did not offer services in the region. ADON reported that Resident 1 was depressed at times, had a history of hospitalization for suicidal thoughts, and had experienced a decline in the ability to perform activities of daily living, including dressing, washing, and bathing. The ADON also stated that Resident 1 isolated and refused to participate in group activities.A review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting notes dated [DATE] indicated under Psych Services that the current provider typically calls in once a month. We would love to have weekly. He cannot do that at the current time. QAPI meeting notes dated [DATE] further indicated under Psych Services that the current provider has not been consistent and that appointments were scheduled and then cancelled on the same day.2. A review of Resident 2's admission Report record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of cognitive social and emotional impairment and depression.A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 9 , indicating moderate cognitive impairment.A review of Resident 2's Psychosocial Assessment dated [DATE] indicated, was ordered Zoloft (antidepressant) for depression. Assessment indicated Resident 2 attends activities of his choosing and goes and does individual activities of his choosing.A review of Resident 2's nursing progress note, dated [DATE], indicated that Resident 2's brother passed away.A review of Resident 2's nursing progress note, dated [DATE], indicated Resident 2 was frustrated, yelling at another resident.During a concurrent observation and interview on [DATE] at 12:50 pm with Resident 2, in Resident 2's room, Resident 2 stated, How does a person work all his life and end up with a life like this? Resident 2 further stated that he had spoken to facility staff about his feelings, but nobody understands, they don't want to hear I'm unhappy and that he would rather be dead. Resident 2 stated he had felt this way for a while. When asked whether the facility offered mental health services or whether social services had visited, Resident 2 responded, no.During an interview on [DATE] at 2:10 pm with SSD, the SSD stated that Resident 2 was not social, preferred to keep to themself, and had behaved this way since admission.During a concurrent interview and record review on [DATE] at 4:00pm with ADON, the ADON stated that Resident 2 was on the list for psychiatric services. The ADON reported that Resident 2's brother had recently died and that the resident's sister no longer visited. The ADON stated that Resident 2 tended to keep to themself and slept frequently. The ADON also confirmed that Resident 2 had requested hospice services but did not qualify.

Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), was treated in a respectful and dignified manner. Resident 1 reported that Certified Nursing Assistant (CNA) A accused the resident of using the call light too often, crossed their arms, and yelled at the resident to shut up.This failure resulted in Resident 1 feeling fearful and worried about possible retaliation from staff.Findings:A review of the facility's policy and procedures titled, Dignity, revised 10/2025, indicated that staff are required to speak respectfully to residents at all times and to treat residents with cognitive impairments with dignity and sensitivity.A review of Resident 1's admission record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke, depression, and paranoid personality disorder (a mental health condition in which the person has distrust and suspicion of others).A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool ) section C - Cognitive Patterns, and section GG - Functional Abilities, indicated on 4/7/26, Resident 1 had a cognitive sore of 7, indicating severe problems with thinking and memory, and on 4/8/26, the functional assessment documented that the resident was dependent on staff for showering, lower body dressing, personal hygiene, and oral care.During a concurrent observation and interview on 6/4/26 at 1:45 pm with Resident 1, in Resident 1's room, Resident 1 stated that CNA A accused them of using the call light too often, crossed their arms, yelled at them, and told them to shut up. Resident 1 stated they could not defend themself and were afraid to report the incident. When CNA A entered the room during hand off rounds, Resident 1's body visibly tensed. CNA A asked the resident if there was anything they needed; Resident 1 turned their face toward the window and closed their eyes in response.During a interview on 6/4/26 at 2:45 p.m. with CNA A, CNA A stated that Resident 1 presses the call light a lot for attention and described Resident 1 as stressed, anxious, and lonely. CNA A acknowledged that sometimes when I talk to residents, I sound authoritative, which may be perceived as aggressive, but that is not my intent. CNA A further stated he became frustrated when responding to Resident 1's call light because, on many occasions, Resident 1 did not have a specific need. He added that he is working on improving the way he communicates with residents and is doing the best I can do right now.

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when 2 (Resident #1 and Resident #2) of 3 sampled residents reviewed for PASARR were diagnosed with a new serious mental illness. Findings included: An undated facility policy titled, PASRR Completion Policy, revealed, The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. 1. An Admission Record revealed the facility admitted Resident #2 on 05/22/2018. According to the Admission Record, the resident had a medical history that included a diagnosis of spastic hemiplegic cerebral palsy. According to the Admission Record, the resident received diagnoses of psychosis, manic episode, and depression on 12/06/2023. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses to include depression, bipolar disorder, and psychotic disorder. Resident #2's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASARR evaluation when the resident received a new mental illness diagnosis. During an interview on 03/25/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility thought the only time the resident needed a new PASARR included a new qualifying diagnosis. During a follow-up interview on 03/25/2025 at 1:38 PM, the DON stated the facility did not have an updated PASARR for Resident #2. 28193 2. An Admission Record revealed the facility admitted Resident #1 on 06/27/2024. According to the Admission Record, the resident had a medical history that included atrial fibrillation, hypertension, and muscle weakness. The Admission Record indicated the resident received diagnoses of bipolar disorder and anxiety disorder on 02/25/2025. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression and bipolar disorder. Resident #1's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASARR evaluation when the resident received a new mental illness diagnosis. During an interview on 03/25/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility thought the only time the resident needed a new PASARR included a new qualifying diagnosis. During a follow-up interview on 03/25/2025 at 1:38 PM, the DON stated the facility did not have an updated PASARR for Resident #1.

Based on interview and record review, the facility failed to timely notify the physician of laboratory results for 1 (Resident #47) of 2 sampled residents reviewed hospitalization . Findings included: An Admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the Admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note, dated 12/22/2024 at 12:18 PM, revealed the physician gave an order for a urinalysis with a culture and sensitivity. Resident #47's Lab Results Report revealed a urine culture with culture and sensitivity was collected on 12/20/2024 and the results were marked final and reported on 12/22/2024. Resident #47's Progress Note, dated 12/30/2024 at 11:32 AM, revealed the nurse practitioner (NP) started the resident on Bactrim DS (an antibiotic medication) two times a day for five days for a urinary tract infection. Resident #47's Order Summary Report, revealed an order dated 12/30/2024, for Bactrim DS oral tablet 800-160 milligrams, give one tablet by mouth two times a day for five days for a urinary tract infection. During an interview on 03/27/2025 at 9:34 AM, the Director of Nursing (DON) stated she could not find any documentation to indicate the physician was notified of Resident #47's laboratory results. During an interview on 03/27/2025 at 4:03 PM, the NP stated her expectation for the staff would be to call the provider with the results of the culture and sensitivity as soon as possible. The NP stated she was available 24 hours a day, as well as the other providers in the group. During a follow-up interview on 03/27/2025 at 12:23 PM, the DON stated she expected the staff to timely notify the physician with laboratory results. During an interview on 03/27/2025 at 2:17 PM, the Administrator stated he expected staff to timely follow through with physician notification of laboratory results.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards, specifically a space heater for 1 (Resident #1) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Electrical Safety for Residents, revised 01/2011, revealed, The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns and fire. The policy specified, 3. Portable space heaters are not permitted in the facility. An Admission Record revealed the facility admitted Resident #1 on 06/27/2024. According to the Admission Record, the resident had a medical history that included atrial fibrillation, hypertension, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an observation on 03/24/2025 at 1:01 PM, a free-standing space heater was noted in the middle of the floor of Resident #1's room. The space heater was plugged into the wall and there was a sign on the door of the resident's room that indicated to not put anything on the space heater, as it would be a fire hazard. During an observation of Resident #1's room on 03/25/2025 at 7:42 AM, the space heater was noted to be on and the resident was lying in bed. The facility incident log for the time frame 10/31/2024 to 03/25/2025, revealed no evidence to indicate a resident burn or injury related to a space heater. During an interview on 03/26/2025 at 2:17 PM, Registered Nurse (RN) #1 stated she was familiar with Resident #1, but did not know exactly how long the resident had the space heater in their room, but that it had been a while. RN #1 stated there was no air conditioning or heat vents in the resident's room, thus the space heater was there to help keep the resident warm during the winter months. RN #1 stated she was not aware of any residents that touched the space heater or been injured as the result of the space heater. Per RN #1, the sign on Resident #1's door about the space heater was a precautionary sign that made people aware of the space heater was there. RN #1 stated the space heater was placed in the resident's room by maintenance and it was not the resident's personal heater, that it belonged to the facility. During an interview on 03/26/2025 at 2:32 PM, RN #2 stated Resident #1 had had the space heater since winter because there was no heating unit in their room. RN #2 stated she was unaware of any incidents related to the space heater and the sign on the resident's door was hung by management to make staff aware the space heater was there and to watch it. During an interview o 03/26/2025 at 2:57 PM, the Director of Nursing (DON) stated the space heater had been in Resident #1's room for three weeks to a month and there had not been any incidents related to it. The DON stated the sign on the resident's door about a fire hazard was placed there by Maintenance Director, who stated the space heater was allowed. According to the DON, she questioned if the space heater was allowed but was told it was a safe model and compliant with state regulations. During an interview on 03/26/2025 at 3:57 PM, the Maintenance Director stated he was told the facility was allowed to have space heaters as long as they met a few criteria, such as being made by an underwriter laboratory (UL) company, had a UL rating, were properly placed in a room, not near curtains or bedding, were oil-based instead of electric coil based, and the facility had proof of frequent checks of the heater. The Maintenance Director stated Resident #1 was in a room without a wall unit for air and/or heat. According to the Maintenance Director, when Resident #1 was too hot, the facility provided the resident a fan and when the resident was too cold, they provided the space heater. The Maintenance Director stated the regulations he based his decision to use the space heater for Resident #1 was a state regulation. Per the Maintenance Director, he was not aware he needed to follow the federal regulation and was not told space heaters were not allowed at all in skilled nursing facilities. During an interview on 03/27/2025 at 2:18 PM, the Administrator stated the Maintenance Director tried to do a lot of research to help meet Resident #1's needs, and thought he was doing a good thing. The Administrator stated the Maintenance Director thought the space heater was okay to have, since when the facility was part of the hospital, they were okay. The Administrator stated he expected space heaters to not be in a resident's room going forward.

Based on interview and record review, the facility failed to timely initiate antibiotic therapy for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization . Findings included: An Admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the Admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note, dated 12/22/2024 at 12:18 PM, revealed the physician gave an order for a urinalysis with a culture and sensitivity. Resident #47's Lab Results Report revealed a urine culture with culture and sensitivity was collected on 12/20/2024 and the results were marked final and reported on 12/22/2024. Resident #47's Progress Note, dated 12/30/2024 at 11:32 AM, revealed the nurse practitioner (NP) started the resident on Bactrim DS (an antibiotic medication) two times a day for five days for a urinary tract infection. Resident #47's Order Summary Report, revealed an order dated 12/30/2024, for Bactrim DS oral tablet 800-160 milligrams, give one tablet by mouth two times a day for five days for a urinary tract infection. During an interview on 03/27/2025 at 9:34 AM, the Director of Nursing stated there was no reason she could find for the eight-day delay in obtaining an order for an antibiotic for Resident #47. During an interview on 03/27/2025 at 4:03 PM, the NP stated eight days was an excessive amount of time to start an antibiotic after a positive urinalysis with culture and sensitivity.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's onset of bilateral leg edema for 1 (Resident #15) of 1 sampled resident reviewed for care planning. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, specified, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, the comprehensive, person-centered care plan, e. reflects currently recognized standards of practice for problem areas and conditions. An Admission Record indicated the facility admitted Resident #15 on 05/08/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and essential hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/15/2025, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #15's Progress Note, dated 12/17/2024 at 7:47 PM, revealed the resident had edema in their bilateral legs. Resident #15's Progress Note, dated 03/11/2025 at 3:44 AM, revealed the resident reported pain and swelling in their right lower leg. The Progress Note indicated to address these symptoms, thrombo-embolic deterrent (TED) hose was prescribed to provide supportive care and alleviate discomfort. Per the Progress Note, the resident's condition would be monitored, and further evaluation would be conducted if swelling or pain persisted. Resident #15's Order Summary Report for active orders as of 03/25/2025, revealed an order dated 08/09/2024, that directed staff to monitor the resident for edema, ascites (a condition that occurred when fluid collected in spaces in the abdomen), abdominal distention related to weight gain every shift and notify the physician if present; an order dated 12/07/2024, that directed staff to monitor the resident for signs and symptoms of ascites and edema one time a day; and an order dated 03/13/2025, that directed staff to place TED hose/compression stocking on the resident in morning and remove at night, one time a day for swelling/edema to the right lower extremity. Resident #15's Care Plan Report, revealed no evidence of a care plan to address the resident's bilateral leg edema. During an interview on 03/26/2025 at 2:41 PM, Certified Nursing Assistant #4 stated Resident #15 complained their feet were swollen. During a telephone interview on 03/26/2025 at 6:25 PM, Registered Nurse #1 stated Resident #15 had pain or swelling in their leg a few months prior. During an interview on 03/27/2025 at 11:03 AM, Licensed Vocational Nurse (LVN) #7 stated edema required a care plan and for any kind of care a resident required, it should be care planned. LVN #7 stated Resident #15 had swelling in their right ankle on 03/27/2025 and did not have a care plan to address their edema. During an interview on 03/27/2025 at 1:06 PM, the MDS Coordinator stated Resident #15 did not have a care plan that addressed their edema and a care plan should have been initiated when the monitoring for edema order was placed and when the TED hose was ordered. During an interview on 03/27/2025 at 11:19 AM, the Director of Nursing (DON) stated edema would require a care plan because it was an issue. The DON confirmed Resident #15 did not have a care plan to address their edema and needed one because it was issue that needed to be monitored and resolved. According to the DON, when the resident was found to have edema, a care plan should have been initiated by the nurse who assessed the resident to have edema. During an interview on 03/27/2025 at 1:19 PM, the Administrator stated he expected the staff to initiate care plan timely.

Based on interview, record review, and facility policy review, the facility failed to provide a bed hold notice upon transfer to the hospital for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization . Findings included: A facility policy titled, Bed-Holds and Returns, revised 10/2022, revealed, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation 1. All residents/representative are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these polices at least twice: a. a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). An Admission Record indicated the facility admitted Resident #47 on 03/16/2022. According to the Admission Record, the resident had a medical history that included diagnoses of atrial fibrillation and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #47's Progress Note dated 01/03/2025 at 8:34 AM, revealed the resident was transferred to the hospital for further evaluation of blood in their urine and hallucinations. Resident #47's Progress Note, dated 01/08/2025 at 9:41 AM, revealed the resident arrived back in the facility. Resident #47's medical record revealed no evidence of a bed hold notice for when the resident transferred to the hospital on 01/03/2025; however, there was evidence to indicate on 01/08/2025, the Admissions Director left a message for Resident #47's family member regarding a bed hold and transfer notice (Resident #47's Progress Note dated 01/08/2025 at 12:16 PM, revealed the Admissions Director left a message for Resident #47's family member regarding bed hold and transfer notice this morning. Awaiting call back.). During an interview on 03/27/2025 at 12:42 PM, the Admissions Director stated bed hold/transfer was explained to a resident's family during the admissions process. Per the Admissions Director, if a resident transferred to the hospital, the resident's family would be asked if they would like to start a bed hold. The Admissions Director stated the bed hold notice should be completed prior to the resident leaving the facility. The Admissions Director stated she was not timely in issuing Resident #47s' bed hold notice. During an interview on 03/26/2025 at 2:57 PM, the Director of Nursing (DON) stated the Admissions Director was responsible for sending out bed hold/transfer notices. According to the DON, the bed hold/transfer notice should be done immediately upon transfer. The DON stated waiting until after Resident #47's return to the facility on [DATE] to contact their family about the bed hold policy was not appropriate. Per the DON, the bed hold/transfer notice should have been sent or the family called when the resident left the faciity on [DATE]. The DON stated the Admissions Director should not have waited until Resident #47 readmitted to discuss bed hold/transfer options. During an interview on 03/27/2025 at 2:17 PM, the Administrator stated if a resident was their own responsible party, it would be difficult to get the notice of bed hold to the resident; however, if the resident had a responsible party, the notice should be given as soon as possible, but at least by the next day after transfer to the hospital. The Administrator stated the facility had an external marketer who could take the notice of bed hold to the hospital when a resident was their own responsible party.

