Every finding on record at Idylwood Care Center

Based on observation, interview, record review, the facility failed to follow its fall policy and procedure, FALL PREVENTION & MANAGEMENT, when staff did not assess, report, and document a fall for one out of three residents (Resident 1) when Resident 1 consistently reported falling and that staff helped her back to bed approximately a week ago; however, the reported fall was not handled according to the facility fall policy for assessment, documentation, post fall monitoring, and physician notification. Subsequent medical evaluation results identified injury the right great toe. This deficient practice left Resident 1 without timely interventions for her fall injuries, which was a change of condition, by the facility.Findings: Review of a facility self-report, dated 6/12/26, indicated, On 6/10/26 during AM shift, Resident 1 had a change in condition of swelling with skin discoloration on the left foot and skin discoloration on the right foot. When the charge nurse asked Resident 1 what happened, Resident 1 claimed that a week ago she tried to stand and fell on the floor mattress. Review of Resident 1's face sheet (document summarizing a resident's personal health information) indicated Resident 1 was admitted on [DATE] with a diagnosis of age-related osteoporosis without current pathological fracture and was self-responsible. Review of Resident 1's comprehensive Minimum Data Set (MDS, an assessment tool used at skilled nursing facilities) dated 3/27/26, indicated she has good short term and long-term memory. The Quarterly MDS dated [DATE] indicated Resident 1 had good short-term memory. During a concurrent observation and interview in Resident 1's room on 06/30/26 at 10:07 a.m., Resident 1 was lying in bed awake with a floor mattress on the floor next to the bed. Resident 1 stated before her foot injuries were discovered, she had a fall the week before. Resident 1 stated when she tried to stand up, she heard crackles (popping noise) from her foot and fell on the floor mattress. Resident 1 stated staff helped her back to bed. Review of Resident 1's Change of Condition (COC) notes, dated 6/10/26 at 12:52 pm, indicated, Resident said, a week ago she tried to stand and fell on her mattress. She was assisted back to bed; she was initially fine and now she has a pain 10/10 on her foot. During review of Resident 1's Emergency Department (ED) record, dated 6/10/26, a Collected collateral hx (history) from EMS (Emergency Medical Services) HPI (History of Present Illness) indicated, . according to collateral and nursing facility staff, patient tripped and fell over her feet. while getting up out of bed. Patient stated his happened a week ago. Has pain to the right big toe. Further review of Physical Exam: Neurological: Mental Status: Residents 1 was alert, oriented to person, place and time. A Radiology Result Report, dated 6/10/26, indicated, FOOT COMPLETE MIN 3V, RIGHT (X-ray of the complete right foot using at least three different picture angles): Findings: There is minimally displaced intra-articular fracture (a bone break that extends into the surface of a joint, crossing through the articular cartilage) of the lateral base of the first proximal phalanx (bone closest to the great toe). CONCLUSION: Fracture of the first proximal phalanx, as above. FOOT COMPLETE MIN 3V, LEFT: Findings: No acute fracture. No dislocation. Moderate degenerative changes are present. Bones are osteopenic. Soft tissues are unremarkable. CONCLUSION: Moderate degenerative changes without acute abnormality. Review of Resident 1's interdisciplinary team (IDT, healthcare staff from various departments within a skilled nursing facility convening together to discuss patients' care), documentation of 6/12/26 for Resident 1's unwitnessed fall on 6/10/26 indicated, Per resident she got up from her bed and tried to walk, but fell and landed on her floor mattress. but was assisted back to bed by 4 staff. During a follow up interview of Resident 1 on 7/1/26 at 11:15 a.m., Resident 1 stated she tried standing up and had a fall onto the bedside floor mattress and heard a crackle, and then a