Based on interview, and record review, the facility failed to adequately document the necessity of a psychotropic medication for one of three sampled residents' (Resident 1) with resident-centered indications for use and monitoring for adverse side effect while on Rexulti (an atypical antipsychotic medication). This failure had the potential to result in Resident 1 not maintaining her highest practicable mental, physical, and psychosocial well-being and put Resident 1 at a high risk for physical harm due to adverse consequences. Findings: During a record review of Resident 1's admission record, indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (a decline in mental abilities that affect daily life), glaucoma (chronic eye disease that can cause vision loss or blindness), dysphagia (difficulty swallowing), and type 2 diabetes (body cannot produce enough insulin). Document indicated Resident 1's primary language was Spanish, and her responsible party (RP)'s primary language was Spanish. During a record review of document titled Minimum Data Set (MDS) Section C, Resident 1's Brief Interview of Mental Status (BIMS) score was 8, indicated moderate cognitive impairment. During a record review of document titled Discontinued Physician Orders (undated), indicated Medical Director (MD) started Resident 1 on Rexulti 2 milligrams (mg) by mouth once daily on 9/6/2024. MD did not document behaviors that indicated the need for the medication order. MD discontinued the medication on 11/8/2024 with no indication for the discontinuation of the order. During a record review of Resident 1's Medication Administration Record (MAR) September 2024, October 2024 and November 2024, indicated Resident 1 received Rexulti 2 mg by mouth once daily from 9/6/2024 - 11/8/2024 for dementia as evidenced by psychotic behaviors. During a website review on www.dailymed.nlm.nih.gov/dailymed/ (undated), Rexulti had a boxed warning (the strongest warning that the Federal Drug Administration (FDA) required, and signified medical studies indicated drug carried a significant risk of serious or life-threatening adverse effects) and indicated increased mortality in elderly patients with dementia-related psychosis. Website further indicated medical studies found that Rexulti is not approved for the treatment of patients with dementia-related psychosis .due to increased risk of death [due to] heart failure, sudden death, and pneumonia. During a record review of facility policy titled Psychotropic Medication Use 2001 MED-PASS, indicated residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Furthermore, the document indicated a comprehensive assessment of the resident needed to be performed prior to describing a psychotropic medication. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Document also indicated when determining whether to initiate, modify, or discontinue medication therapy, the [Interdisciplinary Team IDT] conducts an evaluation of the resident to determine other causes for symptoms, signs and symptoms that were clinically significant to warrant medication therapy, and the actual or intended benefit of the medication is understood by the resident/responsible party (RP). During an interview with Director of Nursing (DON) on 12/31/2024 at 11:56 am, DON stated facility spoke with RP prior to starting Resident 1 on Rexuli 2 mg by mouth once daily and RP agreed to medication. DON confirmed facility could not locate informed consent for MD order of Rexulti 2 mg by mouth once daily. DON stated Resident 1 did really well on medication and staff saw good results when Resident 1 took the medication. DON stated Resident 1's responsible party requested facility discontinue medication order in November 2024. DON stated MD was notified and confirmed medication order was discontinued on 11/8/2024. During an interview on 1/2/2025 at 11:30 am with MD, MD stated he prescribed Rexulti 2 mg by mouth once daily for Resident 1 due to some aggression issues and agitation problems towards staff and other residents. MD could not recall when the order was started, the timeframe Resident 1 took the medication, nor when the order was discontinued. MD stated he did not observe Resident 1's behavior prior to the medication being prescribed or Resident 1's behavior when she took the medication. MD stated he could not remember if he signed an informed consent for Resident 1 to start the medication. MD stated I'm sure I did. Usually, staff will put it in my box and sign it. I don't know. I can't remember. MD stated he prescribed the medication after facility contacted him and specifically requested a prescription for Rexulti for Resident 1. MD was unaware Rexulti had a boxed warning and could have caused adverse consequences for Resident 1. During an interview with Responsible Party (RP) on 1/8/2025 at 10:25 am, RP stated she never spoke to the MD before Resident 1 started Rexuli 2 mg by mouth once daily. RP stated only person she spoke to at facility regarding the medication was a Certified Nursing Assistant (CNA). RP stated she was never updated by facility or MD how Resident 1 did on the medication. RP stated risks and benefits were not explained to her by the MD. RP stated she had no idea how Resident 1 did on the medication due to no communication from facility. RP stated she went to facility in early November 2024 to retrieve laundry from Resident 1 and a housekeeper that spoke Spanish told her how Resident 1 did on the medication and how her behaviors had changed. RP stated she did not like that Resident 1 had a flat expression on the medication, and requested it discontinued. RP stated she made this request through a Spanish-speaking CNA. During an interview on 1/16/2025 at 10:00 am, the Director of Nursing (DON) stated the clinical indication for Rexulti 2 mg by mouth once daily for Resident 1 was dementia with behaviors, like yelling at staff. DON stated she entered the order for Rexulti 2 mg by mouth once daily after speaking with MD. DON stated, I heard it was a new medication for dementia and I thought [Resident 1] would do well on it. DON stated facility did not monitor Resident 1 per facility policy for at least three days when Resident 1 started the medication. DON stated she missed entering the monitoring parameters into Resident 1's MAR for behaviors and side effects of the medication. DON confirmed facility did not monitor Resident 1 on Rexulti 2 mg by mouth once daily. DON stated facility IDT did not determine what behaviors to monitor. DON stated she did not communicate relevant information regarding medication monitoring for Resident 1 to other staff members. DON stated facility did not assess if the medication was effective. DON stated facility did not attempt to reduce the medication. DON stated she did not communicate Resident 1's behavior to MD when she requested the medication for Resident 1.

Based on interview and record review, the facility failed to inform one of three sampled residents (Resident 1) of the risks and benefits of proposed care, treatment, and treatment alternatives in a language she could understand (Spanish) prior to starting a psychotropic (drugs that affect a person's mental state) medication. This failure denied Resident 1's responsible party (RP) her right to participate in Resident 1's treatment decisions and had the potential to affect Resident 1's functional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, and psychosocial status. Findings: During a record review of Resident 1's admission record, indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (a decline in mental abilities that affect daily life), glaucoma (chronic eye disease that can cause vision loss or blindness), dysphagia (difficulty swallowing), and type 2 diabetes (body cannot produce enough insulin). Document indicated Resident 1's primary language was Spanish, and her RP's primary language was Spanish. During a record review of document titled Minimum Data Set (MDS) Section C, Resident 1's Brief Interview of Mental Status (BIMS) score was 8, indicated moderate cognitive impairment. During a record review of facility policy titled Informed Consent Verification (undated), indicated facility shall verify that informed consent has been obtained by the physician before a psychotherapeutic medication is administered. The policy also indicated the facility needed to obtain indication for use from the physician. The policy also indicated a printed or electronic version of the informed consent would be included in resident's medical record. During a record review of Resident 1's Medication Administration Record (MAR) September 2024, October 2024, and November 2024, indicated Resident 1 received Rexulti 2 mg by mouth once daily from 9/6/2024 - 11/8/2024 for dementia as evidenced by psychotic behaviors. During a website review on www.dailymed.nlm.nih.gov/dailymed/ (undated), Rexulti had a boxed warning (the strongest warning that the Federal Drug Administration (FDA) required, and signified medical studies indicated drug carried a significant risk of serious or life-threatening adverse effects) and indicated increased mortality in elderly patients with dementia-related psychosis. Website further indicated medical studies found that Rexulti is not approved for the treatment of patients with dementia-related psychosis .due to increased risk of death [due to] heart failure, sudden death, and pneumonia. During a record review of document titled Discontinued Physician Orders (undated), indicated Medical Director (MD) started Resident 1 on Rexulti 2 milligrams (mg) by mouth once daily on 9/6/2024. MD did not document behaviors that indicated the need for the medication order. MD discontinued the medication on 11/8/2024 with no indication for the discontinuation of the order. During a concurrent interview with Director of Nursing (DON) on 12/31/2024 at 11:56 am, DON stated facility could not locate informed consent for MD order of Rexulti 2 mg by mouth once daily. DON confirmed the informed consent was not scanned into Resident 1's chart. The DON stated Resident 1 did really well on the medication and staff saw good results when Resident 1 took the medication. The DON stated Resident 1's responsible party requested facility discontinue medication order. DON stated MD was notified and confirmed medication order was discontinued. During a concurrent interview with Administrator (Admin) on 12/31/2024 at 12:10 pm, Admin confirmed facility could not locate Resident 1's informed consent for MD order of Rexulti 2 mg by mouth once daily. Admin stated informed consent facility process included a signature by responsible party or resident and scanned into resident's chart. Admin confirmed informed consent was not scanned into Resident 1's chart. During a concurrent interview on 1/2/2025 at 11:30 am with Resident 1's physician (MD), MD stated he prescribed Rexulti 2 mg by mouth once daily for Resident 1 due to some aggression issues and agitation problems towards staff and other residents. MD could not recall when the order was started, the timeframe Resident 1 took the medication, nor when the order was discontinued. MD stated he did not observe Resident 1's behavior prior to the medication being prescribed or Resident 1's behavior when she took the medication. MD stated he could not remember if he signed an informed consent for Resident 1 to start the medication. MD stated I don't know. I can't remember. During a concurrent interview with Responsible Party (RP) on 1/8/2025 at 10:25 am, RP stated she never spoke to the MD before Resident 1 started Rexuli 2 mg by mouth once daily. RP stated only person she spoke to at facility regarding the medication was a Certified Nursing Assistant (CNA). RP stated during a conversation with the CNA, she agreed to start the medication. RP stated the risks and benefits were not explained to her by the MD. RP stated she had no idea how Resident 1 did on the medication due to no communication from facility. RP stated she did not like that Resident 1 had a flat expression on the medication, and requested it discontinued. RP stated she made this request through a Spanish-speaking CNA. During a concurrent interview with DON on 1/16/2025 at 10:00 am, DON stated she heard about Rexulti and thought it would be a good medication for Resident 1. DON stated she contacted MD and requested an order. DON re-confirmed an informed consent could not be located for Resident 1.

Based on interview, and record review, the Medical Director (MD) failed to provide progress notes for one of three sampled residents (Resident 1) that reflected a review of total resident care, current condition (including medications and treatments), and MD decisions about the continued appropriateness of a medical regimen. The facility also failed to work with the MD or seek alternate MD participation to ensure Resident 1 received appropriate care and treatment. This failure had the potential to result in miscommunication of medical diagnosis, treatment, unclear and/or missing direct care staff expectations for Resident 1. Findings: During a record review of Resident 1's admission record, indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (a decline in mental abilities that affect daily life), glaucoma (chronic eye disease that can cause vision loss or blindness), dysphagia (difficulty swallowing), and type 2 diabetes (body cannot produce enough insulin). Document indicated Resident 1's primary language was Spanish, and her RP's primary language was Spanish. During a record review of document titled Minimum Data Set (MDS) Section C, Resident 1's Brief Interview of Mental Status (BIMS) score was 8, indicated moderate cognitive impairment. During a record review of document titled Discontinued Physician Orders, indicated Medical Director (MD) started Resident 1 on Rexulti 2 milligrams (mg) by mouth once daily on 9/6/2024. MD did not document behaviors that indicated the need for the medication order. MD discontinued the medication on 11/8/2024 with no indication for the discontinuation of the order. During a record review of Resident 1's Medication Administration Record (MAR) September 2024, October 2024, and November 2024, indicated Resident 1 received Rexulti 2 mg by mouth once daily from 9/6/2024 - 11/8/2024 for dementia as evidenced by psychotic behaviors. During a record review of document titled Physician Note September 2024, MD indicated no new behaviors, though continues to have occasional verbal outbursts and yelling at staff. MD did not document the order for Resident 1 to start Rexulti 2 mg by mouth once daily on 9/6/2024. MD did not document Resident 1 received Rexulti 2 mg by mouth once daily from 9/6/2024 - 9/30/2024. MD indicated no changes to medications this month. During a record review of document titled Physician Note October 2024, MD indicated no new behaviors documented. MD did not document that Resident 1 received Rexulti 2 mg by mouth once daily for the entire month. During a record review of document titled Physician Note November 2024, MD indicated resident noted to be pinching other residents and making false accusations .some bruising noted on right forearm. Resident denies any aggressive behaviors. MD did not document that Resident 1 received Rexulti 2 mg by mouth once daily from 11/1/2024 - 11/8/2024. MD indicated in document no changes to medications this month. During an interview on 1/2/2025 at 11:30 am with MD, MD stated he prescribed Rexulti 2 mg by mouth once daily for Resident 1 due to some aggression issues and agitation problems towards staff and other residents. MD could not recall when the order was started, the timeframe Resident 1 took the medication, nor when the order was discontinued. MD stated he did not observe Resident 1's behavior prior to the medication being prescribed or Resident 1's behavior when she took the medication. MD stated he could not remember if he signed an informed consent for Resident 1 to start the medication. MD stated I don't know. I can't remember.

Based on in interview and record review the facility failed to provide the residents food that is palatable (tasty, and flavorful), visually pleasing presentation, and an appetizing temperature for 23 of 47 residents (Residents: 53, 39, 28, 42, 35, 63, 24, 50, 16, 27, 52, 40, 58, 33, 56, 4, 59, 6, 5, 32, 18, 9, and 22) when residents complained of food not tasting good, visually unappealing/unrecognizable presentation, and being cold on a regular basis. This failure had the potential to result in residents not obtaining adequate nutritive intake, precarious weight loss, increased health issue complications, and diminished emotional well-being. Findings: During a record review of the facility's policy and procedure titled, Food: Quality and Palatability, Revised 9/2017, the Food: Quality and Palatability policy indicated, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature . 1.A review of Resident 53's medical record indicated that resident 53 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, High Blood Pressure, Peripheral Vascular Disease (PVD, Circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During an interview on 3/5/24 at 9:50 am, with Resident 53, stated, Food is not good. (Related to all food) All things, not good. Every day is scrambled eggs. Taste like Hell. 2.A review of Resident 39's medical record indicated that resident 39 was admitted on [DATE] with diagnoses that included, Degenerative Disease of the Basal Ganglia (Rare disease, over time, causing areas of the brain to shrink, nerve cells break down and die affecting areas of the brain that process information and control movement), High Blood Pressure, Intervertebral Disc Degeneration (Breakdown of one or more of the discs that separate the bones of the spine) During an interview on 03/05/24 9:50 am, with Resident 39, stated, always get scrambled eggs. every day is scrambled eggs, never changed. (Food) Temp is cold. 3.A review of Resident 28's medical record indicated that resident 28 was admitted on [DATE] with diagnoses that included, Fracture of the fifth lumbar vertebra, Diabetes Mellitus, High Blood Pressure. During an interview on 03/05/24 1:55 pm, with Resident 28, stated, The flavor is not good. I need lots of salt in the food (to eat it). the gravy isn't good. The problem is food .no salt, no eat, (I go) hungry . 4.A review of Resident 42's medical record indicated that resident 42 was admitted on [DATE] with diagnoses that included, Anoxic Brain Damage (Blood flow is disrupted to the brain causing complete, lack of oxygen resulting in death of brain cells), Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung disease that block airflow and make it difficult to breathe), Congestive Heart Failure (CHF, heart muscle does not pump blood effectively). During an interview on 3/5/24 at 10:09 am, with Resident 42, stated, (The food is) Bland, no flavor, not good. 5.A review of Resident 35's medical record indicated that resident 35 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, Non-ST Elevation Myocardial Infarction (NSTEMI, less severe form of heart attack, inflicting less damage on the heart), COPD. During an interview on 03/05/24 9:50 am, with Resident 35, stated, The food is the main issue, no taste. 6.A review of Resident 63's medical record indicated that resident 63 was admitted on [DATE] with diagnoses that included, Acute Embolism and Thrombosis of Unspecified Deep Veins of Bilateral Lower Extremities (Blood clots forming in deep veins of the legs blocking blood flow), Polyneuropathy (Many nerves outside the brain and spinal cord are damaged causing weakness, numbness, and pain), and High Blood Pressure. During an interview on 03/05/24 10:15 am, with Resident 63, stated, Food is unrecognizable. 7.A review of Resident 24's medical record indicated that resident 24 was admitted on [DATE] with diagnoses that included, Dementia, Benign Prostatic Hyperplasia (BPH, Age related condition where the prostate becomes enlarged. The prostate is a small gland that helps make semen, found below the bladder, the enlargement results in blocking the flow of urine out of the bladder), Malignant Neoplasm of Colon (Colon cancer). During an interview on 03/05/24 10:15 am, with Resident 24, stated, Food is sometimes ok. I am not able to recognize what it is .I do not like to eat what I do not know what is. I can't recognize (the food) at all. I have told them when it isn't hot .I do not return food, I just try to eat it, or I just don't eat. 8.A review of Resident 50's medical record indicated that resident 50 was admitted on [DATE] with diagnoses that included, Cerebral Infarction (stroke), Hemiplegia and Hemiparesis following Cerebral Infarction (weakness and paralysis on one side of the body)), Malignant Neoplasm of breast (Breast cancer). During an interview on 03/05/24 10:42 am, with Resident 50, stated, (Food is) Yuck. 9.A review of Resident 16's medical record indicated that resident 16 was admitted on [DATE] with diagnoses that included, COPD, Diabetes Mellitus, Hyperkalemia (High Potassium levels in the blood). During an interview on 03/05/24 10:45 am, with Resident 16, stated, I am on specified diet, I am not supposed to have process food. but everything they offered me is processed food. I would be going hungry .every single meal I have gravy and mash potato for breakfast, they told me I cannot have greens, but they still gave it to me. They are not consistent .often it doesn't taste good. 10.A review of Resident 27's medical record indicated that resident 27 was admitted on [DATE] with diagnoses that included, Fracture of Lumbar Vertebra, Heart Failure, Atrial Fibrillation (A Fib, Irregular often rapid heart rate that causes poor blood flow, the heart's upper chamber beat out of coordination with lower chambers). During an interview on 03/05/24 10:48 am, with Resident 27, stated, I got scrambled eggs every day. Food is cold. 11.A review of Resident 52's medical record indicated that resident 52 was admitted on [DATE] with diagnoses that included, COPD, Unspecified Protein- Calorie Malnutrition (nutritional status with reduced availability of nutrients), High Blood Pressure. During an interview on 3/5/24 at 10:54 am, with Resident 52, stated, The food isn't what I like (taste). 12.A review of Resident 40's medical record indicated that resident 40 was admitted on [DATE] with diagnoses that included, Paroxysmal A Fib, High Blood Pressure, PVD. During an interview on 03/05/24 11:15 am, with Resident 40, stated, The food is not very good, but I eat it. 13.A review of Resident 58's medical record indicated that resident 58 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, Muscle Weakness, High Blood Pressure. During an interview on 03/05/24 11:32 am, with Resident 58, stated, There is not enough food, and the food is only so-so (taste). 14.A review of Resident 33's medical record indicated that resident 33 was admitted on [DATE] with diagnoses that included, Vascular Dementia (Damaged blood vessels in the brain impairing the blood flow to the brain resulting in brain damage and causing memory, reasoning, and thought process problems), Generalized Muscle Weakness, Chronic Pain Syndrome. During an interview on 03/05/24 11:55 am, with Resident 33, stated, Food is horrible. Slop. They cannot even cook a grilled cheese. 15.A review of Resident 56's medical record indicated that resident 56 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, High Blood Pressure, Benign Prostatic Hyperplasia (BPH, Age related condition where the prostate becomes enlarged. The prostate is a small gland that helps make semen, found below the bladder, the enlargement results in blocking the flow of urine out of the bladder). During an interview on 03/05/24 12:10 pm, with Resident 56, stated, In morning, breakfast, especially eggs, almost always cold. 16.A review of Resident 4's medical record indicated that resident 4 was admitted on [DATE] with diagnoses that included, Acute Pyelonephritis (Bacterial infection causing inflammation to the kidneys), High Blood Pressure, Mixed Hyperlipidemia (condition with high levels of fats in the blood, low density (LDL) cholesterol and triglycerides, which increase the risk of heart disease). During an interview on 03/05/24 12:40 pm, with Resident 4, stated, There is not enough food. It tastes ok sometimes. 17.A review of Resident 59's medical record indicated that resident 59 was admitted on [DATE] with diagnoses that included, Dementia (Entails a decline in mental function from a previously higher level severe enough to interfere with daily living), Transient Ischemic Attack (TIA, Brief blockage of blood flow to the brain resulting in stroke like symptoms), Presence of Cardiac Pacemaker (Small battery powered device implanted under the skin near the collarbone that prevents the heart from beating too slow). During an interview on 03/05/24 1:55 pm, with Resident 59, stated, Food is cold, didn't know there were alternatives, I was taught to eat what I was given. 18.A review of Resident 6's medical record indicated that resident 6 was admitted on [DATE] with diagnoses that included, Acute Myocardial Infarction (MI, heart attack), Hemiplegia and Hemiparesis following Cerebral Infarction, High blood pressure. During an interview on 03/06/24 2:00 pm, with Resident 6, stated, Scrambled eggs every morning. I do not like it. Food is always cold and does not taste good. 19.A review of Resident 5's medical record indicated that resident 5 was admitted on [DATE] with diagnoses that included, Epilepsy (Disorder of the brain causing recurrent seizures, brief episodes of involuntary movement that may involve a part of the body (partial), or the entire body (generalized), and are sometimes accompanied by loss of consciousness and loss of bladder/ bowel control), Liver Cancer, Parkinson's Disease (Progressive disorder of the central nervous system, causing nerve cell damage, affecting movement, often including tremors). During an interview on 3/6/24 at 09:19 am, with Resident 5, stated, Food is not so good (taste), the food temp is mostly cold. 20.A review of Resident 32's medical record indicated that resident 32 was admitted on [DATE] with diagnoses that included, A fib, Heart Failure, High Blood Pressure. During an interview on 03/06/24 1:15 pm, with Resident 32, stated, Food is not good, no taste. It is cold, especially the scrambled eggs. 21.A review of Resident 18's medical record indicated that resident 18 was admitted on [DATE] with diagnoses that included, Cerebral infarction (stroke, disruption of blood flow to the brain due to problems with the blood vessels that supply it), Malignant Neoplasm of Left Breast (breast cancer), Heart Failure. During an interview on 03/06/24 1:15 pm, with Resident 18, stated, Food is unrecognizable, can't tell what it is. Taste is tolerable, but not great. 22.A review of Resident 9's medical record indicated that resident 9 was admitted on [DATE] with diagnoses that included, High Blood Pressure, Unspecified Severe Protein Calorie Malnutrition, Cellulitis of the Buttock (Bacterial skin infection resulting in inflammation and pain). During an interview on 03/06/24 1:15 pm, with Resident 9, stated, The food has no taste. It is cold, especially the breakfast and scrambled eggs. 23.A review of Resident 22's medical record indicated that resident 22 was admitted on [DATE] with diagnoses that included, Cirrhosis of the Liver (Permanent scarring that damages the liver and interferes with the function), Hypotension (Low blood pressure), Spinal Stenosis (Narrowing of one or more spaces within the spinal canal). During an interview on 03/06/24 8:25 am, with Resident 22 stated, I do not like the food at all (taste/presentation). During a review of Resident Council Minutes, Resident Council Discussion of New Business, and Resident Council Action Form, dated December 2023 through January 2024, the Resident Council Minutes, Resident Council Discussion of New Business, and Resident Council Action Form, indicated, food could be better, (food had) no taste, food was not at desirable temperatures, residents dislike some meals and wanted changes. During an interview on 3/7/24 3:00 pm, with DM, DM stated, I know we have complaints .We are looking at what we can do to try and alleviate this issue and make food more acceptable to our residents. During an interview on 03/08/24 11:12 am, with Admin, Admin stated, I expect the food served to the residents be edible, appetizing, aesthetically pleasing, nutritious, with an appropriate temperature, and to their satisfaction.

Based on observation, interview, and record review, the facility failed to properly label and store COVID-19 (a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2) rapid test kits when the kits stored in one medication cart had expired. This failure had the potential to cause inaccurate test results which could have put the residents at risk for inappropriate care and treatment based on the test results. Findings: During a concurrent observation and interview, on [DATE], at 9:52 AM, at Medication Cart One, the Assistant Director of Nursing (ADON) opened the locked cart. In the bottom drawer were four boxes of COVID-19 Antigen (any substance that caused the body to make an immune response against that substance) Rapid Test kits. Each box contained two tests. ADON confirmed the expiration date printed on the boxes was [DATE]. The lot number was 221CO20907. The United States Food and Drug Administration Authorized At-Home Over-the-Counter Diagnostic Tests and Expiration Dates table, located online at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests#list, was reviewed. The table contained a list of various manufacturers' COVID-19 testing kits, information about the tests, links to directions for use, expiration dates and expiration date extensions based on lot numbers. The table indicated that for test lot number 221CO20907, with a printed expiration date of [DATE], the expiration date had been extended to [DATE], which had already passed.

Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety when a case of Glucerna (a sugar-free nutritional supplement protein shake), had expired on [DATE], and was still on the shelf and available for use. This failure had the potential to result in health and safety concerns for individual residents that consumed the shake for nutritional supplement. Findings: During a concurrent observation and interview on [DATE] at 09:30 am with the Dietary Manager (DM) in the dry storage food pantry, a case of Glucerna that expired on [DATE], was available for use. DM stated, I see the date, yes, they are expired. I will get rid of them immediately. During a review of the facility's policy and procedure titled, Receiving HCSG Policy 017, dated ,d+[DATE], indicated, safe food handling procedures for time .will be practiced in storage of all food items. During a review of the United States (U.S.) Food and Drug Administration (FDA) Food Code 2022, indicated, regarding commercially processed food requirements .processed .foods that exceed the use-by date or manufacturer's pull date .must be disposed of in a proper manner.

Based on observation, interview, and record review, the facility failed to ensure a care plan for one of 16 sampled residents (Resident 46), was revised and updated to reflect current individual needs for feeding assistance required. This failure resulted in the resident's individual care needs to go unrecognized, and the potential for a further decline in resident's physical, mental, and psychological status. Findings: During a review of the facility's policy, not dated, titled, Care Plans, Comprehensive Person-Centered, indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Each resident's care plan is consistent with the resident's rights to receive the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psycho-social wellbeing. This facility's policy also indicated, Assessments of residents are ongoing and care plans are revised as information about the residents' condition changes. A review of Resident 46's clinical record indicated Resident 46 was admitted to the facility on [DATE] for diagnoses that included high blood pressure, Palliative Care (a program appropriate with any serious medical condition with the primary goal to improve quality of life while providing comfort), Dyspnea (medical term for shortness of breath), and chronic pain. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool), for Resident 46 dated 9/1/23, indicated Resident 46 had a brief interview for mental status (BIMS) score of 13 of 15, no noted cognitive impairment and was her own responsible party. A review of a care plan revised 9/20/23 indicated Resident 46 was admitted to Hospice Services (end of life care), and to coordinate plan of care with hospice agency and to update with any changes. Resident 46's care plan dated 9/20/23 also indicated, Establish a plan of care and update/revise plan frequently. During a concurrent observation and interview on 10/5/23 at 8:15 am, Resident 46 was unable to reach water and yogurt left on the bedside table. Resident 46 stated, Yes, I am hungry, but I need help please. During an interview on 10/5/23 at 8:25 am, Registered Nurse (RN) A confirmed Resident 46 had a recent decline and needs assistance from staff with eating and drinking. During an interview on 10/5/23 at 8:32 am, Certified Nursing Assistant (CNA) H stated, I know [Resident 46] needs help with feeding now, that changed sometime last week. I told the nurse, and I have been helping [Resident 46]. During an interview on 10/5/23 at 8:40 am, CNA G stated, Yes, I was told by CNA H [Resident 46] needs help with feeding assistance, she cannot do it herself now. During an interview on 10/5/23 at 8:45 am, Director of Staff Development (DSD) confirmed the change in condition for Resident 46's self-feeding ability was not updated on the care plan. A review of Resident 46's clinical record dated 10/5/23 at 13:22, titled, General Note, indicated, Resident 46 was noted to have a decline in ability to self-feed, Hospice notified of change, Medical Doctor (MD), updated and resident agrees with needing assistance During an interview on 10/5/23 at 2:55 pm, MDS Coordinator (MDS) stated, I cannot believe no one told me about this decline with [Resident 46], but I will make sure it is added to the care plan. During an interview on 10/5/23 at 3:45 pm, Interim Director of Nursing (IDON) confirmed all changes should be added to the care plan as soon as staff is aware to meet the individual needs of all residents in a timely manner. IDON confirmed the care plan was not revised or updated for Resident 46 in a timely manner.

Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 12), a copy of the Resident [NAME] of Rights. This failure had the potential for new residents to be unaware of their rights that maintain quality of life while undergoing care in the skilled nursing setting. Findings: A review of an admission record was done. Resident 12 was admitted on [DATE] with diagnoses which included severe protein-calorie malnutrition, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), weakness and difficulty walking, and lumbar disc degeneration. A concurrent interview and record review was conducted on 10/05/23 11:54 am, with the Admission Coordinator (AC) who stated that the admission process was completed using an iPad device and residents signed the California Standard Admission Agreement for Skilled Nursing Facilities electronically. In her estimation, half of residents requested a printed copy of the e-documents they sign which she prints and provides. AC was asked to print a completed admission packet for Resident 12, it was noted that the Resident [NAME] of Rights had not printed, and AC was unable to explain why that particular section had not printed. A review of a California Standard Admission Agreement for Skilled Nursing Facilities (AKA admission packet) was made. Attachments A through F were listed in the table of contents, with Attachment F designated for the Resident [NAME] of Rights. Section iv, Your Rights as a Resident, specified as follows, Residents of this Facility keep all their basic rights and liberties as a citizen or resident of the United States when, and after, they are admitted . Because these rights are so important, both federal and state laws and regulations describe them in detail, and state law requires that a comprehensive Resident [NAME] of Rights be attached to this agreement. Attachment F, entitled 'Resident [NAME] of Rights,' lists your rights, as set forth in State and Federal law, and further directs, You should review the attached Resident [NAME] of Rights very carefully. A review of Attachment F, the Resident [NAME] of Rights, was made. Attachment F consisted of 31 pages detailing rights that relate to quality of life and care in the following categories: privacy and confidentiality, participation in the plan of care and in groups and activities, living accommodations, the protection of money and possessions, visitors, self-determination in how to spend one's time, addressing grievances, refusal/participation in medical care and treatment, and freedom from abuse and restraints, among others. A review of Resident 12's admission packet dated 8/30/22 was done. The signature was done electronically. Attachment F was not among those documents. In an interview on 10/05/23 12:50 pm, the Administrator stated that the facility's Information Technologist (IT) had discovered that Attachment F, Resident [NAME] of Rights, had not been selected during the initial set-up of the electronic records process and therefore, Attachment F did not print out with the admission forms when residents requested a copy of their admission documents. This was confirmed with IT, who was present.

Based on observation, interview, and record review the facility failed to protect one of two sampled residents (Resident 1) from abuse when Certified Nurse's Assistant (CNA) 1 roughly threw Resident 1 into bed, put a pillow on her face, and hit her on her head. This incident was heard by Resident 2. This resulted in Resident 1 to have an injury to the head with bruising and pain; and Resident 1 and Resident 2 to experience emotional distress. Findings: Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/4/21, indicated that the facility would protect residents from being abused by facility staff, ensure adequate oversight, and implement policies and procedures that would identify and prevent abuse. Additionally, the policy indicated that the facility would maintain a culture of compassion and caring for all residents, particularly those with cognition and mentation deficits (a decline in mental ability). A review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnosis of kidney infection, left hip pain and recent falling. Review of two documented Minimum Data Sets (MDS, a Resident assessment tool) dated 1/20/23 and 4/22/23, indicated that Resident 1 scored a nine on the Brief Interview for Mental Status (BIMS), which indicated she had moderately impaired mentation (a slight decline in mental ability), had no disordered thinking and was able to recall words. During an interview on 5/5/23 at 10 AM, Resident 1 stated, CNA 1 slapped me, roughly threw me into my bed, put a pillow over my face and hit me here on my head (Resident 1 was pointing to her right forehead). Resident 1 stated, I was afraid and crying. Resident 1 confirmed that her roommate (Resident 2) called for help and that she had reported what happened to a nurse. Resident 1 stated, I feel safe now because the Administrator told me CNA 1 will not be coming back. Review of a record title MDS dated [DATE], indicated that Resident 2 had a BIMS score of 15 and had no difficulty with mentation or word recall. During an interview on 5/5/23 at 11:15 AM, Resident 2 (Resident 1's roommate) stated, CNA 1 came into the room, she was being rough with my roommate, I heard CNA 1 slap her, I could hear everything. Resident 2 explained that she was in her bed and that Resident 1 was in her wheelchair on the other side of the curtain. Resident 2 explained she could hear thrashing and Resident 1 hollering for CNA 1 to stop hurting her. Resident 2 stated, I heard my roommate crying and calling for help, I heard a slap, and my roommate saying she could not breath. Resident 2 stated, I felt so disgusted that I could not help, and I was afraid. Resident 2 confirmed that she had called for another nurse to come into the room and that Resident 1 had told them what happened. Resident 2 stated, I was afraid for her, she was crying and so upset. Resident 2 stated, The Administrator told me that her (Resident 1's) bed controller had slipped from the CNA's hand accidentally and that is all that I heard; he said I should not talk about it but what she (CNA 1) did was not right. Review of a document titled Final Report: Allegations of Abuse written by the Administrator, dated 4/25/23, indicated that during an interview on 4/21/23, Resident 1 stated that CNA 1 had hit her in the face, and that during another interview on 4/24/23 Resident 1 had stated that CNA 1 had hit her on the face and tried to smother her with a pillow. The report also indicated that on 4/22/23 a mark was visible on Resident 1's right head at the hair line and that Resident 2 had stated during the investigation interview that CNA 1 was grumpy when she entered the room, cursed while providing care, that she had heard slapping and hitting sounds, and had that she heard Resident 1 yell out twice, once indicating that she could not breath. Lastly, the report indicated that CNA 1 was allowed to return to work. During an interview on 5/5/23 at 10:18 AM, Licensed Vocational Nurse (LVN 1) stated that Resident 1 was not one to complain about others, was usually calm, nice, cooperative, and was not easily influenced. LVN 1 stated, I am very familiar with Resident 1, her memory is good. LVN 1 stated, yes, I think you can believe a confused resident. During an interview on 5/5/23 at 11 AM, the Administrator confirmed that CNA 1 was new to the facility and that he had planned on terminating her after the abuse was reported to him but that after his investigation he did not. The Administrator stated during his investigation, CNA 1 had stated she did not hit Resident 1, that the bed controller had slipped from her hand and may have hit Resident 1. CNA 1 explained she had not seen or heard it hit, and that Resident 1 said to her You hit me but she saw the resident was fine, had apologized and then left the room. Administrator stated, While conducting my investigation, Resident 1 changed her story from being hit to being smothered with a pillow, I believe her roommate (Resident 2) influenced her recollection of the event. Administrator explained that Resident 1's roommate likes to get into everyone's business and is a Confabulator. The Administrator stated, my investigation determined that CNA 1 did not intentionally hit Resident 1 and she was allowed to return to work. When asked, the Administrator stated, You can believe a confused resident, but again explained that his investigation determined that Resident 1's recollection of how she got the bruise on her head was not accurate. During an interview on 5/9/23 at 11:08 AM Resident 1 was observed with a pale-yellow green bruise with a small thin white scab to the center just below and extending to the hairline on the right forehead that was approximately 2.5 x 3 centimeters in size. When asked how she got the bruise Resident 1 stated, A CNA hit me. When asked to provide more details Resident 1 explained that CNA 1 had thrown her into bed, then hit her and held a pillow over her face. When asked what hit her, Resident 1 stated She hit me with her hand, and the television controller. When asked if she had told anyone, Resident 1 stated that her roommate (Resident 2) was there and that she called for help and then two staff members came into the room. Resident 1 stated that she was unable to call for help during the attack and that she was upset, crying, and scared. Resident 1 indicated she was in her wheelchair on the left side of the bed (near Resident 2 ' s bed) just before it happened. Resident 1 stated that she did not know why CNA 1 did this, and that she had asked the CNA why she was so mean. Resident 1 indicated that CNA 1 had not been in her room since and stated, I am afraid of her. Resident 1's bed control remote was observed hanging from the bed rail, when asked if the bed control had hit her, Resident 1 stated, No, the television (TV) control (Resident 1 held up the TV controller in her hand). Resident 1 was observed using the TV control without difficulty and identified the call assist button, demonstrating she knows the difference between the items. Resident 1 stated, I feel safe now, I know they will not let her come back. During an interview on 5/9/23 at 1:15 PM, LVN 2 stated, CNA 2 came and got me, she was saying that the Resident 1 was crying, and that a CNA had abused her; I went into the room and saw both residents upset. Resident 1 was crying when she stated, CNA 1 had hit her, put a pillow over her face and choked her. LVN 2 explained Resident 1 was very sweet and never had conflict with anyone. LVN 2 stated he informed the Administrator and CNA 1 was sent home. During an interview on 5/9/23 at 1:38 PM, CNA 2 stated, Resident 1 told me CNA 1 had hit her, and I saw there was a red bump forming on the right side of Resident 1's head. CNA 2 explained that Resident 1 was crying and so upset that she could hardly get her words out, and that Resident 2 had stated to her I heard Resident 1 getting hit and yelling, stop you ' re hurting me, and I can ' t breathe. CNA 2 explained that the next day Resident 1 had stated to her, my head really hurts and then again stated, CNA threw me on the bed, hit me and held a pillow over my face. CNA 2 stated, The small bump on her head had formed into a larger raised bruise. CNA 2 confirmed she was familiar with Resident 1, and stated, she never cries out like that, I had never seen her so upset. CNA 2 stated, I had only worked with CNA 1 a few times before, she was different that day, she was angry and confrontational when she arrived. During an interview on 5/9/23 at 1:50 PM, CNA 1 stated, I was helping The lady (Resident 1) back into bed, I got her laid back down, I lost my grip, the bed controller slipped out of my hand and struck the lady on the head, I changed her, She was ok. CNA 1 confirmed that she had not told anyone about what had happened and stated, She (Resident 1) had a tiny bruise forming, and I did not think it was a big deal, I had already said I was sorry, and the lady was fine when I left the room. CNA 1 denied being upset about anything prior to or during her shift, having any conflicts and stated, other than calling off for the morning my shift, I had started as usual that day. During an interview on 5/12/23 at 10:50 AM, CNA 3 stated, she was near the nurses station just before Resident 1 reported the abuse. CNA 3 explained that CNA 1 approached her looking for CNA 2. CNA 3 told her that CNA 2 was at lunch, then CNA 1 turned abruptly and walked off towards the break room with a fast pace like she was Angry. Review of Nursing Note written on 4/21/23 at 5:10 PM, Licensed Nurse (LN) 3 indicated that Resident 1 complained of a headache that required pain medication. LN 3 indicated that Resident 1 was crying, had bruising to her right head, and had reported that CNA 1 threw her on to the bed, slapped her on the head, and put a pillow over her face that smothered her. Review of a Medication Administration Record, indicated that LN 3 gave Resident 1 Acetaminophen (pain medication) on 4/21/23 at 7:18 PM. Review of a nursing note dated 4/23/23 at 5:45 AM, by Registered Nurse 1 indicated that Resident 1 had a bruise to the right side of her head. Review of an Interdisciplinary team (IDT) note dated 4/24/23 at 9:30 AM, Director of Nursing (DON) indicated that Resident 2 stated she heard a slapping sound, that Resident 1 stated a CNA 1 had slapped her, and that the facility assured Resident 1 that CNA 1 would not be coming back.