big and tall staff grabbed her shoulder to assist her back to bed. During an interview with LVN C on 7/1/26 at 1:01 p.m., LVN C, who was the assigned nurse, stated, Resident 1 complained of pain. the dorsal area of her foot was swollen and discolored. LVN C stated Resident 1 tried to stand up had a fall. she was assisted back to the bed by nursing assistants. I don't know by whom . she needs assist by Hoyer lift (mechanical lift used to transfer a patient). LVN C stated when Resident 1 was asked if she was able to get back to bed, Resident 1 answered No. During an interview with LVN D on 7/1/26 at 1:49 p.m., LVN D stated he was the assigned nurse supervisor that assessed Resident 1 on 6/3/26 and no incident occurred during his shift. LVN D stated, however, on 6/10/26, Resident 1's assigned nurse informed him about Resident 1's skin discoloration. LVN D stated he went to investigate. LVN D stated Resident 1 reported that a week ago, I got up and fell on the floor mattress. LVN D asked Resident 1 who caried her back to bed, and she stated, You carried me back to bed. LVN D stated the resident is total assist and uses a Hoyer lift. During an interview with the Assistant Director of Nursing (ADON) on 7/1/26 at 2:29 p.m., she stated, upon knowledge of Resident 1's foot discoloration, they investigated it as an injury of unknown source. The ADON stated Resident 1 reported she had a fall and multiple people helped her. The ADON stated Resident 1 needs total assist and a mechanical lift. During an interview with the Assistant Director of Nursing (ADON) on 7/1/26 at 3:55 p.m., she stated, When a resident falls and sits on a mattress, we treat it as a fall. we do the assessment, we do a care plan, we talk as a team to discuss interventions . we investigate it. Review of the facility's policy and procedure titled, FALL PREVENTION & MANAGEMENT, revised date 09/01/13, indicated, It is the goal of this facility to prevent or reduce the occurrence of falls and severity of fall-related injuries. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Procedure for responding to a fall: 1. Resident to be immediately evaluated by a licensed nurse at the location of the fall. Assessment should include, but not limited to, an evaluation of ABC, signs of bleeding, trauma, physical injury, head injury, muscular or skeletal trauma, an evaluation of pain, and vital signs. Assist resident to a comfortable position as tolerated, paying attention to verbal & non verbal indicators of pain /discomfort. 2.Nurses are to intervene according to symptoms and clinical manifestations. It may be necessary to provide oxygen, emergency first -aid, or ambulance via 911 transport depending on the severity of the situation and advance directives. 3. Physicians is to be notified as soon as practicable following the fall. Collaborative effort is needed in the event, and injury has occurred or is suspected. 4. An X-ray should be ordered by the physician to R/O (rule out) fracture when it is suspected by indicators of pain, redness, swelling, shortening and/ or external rotation of a lower extremity. (Remember that in most fall incidents, Fall+Pain=X-ray). 5. Resident is to be placed on observation of vital signs, pain, and other post-fall complications. Fall details, assessment findings, interventions, & notifications are to be documented in resident's clinical record & care plan updated accordingly. 6. Continued monitoring is necessary, as symptoms may present at the time, even days following the actual event. Promptly notify the MD about abnormal symptoms.7. Residents with an unwitnessed fall, (who are not oriented enough to give an accurate history), and an actual or suspected head injury will have neurological check implemented and documented per neuro check policy. 8. Follow up vital signs, assessment, pain evaluation, and neurological check (when indicated) will be conducted for a minimum of 72 hours for any actual or suspected fall, with or without injury. 9. Recent falls will be reviewed each week by the interdisciplinary team to evaluate trends, identity educational needs, and determine strategies to prevent recurrence for each resident.