Based on observations, interviews, and record review it was determined the facility failed to ensure the use of antipsychotic medications was used only for an appropriate diagnosis, safe dosage and monitor for adverse effects and behaviors for three (Residents(R)31, R23, and R47) of 19 sampled residents. Specifically, R31 was prescribed antipsychotic medication without an acceptable [DIAGNOSES REDACTED]. The resident has had a significant decline in functional status since admission. The use of antipsychotic medication in excessive dose has caused extrapyramidal side effects. The facility did not meet its burden to find the root cause of behaviors prior to using an antipsychotic medication to chemically restrain & manage behaviors for R31. R23 was administered anti-psychotic medication without an appropriate diagnoses, and R47 was administered anti-psychotic medications without behavioral monitoring. The continued administration of an anti-psychotic medication without an appropriate [DIAGNOSES REDACTED]. Findings include: Review of the facility's policy titled Antipsychotic Medications, dated 12/18/19 documents, .use of such medications shall be in the best interest of the resident to improve his/her quality of life. An unnecessary drug is any drug when used: .without adequate indications for its use; or in the presence of adverse consequences which indicates the dose should be reduced or discontinued; or any combination of the above .Antipsychotic drugs: based on a comprehensive assessment of a resident, the facility must ensure that residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .The medication regimen helps promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being . 1. Review of R31's electronic health record (EHR), Face sheet, documented the resident was originally admitted on [DATE] with [DIAGNOSES REDACTED]. On 06/10/19 dementia with behavioral disturbance and delusional disorders were added to the resident's [DIAGNOSES REDACTED]. Review of R31's previous Admission Minimum Data Set (MDS), assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 05/26/19, located under the MDS tab of her EHR. Under Section G-Functional Status revealed resident required supervision or one person for transferring, locomotion on/off unit, and was independent when eating. The resident required limited assistance of one person for bed mobility, walking in room/corridor, dressing and toilet use. The resident was not steady, but able to stabilize without staff assistance during transitions and walking and had no impairment of his upper and lower extremities. The resident was occasionally incontinent of bowel and bladder. Review of R31's last Admission MDS with an ARD of 08/23/19, indicated the resident was readmitted to the facility from a psychiatric hospital on [DATE]. The resident's functional status now indicated the resident required extensive assistance of two or more-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. The activity did not occur for walking in room/corridor. The resident was not steady, only able to stabilize with staff assistance during transitions and walking. The resident was indicated as being frequently incontinent of bowel and bladder. Review of an AIMS Assessment (Abnormal Involuntary Movement Scale completed on 06/20/18 revealed a score of zero, indicating no extrapyramidal symptoms at that time prior to the use of antipsychotic medications. A second assessment was not completed upon R31's readmission to the facility. Observations conducted on 10/01/19, 10/0219 and 10/03/19 revealed the resident was unable to transfer from his wheel chair without total assistance, staff fed him his meals, and he suffered from jerking movements, shuffling, hallucinations and unrecognizable mumbling. Further observations revealed the resident was frequently placed in the hallway after lunch was finished, where on 10/02/19 he was observed to grab R6's wheelchair in an attempt to stop the resident from passing, staff quickly intervened and redirected R31 in another direction. Review of R31's Medication Administration Orders, indicated the resident was receiving [MEDICATION NAME](anti-depressant) 15 milligrams(mg) in the evening for mood liability AEB(as evidenced by) agitation, [MEDICATION NAME] (anti-anxiety) 0.5 mg two times a day for anxiety AEB inability to relax, and [MEDICATION NAME] (anti-psychotic) 250 mg in the evening and 25 mg at lunch for [MEDICAL CONDITION], paranoid delusions, agitation related to dementia with behavioral disturbance. The resident was prescribed [MEDICATION NAME] 1 mg at bedtime for jerking movements on 09/16/19. [MEDICATION NAME] ([MEDICATION NAME]) is used to treat involuntary movements due to the side effects of certain psychiatric drugs such as antipsychotics. A review of the Federal Drug Administration (FDA) Boxed Warning which accompanies second generation anti-psychotics states, Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical anti-psychotic drugs are at an increased risk of death. https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm 1.htm Review of FDA medication Guide for [MEDICATION NAME] located at https://www.fda.gov/files/drugs/published/[MEDICATION NAME]-Medication-Guide.pdf, indicates [MEDICATION NAME] may cause serious side effects, including risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. Review of R31's History and Physical, dated 08/14/19, documented the assessment/plan, dementia with behavioral disturbances, patient now taking scheduled [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg bid as well as [MEDICATION NAME] ([MEDICATION NAME]) 15 mg with dinner and quetiapine ([MEDICATION NAME]) 25 mg at lunch and 250 mg with dinner. Patient appears more compliant and redirectable since changes in medications. Review of R31's care plan dated 08/10/19 indicated the resident had an increase in behaviors such as angry outbursts. The staff was instructed to administer [MEDICATION NAME] 250 mg at dinner and 25 mg at lunch as ordered by MD (Medical Doctor) on 08/10/19 and to monitor behaviors daily. There were no non-pharmacological interventions documented. Continued review of the care plan dated 08/10/19 for R31 revealed the use of the [MEDICAL CONDITION] medication ([MEDICATION NAME]) related to behavior management, disease process (delusional disorders), and potential for injury to self or others. The staff are instructed to administer [MEDICAL CONDITION] medications as ordered by physician, monitor for side effects and effectiveness every shift. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor/document/report PRN (as needed) any adverse reactions of [MEDICAL CONDITION] medications . such as tardive dyskinesia, extrapyramidal symptoms (EPS) . There were no none pharmacological interventions documented. Further review of the care plan identified an entry dated 09/12/19 that R31 exhibited extrapyramidal symptoms. The staff interventions included administer [MEDICATION NAME] every evening, notify MD/RP (responsible party) and, vital signs every shift. Antipsychotic medications commonly produce extrapyramidal symptoms as side effects. The extrapyramidal symptoms include tardive dyskinesia (jerking). Interview was conducted with R31's physician on 10/02/2019 at 10:26 AM in the conference room. The physician stated that his assessment upon resident's return from the psychiatric hospital is that the resident is more directable when he gets worked up, before he would get quite psychotic. The physician was questioned if the resident was receiving any psychiatric services in the facility? The physician stated, he doesn't qualify for psych services due to delusions, dementia, scattered speech, and paranoid, especially with medications. The physician was given the FDA website recommendations for [MEDICATION NAME] and questioned if he thought the medication was appropriate for the resident? The physician stated, I was following the psychiatric hospitals recommendations and have seen an improvement. The physician was questioned concerning the resident having symptoms of EPS and medication for adverse effects verse adjusting the dosage? The physician answered sometimes the benefits outweigh the adverse effects. The physician was asked if he had noticed a change in R31's functional abilities? The physician stated, before the medications he was higher functioning but also a danger to others. Not as functional as before going to the psych hospital but also not as much a danger to others. A telephone interview was conducted with the Consultant Pharmacist on 10/03/19 at 12:45 PM The Consultant Pharmacist was asked if she was familiar with the resident? She stated, Yes, I remember the resident, and had requested an appropriate [DIAGNOSES REDACTED]. The pharmacist was asked if 275 mg of [MEDICATION NAME] is a high dose for this resident? The pharmacist stated, I have seen residents/patients being administered high doses of [MEDICATION NAME] but always in a psychiatric facility. The pharmacist was questioned about treating the resident's EPS with [MEDICATION NAME]? The pharmacist stated, it wouldn't help to treat it and she would recommend a reduction of medication based on EPS symptoms. Should be decreasing dose instead of medicating EPS. 2. Review of R23's Admissions Record, located under the Profile tab of her EHR, documented she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23's Minimum Data Set (MDS), assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 08/11/19, documented in Section C-Cognition Brief Interview of Mental Status, (BIMS), of 10, indicating moderately impaired cognition. No hallucinations or delusions identified; Section [NAME] Behaviors identified had verbal or physical aggression directed towards others 1-3 days out of the past 7 days. R23's medication orders, located under the Orders tab of her EHR, documented an order for [REDACTED]. Review of R23's behavior monitoring, located on the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. R23's care plan, located under the Care Plan tab of her EHR, documented care plan focus areas, goals and interventions for her dementia were initiated on 05/02/18 and revised on 09/23/19, documented a focus area of the use of the anti-psychotic medication [MEDICATION NAME] relate to dementia with behavioral disturbances as evidenced by spitting and hitting. The goals were documented as the resident would be free from drug related complications, and experience fewer episodes of spitting and hitting. The interventions were to administer medications as ordered; discuss with the physician and family the ongoing need for the use of the medication; and encouraging the resident to participate in activities, go outside, or listen to music. The care plan did not document which activities the resident preferred or what type of music she enjoyed. On 09/26/19, a Pharmacy Consultation report, located in a binder provided by the ADON on 10/03/19, documented a pharmacy recommendation for the physician to attempt a dosage reduction of R23's [MEDICATION NAME] with a goal of discontinuation, a statement that [MEDICATION NAME] was not recommended for use in elderly patients with dementia due to an FDA black box warning that it could cause death, and a recommendation that if the medication was continued the physician should evaluate the benefits of the medication against the potential risks. The physician rejected the recommendations on 10/01/19 and documented the medication dosage had been increased as it was ineffective at addressing the target behavioral symptom. On 10/02/19, R23's physician, who is also the facility's Medical Director, was interviewed. The MD stated he had heard from many other residents and their family members that R23's spitting behavior was upsetting them. The MD stated the resident had been evaluated by Speech Therapy for a potential swallowing problem before being started on [MEDICATION NAME], but no difficulties were noted. The MD stated that he had concluded the behavior was intentional, and because it was so upsetting to other residents and their families, he started R23 on [MEDICATION NAME]. The MD stated he did not have an exact [DIAGNOSES REDACTED]. The MD stated he was not sure that the risks and benefits of the medication had been reviewed. On 10/03/19 at 12:47 PM, the Pharmacist was interviewed and stated in her experience a [DIAGNOSES REDACTED]. The facility's undated Antipsychotic Medications policy documented, Based on a comprehensive assessment of the resident . residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. 3. Review of R47's Admission Record, located under the Profile tab of the Electronic Health Record (EHR) documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/19 for R45 revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating reliable and able to make decisions. The assessment failed to identify any issue with moods or behaviors. Review of R47's care plan revised 09/08/19 revealed resident uses [MEDICAL CONDITION] medications. Administer [MEDICAL CONDITION] medications as ordered by the physician. Monitor for side effect and effectiveness every shift. Review of the R47's Physician order [REDACTED]. [MEDICATION NAME] 0.5 milligrams (mg) twice a day for anxiety. Monitor behavior repetitively asking for the same things even though requests were just met and motor restlessness. [MEDICATION NAME] 2.5 mg at bedtime for persecutorial delusions/[MEDICAL CONDITION]. Monitor behavior of hallucinations and thoughts of imaginary persons causing harm. [MEDICATION NAME] 60 mg every day for depression. Monitor behavior statements of depression. Review of the Medication Administration Record [REDACTED]. On 10/02/19 at 8:53 AM the Assistant Director of Nursing (ADON) stated there was not any behavior monitoring currently being done for R47's antipsychotic medication use. The ADON stated the behavior monitoring instituted on 10/02/19 after staff realized it not completed per policy. Review of the Policy Behavior Monitoring dated 12/18/18, Procedure; Behavior Monitoring will be instituted for all residents exhibiting abnormal behaviors and those requiring pharmaceutical treatment. Monitoring will consist of observation of behavioral occurrences, evaluation of treatment, and observation for side effect of treatment.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who experienced a resident to resident altercation received care and services following a traumatic event causing the harm of continued anxiety and afraid for safety in the facility. This affected one of 19 sampled Residents (R) (R34). The resident continues to experience ongoing unassessed and unaddressed feelings of anxiousness and dehumanization following the altercation and fear for her safety. Findings include: The facility's undated Resident Rights policy documented: Each resident is treated with dignity and respect and in a manner and environment promoting maintenance and enhancement of quality of life and protecting and promoting rights of residents. All activities and interactions with residents by staff .focus on assisting the resident in maintaining and enhancing self esteem and self-worth, and incorporating the resident's goals, preferences, and choices. Resident life style and personal choices identified through the assessment process will be considered when identifying individual needs and preferences. The facility's undated Social Services policy documented: Definition - Assisting residents and their families to understand and cope with the emotional and social problems which affect their health status. Make a patient needs assessment as soon as possible when requested to assist a patient or family. Review of R34's Face Sheet, located under the Profile tab of her Electronic Health Record (EHR) documented she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital History and Physical (H&P), located under the Miscellaneous tab of her EHR and dated 11/08/18, documented R34 was brought to the hospital adjacent to the facility, and subsequently to the facility itself, after both her home and the local hospital in the community where she resided burned in a wildfire; and that R34 had mild dementia. R34's Minimum Data Set (MDS) assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 05/26/19, located under the MDS tab of her EHR. The document revealed under Section C-Cognition, she had a Brief Interview of Mental Status (BIMS) score of 14, indicating she was cognitively intact, and had a Patient Health Questionnaire-9 (PHQ-9) score of 0, indicating no depression. The MDS documented under Section E-Behaviors, R34 had no physical or behavioral symptoms directed at others. On 06/05/19 at 07:45 PM, a Nurse's Note in R34's Interdisciplinary Team (IDT) notes, located under the Prog Notes tab of her EHR, documented a verbal altercation between R34 and another unidentified resident, which a 06/11/19 facility investigation identified as R31. The note documented the two residents separated without further incident. No further details regarding the event documented. A second entry on that date at 09:06 PM documented R34 reported she was fearful after the incident which was causing her to feel stressed. On 06/06/19 at 09:04 AM, a Psychosocial/Social Services (SS) note in the IDT notes documented R34 reported another resident had become verbally aggressive with this resident the previous evening, and she was fearful of that resident. The note further documented R34 went to the doorway of the (unidentified) other resident's room and made remarks about the other resident needing a babysitter. The note concluded that, based on this observation, R34 was not actually fearful. A facility investigation on 06/11/19 identified the other resident as R31. The SS note did not document any further assessment or interventions for R34 after she was observed to approach the doorway to R31's room. On 06/07/19 at 09:33 AM, a SS note in R34's IDT notes documented R34's daughter called to express concern for R34's safety following the verbal altercation, stated R34 was fearful of the other resident, (R31) and requested the other resident not be allowed in the proximity of R34's room. The note documented R34's daughter was informed the facility could not provide such assurances. R34's room is located on the same hallway as R31 but R34's room is at the end of the hallway. On 06/10/19 at 09:12 PM, a Nurses Note (NN) in R34's IDT notes documented R34 was propelling herself towards her room while another (unidentified) resident had a verbal outburst and stomped on her foot. The note documented R34 was tearful following the incident. On 06/11/19 a facility investigation confirmed the unidentified resident was R31. On 06/11/19 a facility Risk Management Form, provided by the Staff Coordinator (SC) and identified as the facility's investigation, documented a resident to resident altercation between R34 and R31 at 07:15 PM on 06/10/19. The form documented R31 was attempting to keep R34 from wheeling past him in her wheelchair. The form documented R31 began to call R34 evil and stated she could not pass. The form documented as R34 passed him, R31 stomped on her foot. The investigation form revealed it confirmed that the week prior to this altercation, R31 told R34 she was evil and ran his wheelchair into hers, and that on the day prior to this incident R31 also refused to let R34 pass him in her wheelchair and stomped on her toe. As part of the investigation, the form documented R34 reported R31 frequently called her evil, said she should die, and said he would make sure that happened. The investigation documented R34 felt unsafe in the dining room with R31, even with assurances that staff are watching out for her. The form did not document where the incident occurred, or which staff were present. On 06/11/19 at 5:18 PM, a SS note in R34's IDT notes documented R34's daughter was informed of the facility recommendations to keep the resident safe, which included 1:1 staffing for the other resident (R31); ensuring all staff were aware and observant of both residents; and offering more dining options for both residents. On 06/12/19 at 07:18 PM, R34's a NN in R34's IDT notes documented R34 stated she did not want to eat in the dining room with that guy (R31) and demanding R31 get kicked out of the dining room. The note documented R34 was informed that could not happen and offered for R34 to eat her meal in her room. The note documented after 35 minutes of talking to the nurse, R34 agreed to eat in the dining room. On 06/12/19 R34's care plan, located under the Care Plan tab of her EHR, documented the initiation of a focus area for a verbal and physical altercation with another resident on 06/10/19. The goal was documented as no further altercations. The interventions included staff to intervene when the residents were in common areas together; alternate dining options were available for both residents; communicate with R34's daughter and welcome further suggestions; and staff should continue to meet R34's care needs. The care plan documented R34 declined mental health services. On 06/13/19 at 1:39 PM, a NN in R34's IDT notes documented she spent most of the shift in her room. At 6:25 PM, the NN documented the resident had spent all shift in her room, and at 9:36 PM, the NN documented R34 had refused her shower. On 06/17/19 at 3:35 PM, a SS note in R34's IDT notes documented R34's daughter had moved to a city several miles away from the facility, and was unable to visit as often, which caused R34 to feel sad. No added measures were added to reassure R34's comfort and support by staff. Review of R31's physician's History and Physical, dated 08/14/19, located in his EHR, documented resident hospitalized at Senior Bridges from 06/26/19 to 08/10/19, Senior Bridges is a behavioral health inpatient program. On 08/11/19, R31's Entry Tracking MDS documented he was readmitted to the facility. There was no documentation in R34's record regarding informing R34 that R31 was returning to the facility, monitoring for her response, or care plan interventions to ensure her safety or feelings of safety with his return. On 08/12/19 at 4:19 PM, a Behavior Note in R34's IDT notes documented R34 was giving unsolicited advice to another (unidentified) resident, causing the other resident to feel anxious. The note documented the nurses instructed R34 not to engage in such interactions, to which R34 responded she would continue to butt in when others needed her. On 08/15/19, R34's care plan was amended to include a new focus area that the resident interfered with the care of others. Interventions included staff encouraging her to provide others privacy, and to notify her daughter if she was not redirectable when this behavior occurred. On 08/24/19, R34's care plan was revised to document that she was verbally and physically aggressive at times, with an intervention to allow the resident to verbalize her feelings. The care plan documented R34 refused counselling services. R34's MDS assessment with an ARD of 08/26/19 documented a BIMS of 14, indicating she was cognitively intact, and a PHQ-9 score of 0, indicating no depression. The MDS Section E-Behaviors documented R34 displayed verbal aggression directed towards others 1-3 days out of the past 7 days. On 08/28/19 at 3:14 PM, a SS note in R34's IDT notes documented R34's behaviors, which generally involve interfering with other residents' care had increased. The note attributed the increase to her daughter's move and decreased frequency of her visits. The SS note did not document an assessment of whether R34 was troubled by R31's return to the facility. On 9/30/19 at 2:00 PM, R34 was interviewed in her room. When asked about interactions with other residents, R34 stated it was complicated. R34 started by stating that she was in trouble with the nursing staff for talking about another resident, whom she identified as R31. R34 stated, There was an incident a few months ago. Everyone knew about him because he would sit in the lobby ordering residents not to pass him, yelling, and just real angry all the time. R34 stated R31 tended to focus his anger on her whenever she was around, calling her evil or the devil, and telling her she had to die, and he would make sure it happened. Interview continued: R34 described that one evening, R31 seemed to be particularly angry at her as she was coming out of the dining room after dinner, on her way to her room. R34 stated R31 was yelling at me not to pass, calling me evil, saying I was a she-Satan. The staff were holding him back and told me to go ahead and go on by to get out of his sight. As I passed him, he broke free. He was really angry and stood up and stomped on my foot, hard. It hurt so bad, it still hurts sometimes. R34 described that after the event, R31 had a sitter for a while, then he was discharged . R34 stated, I was so relieved. I thought I was rid of him for good. Continued interview: R34 stated a few weeks later, R31 returned to the facility. R34 stated, I didn't get any warning or anything. Just boom, there he was. R34 stated, They keep him at the nurse's station all the time. They say they're keeping an eye on him but they're not. R34 described at least one instance since R31 returned to the facility where he came down the hallway and into her room looking for the doctor. She stated he left when she told him the doctor wasn't there, but I was so scared. No one was around, no one knew he was here. R34 stated it also caused her distress that R31 often sits at the nurse's station. R34 stated, If I want to go to the nurse's station to ask for something, or go to the activity room, or go to the dining room, or go sit outside, it means I have to pass by him. It's not fair, but they tell me there's nothing they can do about it because he has rights too. They tell me if I don't like it, I can stay in my room. Interview continued: R34 described that she used to enjoy the dining room at lunch and dinner, but now preferred to eat in her room. R34 stated, I like crafts and games in the activity room, and I like to go outside and sit when it's nice. When there's something on the activity calendar I like to do, I peek out and see if he's at the nurse's station. If he is, I don't go. If he isn't, then I go down and peek in the activity room to see if he's there. If he is, I go back to my room. R34 stated since R31 had returned to the facility, she felt edgy, insecure and depressed. R34 stated she was so upset when she saw R31 had returned that she tried to warn other residents about him, but I got in trouble because they say it's none of my business and to leave other residents out of it, but I'm worried they're in danger and I feel like I have to warn them. R34 stated, He definitely gets preferential treatment. I feel like I can't do anything because I'm so afraid of him, and he gets to go wherever he want and do whatever he wants, because he has 'rights. Well, I think I have rights too. On 10/01/19 at 09:13 AM, R31 observed in his wheelchair at the nurse's station, while R34 was in her room at the end of the 300 hallway. R34 would have had to pass by R31 to access the nurses at the nurse's station, to go to the activity room, or to go outside to the facility's patio area. The Social Service (SS) worker took R31 down to the activity room, where a Bingo game was in progress. The SS worker placed R31 at the back corner of the room, away from the activity that was taking place. R34 did not attend the game. On 10/10/19 at 12:32 PM R34's daughter (F1) was interviewed. F1 stated one of her concerns was that not all staff believed the resident when she reported something. F1 stated the Director of Nursing (DON) was really good about listening to my Mom and takes care of things right away. The problem is, when she's not there, they just do whatever they want. F1 stated, They don't like my Mom, because she gets a bad attitude with them sometimes, but they get a bad attitude with her whenever they don't believe her. Regarding the incident with R31, R34's daughter stated there were two incidents that she was aware of in June, and after the second incident R31 had a sitter and was ultimately discharged . F1 stated R34 was initially upset, and probably acted out a little, because she had to pass his room to get to hers. F1 described R34 as scared following the incident, and relieved when R31 was discharged and she thought she would never see him again. F1 stated, Then he came back, which upset Mom greatly. She inquired to staff, let them know she was concerned for her safety, but was repeatedly told he was on medication now and they couldn't tell her anymore than that. He's supposed to be better now, less belligerent, but that's not always true. F1 reported on one occasion since R31's readmission, R34 had called her, terrified and upset, because R31 had entered her room. F1 stated, I don't think they always believe my mom when she tells them. F1 described that R34 no longer came to the dining room, and her participation in activities had decreased when R31 was either in the hallway or the activity room. On 10/12/19 at 8:44 AM, Certified Nursing Assistant (CNA) 30 was interviewed. CNA30 stated she had worked in the facility for a year. CNA 30 stated she was aware of an incident between R34 and another resident in the past but did not know who the other resident was. She stated the other resident had been discharged from the facility and there was no concern with current residents. The CNA was unable to identify the resident that created a fear for her safety or would know who to watch for to protect R34. On 10/02/19 at 8:51 AM, interview of CNA60 stated she was aware of a past conflict between R31 and R34, and if R31 was around when R34 came down the hall, they needed to move R31 out of the way. On 10/02/19 at 9:14 AM, the Activities Director stated she had seen R34 in the activity room at times when R31 was also there, and she seems a little uneasy so she stayed on the other side of the room. The AD stated R34 had stopped coming to activities lately, which she initially stated was because she did not feel well, but recently admitted was because R31 was there. On 10/02/19 at 10:27 AM, R34's physician, also the facility's Medical Director (MD) was interviewed. The MD stated he was not the facility's Medical Director at the time of the incident but was aware F31 had a violent history and there had been an encounter between R31 and R34. The MD stated he had not been informed that R31 had gotten into R34's room since he was readmitted , but I can see how that might have happened. The MD stated he often spoke to R34, and while she had not mentioned R31, I'm sure she will have strong memories of that event for years to come. On 10/02/19 at 11:40 AM, the Referral Coordinator (RC) who had been acting as the facility's Social Services (SS) designee during the month of (MONTH) only, was interviewed. The RC stated she had taken a state-sponsored course to be able to provide social services in a skilled nursing facility, but the course did not include the completion of a psychosocial assessment of a resident, completing behavioral assessments, or developing behavioral care plans. The RC stated R34 was manipulative, and would tell one person one story, and another person a different story, about the same event, which made it difficult to believe reports from R34. The RC stated it was her determination that R34 had instigated the 06/10/19 event by following R31 to his room and mocking him for having a babysitter after the 06/05/19 event. The RC stated the facility had informed R34's daughter of the event, and she had no concerns, so there was no reason to further assess or develop further care plan interventions. The RC stated R31's readmission to the facility was really none of her (R31's) business and that R34 was in no real danger from R31. The SS designee stated R34 had the option of taking her meals in her room, so there was no need to make further accommodations for her feelings of safety in the dining room, and that both residents had an equal right to be in an activity so if R31's presence in the activity bothered R34 then she could choose not to go. On 10/02/19 at 12:40 PM, the Director of Staff Development (DSD) was interviewed. The DSD stated he had started working at the facility just before the 06/10/19 incident and was aware R34 was fearful of R31 after the event. The DSD stated he was usually in the dining room for meals and made sure there was a seat at a table next to the window for R34 and R31 was on the opposite side of the room after the event. The DSD stated R34 expressed fear of R31 in the dining room after the event until his discharge on 06/26/19 but had not expressed those same concerns since his return. The DSD stated R31 now required assistance at meals, so the two no longer ate in the same dining room, and R34 often chose to take her meals in her room for fear of passing by R34. On 10/02/19, R34 was re-interviewed regarding the documentation in her record surrounding the event, and the staff interviews obtained. R34 stated she felt supported by the DSD and DON, but not by the CNAs or Social Services staff. R34 stated no one had talked to her regarding her feelings about the incident other than a couple of nurses were nice to me when I was upset, but I was never sure what they were doing overall to ensure my safety. R34 admitted that she had gone by R31's room and made angry remarks after the 06/05/19 incident, but only because she had to pass his room to get to her own, and I was angry and scared. R34 stated she was aware the DSD assured her of her safety in the dining room, but, Staff were there holding him back the first time and he broke free. I don't know how they can promise me I'm safe. R34 stated, They say I have nothing to be afraid of because he can't remember me. Well I remember him. The worst thing after a man hurts you is to sit and watch him have a good time, have fun, after he has hurt you, and you are still hurting inside. On 10/02/19 at 03:14 PM, the SC was interviewed about R34. The SC described her role in the facility as, an assistant Administrator of sorts, and that she oversaw the day to day operations of the skilled nursing facility. The SC stated she had participated in the investigation of the 06/10/19 event, and felt the facility ensured R34's safety by providing a 1:1 attendant with R31 until he was discharged . When asked about the facility's plan to monitor and provide support for 34's emotional needs after the incident, the SC stated, I really have no idea. The SC stated she was unaware a determination had been made that R34 was considered manipulative and no plan was developed for her. The SC stated she would have expected a psychosocial assessment of R34 after the event, monitoring her response over time, and a plan to ensure her feelings of safety after R31's readmission to the facility.

Based on record review, observation and staff interview the facility failed to ensure one of 16 sampled residents (Resident (R) 31's, ability to complete activities of daily living tasks was maintained. The resident was prescribed medications in excessive dose and without a [DIAGNOSES REDACTED]. The resident has had a significant decline in functional status since re-admission including not able to transfer himself, dress, and bath himself now requiring two person assistance in care. The resident is now being spoon fed by staff related to the use of antipsychotic medication in excessive dose and suffering extrapyramidal side effects (a group of symptoms that can occur in people taking antipsychotic medications). The facility did not meet its burden to find the root cause of behaviors prior to using an antipsychotic medication to chemically restrain & manage behaviors. The resident suffered a functional decline as a result. Findings include: 1. Review of R31's electronic health record (EHR), Face sheet, documented the resident was originally admitted on [DATE] with [DIAGNOSES REDACTED]. On 06/10/19 dementia with behavioral disturbance and delusional disorders were added to the resident's [DIAGNOSES REDACTED]. Review of R31's first Admission Minimum Data Set (MDS), assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 05/26/19, located under the MDS tab of her EHR. Section C Cognition score was unable to be completed by the resident. The resident was documented to have no delusions or hallucinations. Under Section G-Functional Status revealed resident required supervision or one person for transferring, locomotion on/off unit, and was independent when eating. The resident required limited assistance of one person for bed mobility, walking in room/corridor, dressing and toilet use. The resident was not steady, but able to stabilize without staff assistance during transitions and walking and had no impairment of his upper and lower extremities. The resident was occasionally incontinent of bowel and bladder. Review of R31's last Admission MDS with an ARD of 08/23/19, indicated the resident was readmitted to the facility from a psychiatric hospital on [DATE]. Section C of the MDS identified a score of 4 indication of severe cognition deficit with no delusions but inattention and disorganized thinking. The resident's functional status under Section G-Functional Status now indicated the resident required extensive assistance of two or more-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. The activity did not occur for walking in room/corridor. The resident was not steady, only able to stabilize with staff assistance during transitions and walking. The resident was indicated as being frequently incontinent of bowel and bladder. Review of an AIMS Assessment (Abnormal Involuntary Movement Scale completed on 06/20/18 revealed a score of zero, indicating no extrapyramidal symptoms at that time prior to the use of antipsychotic medications. A second assessment was not completed upon R31's readmission to the facility. Observations conducted on 10/01/19, 10/02/19 and 10/03/19 revealed the resident was unable to transfer from his wheel chair without total assistance, staff fed him his meals, and he suffered from jerking movements, shuffling, hallucinations, and unrecognizable mumbling. Review of R31's Medication Administration Orders, indicated the resident was receiving [MEDICATION NAME](anti-depressant) 15 milligrams(mg) in the evening for mood liability AEB(as evidenced by) agitation, [MEDICATION NAME] (anti-anxiety) 0.5 mg two times a day for anxiety AEB inability to relax, and [MEDICATION NAME] (anti-psychotic) 250 mg in the evening and 25 mg at lunch for [MEDICAL CONDITION], paranoid delusions, agitation related to dementia with behavioral disturbance. The resident was prescribed [MEDICATION NAME] 1 mg at bedtime for jerking movements on 09/16/19. [MEDICATION NAME] ([MEDICATION NAME]) is used to treat involuntary movements due to the side effects of certain psychiatric drugs such as antipsychotics. Review of R31's History and Physical, dated 08/14/19, documented the assessment/plan, dementia with behavioral disturbances, patient now taking scheduled [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg bid as well as [MEDICATION NAME] ([MEDICATION NAME]) 15 mg with dinner and quetiapine ([MEDICATION NAME]) 25 mg at lunch and 250 mg with dinner. Patient appears more compliant and redirectable since changes in medications. Review of R31's care plan dated 08/10/19 indicated the resident had an increase in behaviors such as angry outbursts. The staff was instructed to administer [MEDICATION NAME] 250 mg at dinner and 25 mg at lunch as ordered by MD (Medical Doctor) on 08/10/19 and to monitor behaviors daily. There were no non-pharmacological interventions documented. An interview with R31's physician on 10/02/19 at 10:26 AM in the conference room, the physician stated that his assessment upon resident's return from the psychiatric hospital was that the resident was more directable when he gets worked up, before he would get quite psychotic.The physician stated, he doesn't qualify for psych services due to delusions, dementia, scattered speech, and paranoid, especially with medications.The physician stated, I was following the psychiatric hospitals recommendations and have seen an improvement. The physician was questioned concerning the resident having symptoms of EPS (extrapyramidal symptoms) and added medication for adverse effects verse adjusting the dosage of the antipsychotic [MEDICATION NAME]? The physician answered sometimes the benefits outweigh the adverse effects. The physician was asked if he had noticed a change in R31's functional abilities? The physician stated, before the medications he was higher functioning but also a danger to others. Not as functional as before going to the psych hospital but also not as much a danger to others. A telephone interview was conducted with the Consultant Pharmacist on 10/03/19 at 12:45 PM. The Consultant Pharmacist was asked if she was familiar with the resident? She stated, Yes, I remember the resident, and had requested an appropriate [DIAGNOSES REDACTED]. The pharmacist was asked if 275 mg of [MEDICATION NAME] is a high dose for this resident? The pharmacist stated, I have seen residents/patients being administered high doses of [MEDICATION NAME] but always in a psychiatric facility. The pharmacist was questioned about treating the resident's EPS with [MEDICATION NAME]? The pharmacist stated, it wouldn't help to treat it and she would recommend a reduction of medication based on EPS symptoms. Should be decreasing dose instead of medicating EPS.