38573 Based on observation, interview and record review, the facility failed to maintain proper infection control practices when: 1. Resident 77 had an opened plastic bag with gastrostomy (GT, a surgical opening into the stomach for administration of nutrition and medications) syringe dated [DATE] and his urinary catheter attached to urinary catheter drainage bag (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) was not properly positioned; 2. Resident 5's and 31's room had an opened and unlabeled GT syringe; 3. Resident 32 had an opened unlabeled plastic bag with enteral feeding tube (used to deliver nutrients directly into the stomach or small intestine, bypassing the mouth and swallowing process); 4. Resident 100's used spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs that measures ventilation, the movement of air into and out of the lungs) mouthpiece had a dried yellowish substance and was touching the inside part of a wash basin; 5. A dirty plastic garbage bag was touching a box of clean gloves on top of Resident 100's bed and Dakin's solution (used to clean wounds) was not cleaned before storing in the treatment cart; 6. Nasal cannulas (NC, a tubing used to deliver oxygen) for Residents 43 and 40 were not in the resident's nostrils and were not stored properly; 7. A nurse was wearing an N95 (personal protective mask that filters out at least 95% of airborne particles, designed to form a seal around nose and mouth) face mask below her nose and mouth; 8. Resident 17's foley catheter (F/C, thin, flexible tube used to drain urine from bladder) drainage bag (urine collection bag) was on the floor; 9. The enteral feeding tubing for Residents 56, 28, and 17 were not dated; 10. The filters in Resident 27's concentrator were dirty. 11. A nurse did not sanitize a stethoscope after use. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. During the initial tour observation of the facility on [DATE] at 9:50 a.m., Resident 77's bedside table has plastic bag with GT syringe dated [DATE]. During the initial tour observation of the facility on [DATE] at 9:51 a.m., Resident 77's had a urinary catheter attached to a urinary catheter drainage bag. The position of the tubing of the urinary catheter was above the level of the bladder and was kinked. During a concurrent observation and interview on [DATE] at 9:52 a.m., with licensed vocational nurse Q (LVN Q) she acknowledged the above observation and stated the GT syringe should not be there. During a concurrent observation and interview on [DATE] at 9:55 a.m., with LVN Q, she confirmed the above observation and stated the position of the tubing was above the level of the bladder, urine was going back to the bladder, and it should not have been kinked. During a concurrent interview and record review on [DATE] at 8:57 a.m., with the assistant director of nursing (ADON), the ADON reviewed Resident 77's clinical records and stated that Resident 77 was readmitted to the facility on [DATE] and had a suprapubic catheter (small flexible tube surgically inserted into the bladder through an incision in the lower abdomen) insertion procedure on [DATE] due to diagnosis of obstructive and reflux uropathy. The ADON further stated that the care plan for suprapubic catheter was initiated on [DATE] and indicated that one of the interventions was to position catheter bag and tubing below the level of the bladder and away from the entrance room door. 2. During the initial tour observation of the facility on [DATE] at 10:06 a.m., a room was shared by two residents, Resident 5 and Resident 31. There was a bedside table in the middle of the room. On top of the bedside table there was an opened and unlabeled GT syringe. During a concurrent observation and interview on [DATE] at 10:10 a.m., with LVN Q, she confirmed the above observation and stated it should have been labeled because both residents are on isolation precautions. 3. During an observation on [DATE] at 10:27 a.m., Resident 32's bedside table had an opened plastic bag with enteral feeding tube inside. The bag was undated, unlabeled, and touching an opened package of A and D ointment (used to moisturize skin). During a concurrent observation and interview on [DATE] at 10:30 a.m., with LVN Q, she confirmed the above observation and stated it should have been labeled and dated. She further stated that A&D ointment that was used and opened should have been discarded to prevent contamination. 