Based on observation, interview, and record review, the facility failed to provide smoking safety assessments based on each individual resident's assessed needs, adequate monitoring, and safety equipment to ensure the safety of three of three sampled residents (Residents 13, 16, and 32) who smoke when: 1. Resident 16 was not assessed for smoking safety since (YEAR), was observed smoking in an undesignated smoking area without using safety equipment (smoking apron), managed his cigarette supplies, and did not dispose of cigarettes in the proper smoking receptacle. 2. Resident 13 had no smoking screen assessments done, was not wearing smoking safety equipment (smoking apron), was not in a designated smoking area, and did not use appropriate trash receptacles when disposing of cigarettes. 3. Resident 32 was smoking with a smoking apron, in an undesignated smoking area and did not use the appropriate smoking receptacles consistently. This had the potential for Resident 13, 16, and 32 to be at risk for smoking related injuries. This failure to not ensure residents had a current accurate smoking assessment, were smoking in a designated area without safety equipment placed all residents (52), staff, and visitors at risk for fire related injuries. Refer to F 835, F 837, F 841 F 867 and F 926. These failures led to an Immediate Jeopardy (IJ) being declared 10/31/18 at 2:50 pm, in the presence of Chief Nursing Officer (CNO) and the Administrative Assistant (AA) for failure to provide adequate assessments, supervision and care to prevent potential hazards related to the three residents smoking (Residents 13, 16 and 32). An immediate corrective action plan to address supervision, assessment and environmental changes to the smoking area was provided by the facility's administration. Findings: A review of the facility's policy, titled, Smoke Free Environment undated, indicated smoking is prohibited on all grounds, parking lots and personal vehicles. This prohibition applies to all faculty, staff, patients, visitors, volunteers and other visitors, the only exception to this policy is those skilled nursing residents with physician's orders [REDACTED]. 1. Resident 16's record was reviewed and indicated that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's record's last Smoking Safety Screen, dated 2/23/15, indicated Resident 16 was safe to smoke independently in the designated smoking areas of the hospital, and that he refused to wear the smoking safety apron. The Interdisciplinary Team decision note area indicated Resident 16 would smoke in the designated area and safe to smoke without supervision. A review of Resident 16's medical record, and concurrent interview with the Administrative Licensed Nurse 1 on 10/31/18 at 11:30 am, indicated the last smoking assessment obtained for Resident 16 was on 2/23/15, and she did not know how frequent the resident smoking assessments should be reevaluated. During an interview, on 10/30/18 at 10:30 am, Certified Nursing Assistant (CNA) 4 stated Resident 16 smokes one pack every 2-3 days, his cigarettes and lighters are kept with him in his room and he smoked outside across the parking lot by himself. CNA 4 stated that she did not know if the facility had a smoking policy. During a concurrent interview and observation, on 10/31/18 at 1 pm, Resident 16 was seen coming in the front entry way in his electric wheelchair, CNA 4 stated that his wheelchair battery frequently dies and they often need to push him back into the facility. During a concurrent observation and interview, with Engineering Technician (ET), on 10/31/18 at 1:50 pm, Resident 16 was smoking in his wheelchair outside between the gazebo (designated smoking area) and the front door of the facility. The gazebo had a fire extinguisher and smoking trash receptacle, and no fire blanket present. When Resident 16 was finished smoking, he flicked the cigarette butt into the grass area to the left of the sidewalk. ET confirmed that Resident 16 smokes unsupervised, which was, scary due to hands shaking and he falls asleep while smoking. ET confirmed Resident does not wear a smoking apron, and often flicks the cigarette butts onto the ground. ET often picks up multiple cigarette butts from lawn and surrounding area, and has not informed administration about his concerns. ET stated he was unaware that fires can potentially start from cigarette butts, and was unaware of smoking requirements and safety equipment for a designated smoking area. During a concurrent observation and interview, of Resident 16's dressing change to his right leg, right lateral foot, heal and right lateral calf on 10/31/18 at 2:00 pm, Licensed Nurse (LN) 4 confirmed the burn to his right lateral calf wound resulted from a lit cigarette. LN 4 applied [MEDICATION NAME] (cleanses wounds) to the two by two centimeter circular wound that had a scab. Resident 16 confirmed that he had sustained this burn when he dropped a lit cigarette. A review of the newest smoking safety screen assessment, dated 10/31/18, indicated Resident 16 was able to store a lighter and cigarettes and did not require supervision. The care plan used would assure that resident is safe while smoking. The Interdisciplinary Team's decision was Resident 16 was safe to smoke without supervision. A review of a new smoking care plan dated 10/31/18, indicated the Resident 16 will be monitored for adverse effects of smoking and offered a smoking apron. There was no interventions that addressed the need for scheduled smoking supervision, ensuring resident uses appropriate smoke receptacle, if he could manage his own smoking supplies, and how to prevent further smoking burns. 2. Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 13's medical record, indicated that no smoking safety screening had ever been completed on this particular resident by the facility. Resident 13 had a physician's orders [REDACTED]. During a concurrent interview and observation, on 10/31/18 at 1:37 pm, Resident 13 was observed with ET, smoking with no smoking apron within the area between the facility and the designated smoking area (gazebo). When finished Resident 13 flicked the cigarette butt into the lawn. When questioned, Resident 13 stated he usually leaves butts in the lawn and does not use appropriate smoking receptacles at the gazebo or at the post at the front area to the facility. A review of a newest smoking safety screen assessment, dated 10/31/18, indicated that Resident 13 did not need any safety adaptive equipment, no supervision, and could store lighter/cigarettes. This assessment indicated that Resident 13 was knowledgeable in the proper disposal of his used cigarettes. The IDT decision was he was able to safely smoke without supervision. A review of a new care plan, dated 10/31/18, indicated Resident 13 was to be monitored for adverse effects of smoking and offer smoking apron. There was no new interventions to address scheduled smoking supervision, disposing of cigarette butts in appropriate receptacles, management of smoking supplies, and using a designated smoking area. 3. Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 32's physician orders, dated 9/20/18, indicated that he had intact mental capacity (the ability to experience, or understand something) and could smoke independently. A facility smoking safety screening was completed upon admission to facility. During an interview, on 10/30/18 11:09 AM, Resident 32 stated, that he normally was not supervised while smoking and does not wear the facility provided apron, as he does not think that it was necessary. During a concurrent interview and observation, on 10/31/18 at 1:40 pm, Resident 32 was observed with ET, returning to the facility after finishing smoking from an area between the front of the facility and the gazebo area. When questioned about how he disposed of his cigarette butts, he showed the cigarette butt in his lap, rolled up in a fold of his flannel pajama pants. Resident 32 acknowledged that he was not in the designated smoking area and that he was sitting on his smoking apron (it was not on). Resident 32 then deposited the cigarette butt into smoking receptacle near facility entry. Resident 32 stated he sometimes disposed of cigarette butts on the ground and does not place them in designated receptacles all the time. During an interview, with the Chief Nursing Officer (CNO) and the Administrative Assistant (AA) at 10/31/18 at 3:05 pm, they confirmed that Residents 16 and 32, were non-compliant in terms of wearing their smoking aprons while outside smoking. Both were unaware that Resident 13 was actively smoking at this time. The CNO acknowledged that the facility's smoking policy needed to be revised. The IJ was abated on 11/1/18 at 2:30 pm, with evidence of Residents 13, 16 and 32 smoking assessments being updated, a supervised smoking schedule being developed, improvements to the outside resident smoking environment to include moving it closer to the facility and adding all required safety equipment (aprons, fire extinguishers, approved ash tray, change to the smoking policy, and evidence of on going staff education provided on all of these changes.

Based on observation, interview, and record review, the facility failed to provide treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing for one of ten sampled residents (Resident 1) when: A complete wound assessment was not conducted for Resident 1's existing pressure ulcer (Mid-line buttock/sacrum, Site 1), upon admission. Skin Integrity/pressure ulcer/wound care plans were not developed and revised to include individualized care interventions to aid in the prevention of Resident 1's wound progression and development and skin/wound infections. A Specialized Wound Physician (SWP) examination and treatment was not obtained, although requested by Resident 1's family (FM), for three months. Resident 1's mid-line buttock wound (Site 1), present on admission, deteriorated to a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer), and was infected with [MEDICAL CONDITION] (MRSA, a bacteria that is resistant to many antibiotics), requiring contact isolation (procedures to help isolate and prevent the spread of the bacteria to others). Resident 1 developed a Stage II sacrum pressure ulcer (Site 2), was subjected to moisture from urine and bowel which became infected, contributing to the wound deteriorating to a Stage III (full thickness tissue loss) and a wound infection. Resident 1 developed a pressure ulcer (unstaged) to the right buttocks (Site 3). Resident 1 developed a fungal infection to the groin and perianal area. These failures contributed to incomplete assessment and inadequate care planning for Resident 1's impaired skin integrity, delayed SWP evaluation and treatment, moisture related [MEDICAL CONDITION] to the buttocks/sacrum, due to urine/bowel incontinence, the deterioration of Resident 1's existing Site 1 wound, the development of and further deterioration of Resident 1's Site 2 wound, a Stage III sacrum pressure ulcer, which became infected with Pseudomonas and [MEDICATION NAME] bacteria, the development of a third wound (Site 3) and a fungal infection to the groin/perianal area. The pressure ulcers required surgical debridement (cleaning out the wound bed with a sharp instrument) and cauterization (heat applied to reduce bleeding in the wound) by SWP. Resident 1 was evaluated in ED, diagnosed with [REDACTED]. Findings: Resident 1's record was reviewed. The record included a Specialized Wound Physician (SWP) progress note, dated 2/13/15, five days prior to Resident 1's admission to the facility, indicating Resident 1 had a wound of the midline buttock (referred to as Site 1), healing with measurements of 1 cm L x 0.4 cm L with a not measurable depth with moderate serous drainage and 100% granulation tissue and no (0%) necrotic tissue. The note indicated Resident 1 received wound care as follows: Foam, daily and as needed, rinse wound base with normal saline and pat dry completely with 4 x 4 gauze daily with paper tape for covering. Mupirocin (an antibiotic cream) daily. Calcium agitate ( specialized dressing) daily. Off load wound (keep pressure off the wound). A follow up examination by SWP was to occur in fifteen to 21 days. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission face sheet, a document that lists pertinent information about the resident such as diagnoses, allergies [REDACTED]. A Nursing Admission Screening History, dated 2/18/15 at 9:08 am, indicated Resident 1 was totally dependent on staff for his care, incontinent (involuntary, lack of control) of bowel and urine, and documentation on a body diagram referred to an area located above the gluteal crease (midline of the buttocks) referred to as sacrum (the tailbone area) measured 1 centimeter (cm) in length (L) by (x) 0.5 width (W), with a depth documented as superf (superficial). There was no documented description of the pressure ulcer (such as the presence of slough (shedding dead tissue) or eschar (black dead tissue)). Under Stage, the admitting nurse documented, N/A (Not Available, according to the Nursing Admission Screening History instructions). Staging is a standardized assessment with various Staging definitions provided by the National Pressure Ulcer Advisory Panel, NPUAP). The Staging definitions include: Stage I- intact skin with non balanceable redness of a localized area over a bony prominence. Stage II- partial thickness loss of dermis presenting as a shallow open ulcer with a red wound bed without slough. Stage III- full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. Stage IV- full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts. Often includes undermining and tunneling. Unstageable- full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black) in the wound bed. A Nurses Note, dated 2/18/15 at 1:55 pm, indicated Resident 1 was admitted to the facility by wheelchair on this date at 8:30 am, accompanied by a family member (FM). The note read his Physician, the Medical Director (MD), was in at 9:30 am, the same day, to examine Resident 1 and that Resident 1's dressing was changed to his coccyx (tail bone) region after he had a bowel movement. A Braden Scale (a standardized assessment for predicting pressure sore risk), dated 2/18/15, identified a score of 12, Resident 1 was at high risk for pressure sores due to very limited sensory perception, inability to walk (confined to bed), very limited mobility, probable inadequate nutrition, friction and shear from repositioning. The Braden Scale indicated Resident 1's skin was rarely moist and usually dry, although he was incontinent of bowel and urine, daily. An undated Mosby's Skills online resource provided by the facility as their standard, indicated wound assessment provides the baseline for planning and evaluating the wound care plan. Review of a Decreased Physical Mobility care plan, dated 2/18/15, indicated Resident 1 had joint pain, contractures to both arms, weakness, and inability to reposition himself. The care plan goal was for Resident 1 to be free from skin breakdown. Review of a Potential/Actual Impaired Skin Integrity care plan, dated 2/18/15, indicated Resident 1 had fragile skin and an area open on his coccyx measuring 0.5 by 1 centimeter (cm). The care planned goal was for Resident 1 to maintain/develop clean intact skin. The only intervention was to identify/document potential causative factors and eliminate/ resolve when possible. On 3/3/15 a revision of the above coccyx wound care plan included encouragement of good nutrition and hydration. The measurements of the coccyx were documented to be 0.5 cm x 1 cm. A review of licensed nursing notes (LN) indicated the following documentation during the care plan period from 2/18 to 3/3/15: On 3/3/15 at 9:51 am, a LN documents that Resident 1's coccyx pressure ulcer is measuring, 2 cm L x 1.5 cm in size. Width and depth not documented. These measurements did not match the 3/3/15 care plan revision measurements of 0.5 cm x 1 cm. A revision of the coccyx wound care plan interventions from 4/2015 to 7/2015 indicated that the MD would be notified of changes. Review of a SWP progress note, dated 2/20/15, indicated Resident 1 was discharged from this facility to another since last visit. A review of the facility's Minimum Data Sets (MDS, a standardized resident assessment), dated 3/3/15 (fourteen days after admission) and 6/3/15 (a quarterly assessment), indicated Resident 1 had one Stage II pressure ulcer, was non ambulatory, depended on two staff for transfers and bed mobility, and was always incontinent of urine and bowel. The assessments additionally indicated that Resident 1 was always incontinent of urine and bowel which were not included in the skin integrity coccyx care plan. On 7/28/15 at 9:40 am, Resident 1 was observed lying in bed sleeping in his room. A sign outside his room indicated that Resident 1 was in contact isolation (for infectious diseases). Concurrently, QA/ICN stated Resident 1 was in isolation [MEDICAL CONDITION], and stated the infection was in in his pressure ulcer. On 7/29/15 at 1:30 am, Resident 1's Family Member (FM) was interviewed. FM stated they come to the facility at least daily, often three times a day, to feed Resident 1. FM stated, prior to his admission, Resident 1 was being seen by a local SWP weekly, and the pressure ulcer was almost healed. FM stated that the facility had no wound specialist, and the pressure ulcer was getting worse. FM stated that after three months, Resident 1's Physician (MD, the facility's Medical Director) requested SWP services for Resident 1's wound care. On 7/30/15 at 8:25 am, a policy for pressure ulcers was requested of the Quality Assurance /Infection Control Nurse (QA/ICN). QA/ICN stated he did not think the facility had a policy on pressure ulcers, and they followed Mosby's nursing standards (a nursing educational consultant that teaches clinical best practices of resident care). QA/ICN was asked at this time who was responsible for assessing and Staging pressure ulcers. QA/ICN replied, a Registered Nurse (RN), stating the Licensed Vocational Nurses (LVNs) could not assess the pressure ulcers. He stated that a SWP comes in weekly, every Friday. When asked why an RN had not assessed Resident 1's pressure ulcer upon admission and not until fourteen days after his admission on 3/3/15, QA/ICN did not provide an answer, further stating he thought it was more important that a treatment was in place, measurements were done, and the wound was improving. QA/ICN acknowledged that a pressure ulcer could worsen within a week to fourteen days. A undated Mosby's Skills online resource provided by the facility as their standard for assessment and care of pressure ulcers indicated wound assessment provides the baseline for planning and evaluating the wound care plan. The parameters of wound assessment should include location, type of wound, extent of tissue involvement, type and percentage of tissue in the wound bed, the size, exudates (drainage), periwound (the tissue surrounding the wound) area and pain. Comparing the wound assessment to previous assessments helps determine the residents progress towards healing or if the wound has deteriorated requiring specialized services. If there is an increased amount of drainage or odor the wound may be infected and a culture is often necessary to support the use of appropriate antibiotics. A review of nurses notes for February 2015 indicated: On 2/24/15 at 12:50 pm, a LN faxed the MD regarding the opening in Resident 1's buttocks requesting a f/c(Foley catheter - a urinary catheter - a tube placed in the bladder that drains urine into a collection bag) to help reduce skin moisture from urine incontinence. The MD faxed back at 12:50 pm, stating he did not want to use a urinary catheter due to the potential for causing an infection. On 2/26/15 at 2 am, Resident 1 .has soft BM .(bowel movement) all the time and his dressing continues to stay soiled. On 2/27/15 at 9:41 pm, .coccyx wound seems to be getting worse, instead of better .fax to MD. A review of nurses notes for March 2015 indicated: On 3/3/15 at 9:51 am, Resident 1's coccyx pressure ulcer measured 2 cm L x 1.5 cm in size. On 3/16/15 at 11:42 am, Resident 1's coccyx wound .appears to be slightly smaller ., there were no measurements. On 3/19/15 at 11:29 am, Resident 1's coccyx dressing was found soiled and was changed. On 3/24/15 at 2:37 pm, the MD was in to visit and the dressing was applied to Resident 1's coccyx. A physician progress notes [REDACTED].But, recur due to fecal incontinence (referring to Site 1). A review of nurses notes for April 2015 indicated: On 4/23/15 at 9:07 am, Resident 1's dressing to his coccyx was soiled. On the same day at 8:01 pm, Resident 1 was noted to have smeared bowel on his dressing. Review of a physician progress notes [REDACTED]. Review of nurses notes for May 2015 indicated: On 5/12/15 at 10:11 am, a nurse noted Resident 1's coccyx wound had a strong unpleasant odor (a sign of infection) during the dressing change. There was no documentation that the MD was notified of this change in wound condition. On 5/13/15 at 10:19 am, Resident 1's dressing to his coccyx wound was found to be off; the wound was uncovered/unprotected. On 5/14/15 at 12:34 am, Resident 1's wound remained open, was a little larger than the previous day. There were no documented wound measurements or notification to the MD. On 5/15/15 at 2:21 pm, Resident 1 was noted to have a rashy area to his buttocks and the coccyx wound appeared larger in size. There were no documented wound measurements or notification to MD. On 5/19/15 at 11:08 pm, three months after requested by FM, a LN documented the MD was in to see Resident 1 and called a SWP to come examine Resident 1's coccyx wound. At 2:19 pm, the same day, Resident 1's coccyx wound appeared to be breaking down more, and was pending SWP's evaluation. On 5/20/15 at 12:49 pm, Resident 1 was noted to have two open areas to the coccyx that appeared pink and tender. There was no documented notification to the MD. On 5/21/15 at 12:46 pm, Resident 1's coccyx wounds appeared to be spreading, FM voiced concern, and a faxed notification was sent to the MD. A physician progress notes [REDACTED]. Three days after the MD requested a SWP examination, an initial Wound Care Specialist Evaluation by SWP, dated 5/22/15, indicated Resident 1 had two pressure ulcer sites described as follows: Site 1, midline buttock, measuring 2.2 cm in L x 0.9 cm in W with no measurable depth. The site had deteriorated and there was 100 % necrotic (dead) tissue. A surgical procedure (debridement, cutting away dead tissue) was documented as performed by SWP; and Site 2, a Stage II wound of the sacrum, measuring 1.3 cm L x 1 cm W x immeasurable depth. The evaluation documented that Resident 1's alternating pressure mattress setting was not set correctly for his appropriate weight to provide sufficient pressure relief. In a nurses note on 5/22/15 at 1:23 pm, a LN documented the SWP was in to assess Resident 1's coccyx wounds and obtained a culture of the wound. Review of a wound culture report, dated 5/24/15, indicated the presence of mixed skin flora including multiple gram negative rods (bacteria normally found on the skin and in the intestinal tract). A review of physician's orders [REDACTED]. Resident 1 had a Stage II pressure ulcer on his sacrum. The MD ordered a dressing change to apply silver absorbing agent and cover with foam twice daily and as needed, to off load (keep pressure off of) the wound, and reposition the resident every two hours. Resident 1's skin had diffuse (spread over a wide area) bilateral buttock moisture associated [MEDICAL CONDITION] (a condition of the skin in which it becomes red, swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent). The MD ordered to apply zinc oxide on wound and surrounding skin twice daily and as needed with brief (incontinence pants) changes. For Resident 1's mid-line buttock wound, the MD ordered to rinse wound base with normal saline and pat dry completely, then apply silver absorbing agent and cover with foam twice daily. A review of nurses notes indicated the following: On 5/28/15 at 11:13 am, a LN documented the wound cultures came back, were faxed to the MD, and there were no new orders. On 5/29/15 at 11:36 pm, a LN documents that Resident 1's temperature was up to 99.1 from 98.3 ° Fahrenheit (F). On 5/30/15 at 8:36 am, a LN documented that Resident 1's temperature was up to 100° F, with shallow respirations and some congestion to the right upper lobe, and chest x-ray was ordered. FM voiced concern that Resident 1 had a [MEDICAL CONDITION] (TIA, a brief stroke) Observed increase left sided drool and facial, lips purple droop. VS . (vital signs) 100 .(°F, temperature) 155/68, 14, 94 percent . (%) RA (measurement of oxygen in the blood). The note then reads that MD was notified by leaving a telephone message. At 1:46 pm, the same day, LN documented that Resident 1's temperature again was 100° F, and medicated with Tylenol per orders. On 5/30/15 at 12:29 pm, a LN documented that Resident 1's temperature was 100° F then 98.2 ° F, and his chest x-ray was negative for pneumonia. On 5/31/15 at 12:12 am, LN documented that Resident 1 had been running a low grade fever most of the day. A follow up Wound Care Specialist Evaluation by the SWP, dated 5/29/15, indicated the wound culture of the midline buttocks demonstrated gram negative bacteria. There was no further follow up culture in the record or provided by the facility. In a nurses note on 6/4/15 at 12:25 pm, a LN documented the dressing to Resident 1's coccyx was saturated with blood and urine, and FM consented to the insertion of a urinary catheter to promote wound healing. On 6/5/15, SWP ordered laboratory testing to check for [MEDICAL CONDITION] disease/infection: ESR (Sedimentation rate), CRP (C-reactive protein), and CBC (Complete Blood Count), and if elevated results, a bone scan of sacral/coccyx wound, a Foley catheter for 2 weeks to promote wound healing, and wound care for Resident 1's sacrum and midline buttock wounds. The order was not noted by a nurse until 6/10/15. On 6/5/15 at 3:45 pm, a LN documented that a urinary catheter was inserted, after SWP recommended it, for two weeks for wound healing. SWP's wound evaluation, dated 6/5/15, documented there was no improvement noted to the pressure ulcers. On 6/6/15 at 11:03 am, a LN documented two open wounds to Resident 1's sacrum (tailbone) were oozing some yellow pus serous sanguineous (body fluid mixed with blood) . chaffed skin around wounds. There was no documentation to indicate the MD was notified. A follow up Wound Care Specialist Evaluation by the SWP, dated 6/6/15, indicated lab results were reported to be abnormally high (ESR (19), CRP (9.3), and CBC (white blood cell count 11.7)), indicating Resident 1 had an infection. A triple antibiotic ointment was ordered to be applied to the infected wounds, daily. Resident 1's [MEDICAL CONDITION] continued. A bone scan was done and the results were negative. A review of nurses notes indicated: On 6/9/15 at 9:04 pm, a LN documented that Resident 1 was diaphoretic (sweating) at the beginning of the shift and that two tablets of Tylenol 650 milligrams (mg) were administered at 4:20 pm. On 6/10/15 at 10:35 am, a LN documented that Resident 1 had a temperature of 100.2° F, and Tylenol was administered .per schedule. At 9:59 pm, the same day, a LN documented that Resident 1's temperature was 101.1° F, blood pressure 149/104, and MD ordered to send him to the emergency room (ER) at 5:30 pm. The documented reason for transfer to the ER was [MEDICAL CONDITION], urinary catheter required, transient hematuria (blood in the urine) after a traumatic insertion. Resident 1 returned to the facility from the ER at seven pm, one and in a half hours later. At 11:55 pm, a LN documented that MD was called and updated on ER visit, and ordered a complete blood count (CBC), blood cultures (blood test to evaluate if a bacterial infection has spread into the blood) and a urine analysis (UA) now. MD additionally ordered [MEDICATION NAME] (antibiotic) 1 gram, intramuscularly (IM) daily for ten days for urosepsis (serious infection resulting from an untreated urinary tract infection) to be administered after the laboratory results were confirmed. On 6/11/15 at 10:18 am, a LN documented she hand delivered laboratory documents to MD, and then spoke to him later regarding continuing the [MEDICATION NAME] antibiotic due to Resident 1 having a urinary tract infection [MEDICAL CONDITION] and elevated temperatures. Urine in catheter was described as amber colored with sediment in the tubing. Documentation additionally reads that LN received an order for [REDACTED].° F as was previously ordered for pain when nursing staff administered it for fever thus masking the fever/ symptoms. Review of a laboratory result report, dated 6/11/15, indicated that Resident 1's CBC (complete blood count) showed that he had a high white blood cell count of 11.7 (normal range of 4.1 to 11.2) with [DIAGNOSES REDACTED]s elevated at 9.5 (2.1 to 6.1) indicating an infection. The Urinalysis (UA) obtained on 6/11/15 showed a large amount of blood with a culture on 6/14/15 that showed he had greater than 100,00 colony forming units per milliliter of the bacteria [DIAGNOSES REDACTED] Oxytoca (gram negative rod UTI). The blood cultures were not provided by the facility as requested. A follow up Wound Care Specialist Evaluation by the SWP, dated 6/12/15, indicated no change in Site 1 and Site 2 wounds. Wound care continued. A follow up Wound Care Specialist Evaluation by the SWP, dated 6/19/15, indicated Site 1 improved, Site 2 no change. A follow up Wound Care Specialist Evaluation by the SWP, dated 6/26/15, indicated Site 1 improved, Site 2 deteriorated due to infection and Resident 1 had a new fungal infection in the groin and perianal areas. The wound culture results, dated 6/26/15, of Resident 1's infected wound were positive for Pseudomonas (gram negative bacteria) and [MEDICATION NAME] (gram positive bacteria commonly found in the gut). Review of physician's orders [REDACTED]. wound infection. According to the Centers for Disease Control, Pseudomonas infection is caused by strains of bacteria found widely in the environment. Careful attention to routine infection control practices, especially hand hygiene and environmental cleaning, can substantially lower the risk of a pseudomonas infection. Gram-negative bacteria cause infections including pneumonia, bloodstream infections, and wound or surgical site infections in healthcare settings. Gram-negative bacteria are resistant to multiple drugs and are increasingly resistant to most available antibiotics. [MEDICATION NAME] faecalis, commonly found in the human gut, is an opportunistic pathogen that causes a variety of community-acquired and health care-associated infections, such as urinary tract infection. A follow up Wound Care Specialist Evaluation by the SWP, dated 7/3/15, indicated Sites 1 and 2 had deteriorated, due to infection, and identified a new wound to the right buttocks, Site 3, measuring 0.7 cm L x 0.5 cm W x no measurable depth. This site was not Staged. The fungal infection continued. TAC 0.1% ([MEDICATION NAME], synthetic topical steroid used to reduce inflammation) cream was ordered to apply to groin and peri area after antifungal cream for 14 days. And, on 7/5/15, for bilateral buttock moisture associated [MEDICAL CONDITION], the physician ordered to apply zinc oxide to the peri wound, daily and as needed with brief (incontinence pants) changes. A follow up Wound Care Specialist Evaluation by the SWP, dated 7/10/15, indicated Sites 1 and 2 improved and Resident 1 had a Foley catheter to help keep moisture off of the wound. Site 3 at the right buttock resolved. Groin fungal infection improved. Wound treatment continued. A follow up Wound Care Specialist Evaluation by the SWP, dated 7/17/15, indicated Site 1 had resolved. However, Site 2, the sacrum, deteriorated to a Stage III (full tissue thickness loss) cluster wound, now measuring 4 cm L x 4 cm W x depth deteriorated, due to infection, decline in condition, and nutritional compromise. A wound biopsy was taken during the visit which showed Resident 1 [MEDICAL CONDITION] in his sacrum wound. The fungal infection had improved. Wound treatment continued. The SWP recommended added nutrients daily, off loading the wound and limiting the amount of time Resident 1 sits in his wheelchair. On 7/21/15, the physician ordered another antibiotic, [MEDICATION NAME] DS one tablet orally, twice daily for 10 days to treat Resident 1's bacterial wound infection. On 7/30/15 at 9:35 am, Resident 1's dressing change to his pressure ulcer was observed. Licensed Vocational Nurse (LVN) 2 performed the dressing change while the MDS Coordinator, a registered nurse (RN), assisted with positioning Resident 1. LVN 2 was observed setting up the dressing supplies, wearing gloves and a gown. After LVN 2 removed the crumpled up soiled dressing, she cleaned the ulcer with a commercial spray wound cleanser and dabbed the ulcer with dry 4 x 4 gauze dressings. LVN 2 applied Mupirocin (an antibacterial) ointment to the ulcer wound bed, then calcium alginate (dressing that absorbs drainage) and foam followed by a dressing covering the wound. LVN 2 then secured the dressing with zinc oxide tape. LVN 2 was questioned if she had changed her gloves after removing the soiled dressing. LVN 2 confirmed she did not wash her hands between removing the soiled dressing and cleaning and then applying the clean dressing to the ulcer. On 7/30/15 at 10:10 am, QA/ICN stated staff should wash their hands between changing gloves from the soiled dressing to applying the clean dressing. QA/ICN stated, the use of gloves did not take the place of hand washing. A review of the facility's care plans for Resident 1 indicated there were no revisions to address Resident 1's sacrum wound infection and elevated temperature, proper settings for his alternating pressure relieving mattress, or contact isolation (precautions to prevent the spread of an infectious bacteria) information. On 8/5/14 at 10:30 am MDS C confirmed the nursing documentation above and that the care plan was not followed by no documentation of informing MD of the changes to Resident 1's pressure ulcers. She confirmed there was no care plan for Resident 1's bed setting, increased temperature,[MEDICAL CONDITION] infection or isolation. On 8/4/15 at 2:45 pm, Registered Nurse (RN) A was interviewed. RN A stated she completed the admission paperwork for Resident 1's admission to the facility. During a concurrent review of the Nursing Admission Screening /History, dated 2/18/15, RN A stated, I believe he (Resident 1) had a Stage II (pressure ulcer). RN A then stated, I don't even know if we knew he had a decub (pressure ulcer) . until we turned him over. It was small and almost healed. RN A stated Resident 1's FM had been requesting a SWP examination and treatment since Resident 1 was admitted . On 8/5/15 at 10:15 am, during an interview with the MDS Coordinator (MDS) C, she confirmed Resident 1's coccyx wound was not listed on his admission face sheet as a diagnosis, further stating, only the pertinent [DIAGNOSES REDACTED]. MDS C stated staff should have been referring to the pressure ulcer sites. MDS C confirmed there was no Staging or description of Resident 1's coccyx wound on admission by an RN or the MD. SWP was not called to consult until three months after Resident 1's admission, despite FM's request. MDS C stated Site 2 developed to the right on top of Site 1, and they became one worsened ulcer. She stated she was told by SWP that Site 2 was caused by maceration (moisture) from Site 1. MDS C confirmed Resident 1's pressure relieving mattress setting was not correct when SWP first evaluated Resident 1's wounds; it was not set according to his weight. MDS C stated, How would I know. They're different. MDS C confirmed the lacking documentation by LNs of notifying the physician about Resident 1's changes of condition. MDS C confirmed the nursing documentation of the increased temperature, and when asked why laboratory tests were not conducted sooner as Resident 1 was showing signs and symptoms of an infection/sepsis, MDS C offered no response. The Director of Nursing (DON) was not available for interview during the survey on 8/5/15. On 8/6/15 at 11:30 am, during a phone interview, the DON stated the RN who was working when Resident 1 was admitted should have Staged his pressure ulcer. The DON stated he was the RN responsible for assessment and Staging of residents' pressure ulcers along with completing all residents' Braden Scale scores. The DON stated he did not know Resident 1 was admitted with a pressure ulcer until he signed his MDS, fourteen days after admission. The DON confirmed it was his responsibility to ensure care and services for pressure ulcers and that assessments are completed accurately.