4. During the initial tour observation of the facility on [DATE] at 10:00 a.m., Resident 100's used spirometer mouthpiece had a dried yellowish substance and was touching the inside part of the pink wash basin. The spirometer was stored together with string, lotion, plastic and paper. During a concurrent observation and interview on [DATE] at 10:02 a.m., LVN Q confirmed the above observation and LVN Q stated that the spirometer apparatus mouthpiece should not be touching the pink wash basin. LVN Q further stated that after using the spirometer apparatus, it should have been cleaned and put it inside a plastic bag. Review of the facility's undated policy and procedure, titled, Cleaning and Disinfection of Resident-Care Items and Equipment indicated, Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . Disinfection necessary for items used in resident care . Semi-critical items consist of items that may come in contact with mucus membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. 5. During wound dressing change observation on [DATE] at 10:05 a.m., with the TX N, there was a dirty plastic garbage bag on top of Resident 100's bed that contained used gauze, used dressings, and used gloves. The garbage bag was touching and covering more than half of an opened box of clean gloves. The TX N was holding a Dakin's solution bottle with his left gloved hand with the same glove that was used during Resident 100's wound dressing change. The TX N stored the Dakin's solution bottle inside the treatment cart without cleaning the bottle. During an interview on [DATE] at 10:15 a.m., with TX N, he confirmed the above observations. Review of the facility's policy and procedure dated [DATE], titled, Dressing, Non-Sterile and Sterile indicated, Non-sterile (clean) dressing changes are applied in a clean and comfortable manner . Example of Wounds: Pressure Ulcers, Chronic Wounds, Skin tears, Less Invasive Wounds . Clean technique means free of dirt, marks, or stains . Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Review of the facility's undated policy and procedure, titled, Personal Protective Equipment - Gloves indicated gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. 46552 6. Review of Resident 43's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 43 was admitted to the facility on [DATE]. Resident 43's FS also indicated diagnoses included chronic obstructive pulmonary disease (COPD, a progressive lung disease causes airflow limitations and lung tissue destruction) and respiratory failure with hypoxia (a condition with low oxygen [O2, a colorless, odorless, and tasteless gas essential to living organisms] blood levels due to lungs unable to adequately oxygenate the blood). Review of Resident 43's physician orders, dated [DATE] indicated, Administer continuous oxygen at 2 LPM [liters per minute, flow rate of oxygen delivery] via nasal cannula. During an initial observation of Resident 43's room on [DATE] at 10:00 a.m., Resident 43's NC was laying on the bed's left side rail and was connected to an oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a resident in need of supplemental oxygen). Resident 43's oxygen concentrator was on. During an interview with licensed vocational nurse B (LVN B) on [DATE] at 10:17 a.m., LVN B confirmed Resident 43's NC was not in the resident's nostril and was left on the side rail. LVN B stated the NC should not have been left on the side rail due to infection control. Review of Resident 40's FS indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's FS also indicated diagnoses included thrombocytopenia (low levels of platelets [type of blood cells to help to stop bleeding] in blood) and venous insufficiency (a condition when blood flow problems sending from legs back up to heart). Review of Resident 40's physician orders, dated [DATE] indicated, Administer ,d+[DATE] liters of oxygen via nasal cannula to maintain oxygen level of > [greater than] 92% as needed. During an initial observation of Resident 40's room on [DATE] at 10:37 a.m., Resident 40's NC was laying on a humidifier (a medical device that adds moisture to the oxygen delivered to resident during oxygen therapy) and was connected to an oxygen concentrator. Resident 40's oxygen concentrator was on. During an interview with licensed vocational nurse P (LVN P) on [DATE] at 11:40 a.m., LVN P confirmed the above observation. LVN P stated the NC should be in Resident 40's nostril when oxygen is in use. LVN P also stated the NC should not have been left on the humidifier. During an interview with the facility's infection preventionist (IP) on [DATE] at 8:20 a.m., the IP stated nasal cannulas should be in resident's nostrils when oxygen is in use. The IP also stated NC should not have been left on a side rail or humidifier because it would be an infection control issue. Review of facility's policy and procedure (P&P) titled, Labeling of Oxygen Cannula/Tubing, dated [DATE], the P&P indicated, During Use: Place the cannula in the patient's nostrils, ensuring a comfortable and secure fit. 7. During an observation on [DATE] at 9:55 a.m., licensed vocational nurse B (LVN B) was preparing medications in front of the medication cart (movable equipment used in healthcare settings to store, transport, and dispense medications) in the hallway. LVN B's N95 (personal protective mask that filters out at least 95% of airborne particles, designed to form a seal around nose and mouth) face mask was below her nose and mouth. During a second observation on [DATE] at 10:11 a.m., LVN B's N95 face mask was below her nose and mouth while preparing medications in front of the medication cart in the hallway. During an interview with LVN B on [DATE] at 10:15 a.m., LVN B confirmed her N95 was below her nose and mouth. LVN B adjusted her N95 to cover her nose and mouth and stated her N95 should have covered her nose and mouth to form a tight seal. During an interview with the IP on [DATE] at 7:58 a.m., the IP confirmed all staff must wear N95 due to current influenza (a common, sometimes deadly viral infection of the nose, throat, and lungs) outbreak (a sudden and unexpected increase in number of cases) in the facility. The IP stated LVN B's N95 face mask should have covered her nose and mouth to prevent the spread of infection. Review of facility's P&P titled, Personal Protective Equipment, dated [DATE], the P&P indicated, PPE (personal protective equipment) required for transmission-based precautions is maintained outside and inside the resident's room, as needed. Review of facility's P&P titled, Personal Protective Equipment-Using Face Masks, dated [DATE], the P&P indicated, Be sure that face mask covers the nose and mouth. 8. Review of Resident 17's FS indicated Resident 17 was admitted to the facility on [DATE]. Resident 17's FS also indicated diagnoses included ureteral obstruction (blockage of the tubes that carry urine from kidneys [body organ that filter waste and excess water from blood, producing urine] to the bladder [body organ that stores urine]). Review of Resident 17's physician order, dated [DATE] indicated, Indwelling Foley catheter #18 F (size of F/C) with 10 cc [cubic centimeter, unit of measurement] [NAME] to bedside gravity drainage bag. During an observation on [DATE] at 9:30 a.m., Resident 17's F/C drainage bag was on the floor next to the right side of Resident 17's bed. During a concurrent observation and interview with certified nursing assistant T (CNA T) on [DATE] at 9:40 a.m., CNA T confirmed Resident 17's F/C drainage bag was on the floor. CNA T stated the F/C drainage bag should not have been on the floor due to infection control. CNA T also stated nursing staff should have placed the F/C drainage bag in a privacy bag anchored to Resident 17's bed frame. During an interview with LVN P on [DATE] at 10:02 a.m., LVN P stated Resident 17's F/C drainage bag should have been placed in a privacy bag and anchored to the bed frame below the bladder. LVN P also stated nursing staff should not have left F/C drainage bag on the floor for infection control and prevention. During an interview with the IP on [DATE] at 8:15 a.m., IP stated nursing staff should have placed Resident 17's F/C drainage bag in a privacy bag and should not have left the bag on the floor for infection control practice. Review of facility's P&P titled, Catheter Care, Urinary, dated [DATE], the P&P indicated, If drainage bag is packed separately, open package and attach bag to the bed frame. Use an alternate method to keep the drainage bag off the floor. 9. Review of Resident 56's FS indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's FS also indicated diagnoses included gastrostomy (a surgical opening into the stomach, insert thin flexible tube to provided nutrition), and dysphagia (difficulty swallowing). Review of Resident 56's physician order dated [DATE] indicated, Enteral Feed Order every shift isosource [type of ready-to-use liquid nutrition formula] 1.5 at 70 ml/hr [milliliter/hour, metric unit of volume of fluid in one hour] via J-tube [jejunal tube, JT, soft plastic tube surgically inserted through skin into the small intestine to deliver nutrition and medications]. During an observation on [DATE] at 10:50 a.m., Resident 56's JT feeding was in use. The enteral feeding tube was attached to the ready-to-use feeding formula bag and the other end was attached to Resident 56's JT. Resident 56's enteral feeding tube was not dated. Review of Resident 28's FS indicated Resident 28 was admitted to the facility on [DATE]. Resident 28's FS also indicated diagnoses included gastrostomy and dysphagia. Review of Resident 28's physician order dated [DATE] indicated, Enteral Feed Order every shift isosource 1.5 at 70ml/hr via J-tube. During an observation on [DATE] at 11:02 a.m., Resident 28's JT feeding was in use. The enteral feeding tube was attached to the ready-to-use feeding formula bag and the other end was attached to Resident 28's JT. Resident 28's enteral feeding tube was not dated. Review of Resident 17's FS indicated diagnoses included gastrostomy status and dysphagia. Review of Resident 17's physician order, dated [DATE] indicated, Enteral feed order every shift isosource 1.5 at 5 ml/hr via G-tube [GT]. During an observation on [DATE] at 11:13 a.m., Resident 17's GT feeding was in use. The enteral feeding tube was attached to the ready-to-use feeding formula bag and the other end was attached to Resident 17's GT. Resident 17's enteral feeding tube was not dated. During an interview with LVN P on [DATE] at 11:33 a.m., LVN P confirmed the enteral feeding tubes were not dated when started for Resident 56, 28 and 17. LVN P stated nursing staff should have dated the residents' enteral feeding tubes. During an interview with IP on [DATE] at 8:10 a.m., the IP stated nursing staff should have labeled each enteral feeding tube with the date the feeding tube kit was opened. Review of manufacturer's recommendations for the enteral administration kit indicated, Discard administration set and transition connector when delivery is complete within a maximum of 48 hours. 38087 10. Review of Resident 27's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including COPD and pericardial effusion (build up of extra fluid in the space around the heart.) Review of Resident 27's physician order, dated [DATE], it indicated he had an order for continuous supplemental oxygen at 2 to 5 liters per minute. During an observation on [DATE] at 9:48 a.m., Resident 27 was receiving oxygen via nasal cannula being delivered via an oxygen concentrator. The filters on both sides of the oxygen concentrator machine were dusty, with an accumulation of whitish gray substances on the filter sponges. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on [DATE] at 10:07 a.m., he confirmed both filters on Resident 27's concentrator were dirty and he stated the filters should be changed. During an interview with the director of nursing (DON) on [DATE] at 7:30 a.m., she stated the concentrator filter should be cleaned every week and replaced as needed. Review of the facility's policy Cleaning Resident Rooms and Equipment revised [DATE], indicated, . 5. For oxygen tanks, connectors and concentrators: b. Clean oxygen concentrator filters weekly. Review of the Platinum Series XL, 5, 10 operator's manual indicated the following for routine maintenance of the cabinet filters: Remove each filter and clean at least once a week. 50855 11. During medication administration observation on [DATE] at 8:33 a.m., with Registered Nurse E (RN E), she was observed checking the gastrostomy tube (GT tube, a surgical opening into the stomach for administration of nutrition and medications) placement for Resident 34 using a stethoscope. After checking for placement, RN E placed the stethoscope inside the medication cart without sanitizing the stethoscope. During an interview shortly after medication administration on [DATE] at 8:57 a.m., RN E was asked whether she cleaned or sanitized the stethoscope after she used it and before placing it inside the medication cart. RN E stated, I did not sanitize it. She further stated for infection control it should be sanitized before and after use. During an interview on [DATE] at 3:38 p.m., with the Director of Nursing (DON), the DON stated the nurse should disinfect (clean something using chemicals that kill bacteria) the stethoscope after being used and before placing it back in the medication cart for infection control. During a review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 2001, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions.

Based on observation, interview, and record review, the facility had a medication error rate of 18.75% when six medication errors occurred out of 32 opportunities during the medication administration for three out of seven residents (Resident 3, Resident 34, and Resident 139). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), and had the potential for medication complications or residents not receiving full therapeutic effects of the medication. Findings: 1. During the medication administration observation on 4/7/24 at 4:35 p.m., Licensed Vocational Nurse F (LVN F) was observed administering five medications for Resident 3. Included in the medications was eye drops, Brimonidine Tartrate [used to lower pressure in the eyes in patients with glaucoma (high pressure in the eyes that may damage nerves and cause vision loss)]. LVN F asked Resident 3 to open the eyes but did not instruct the resident to look up. LVN F instilled one drop of the medication directly to the inner corner of Resident 3's eye without pulling the lower eyelid down. As soon as the eye drop was instilled to inner corner of Resident 3's eyes, LVN J immediately wiped Resident 3's eyes with a tissue. LVN J did not apply gentle pressure on Resident 3's tear duct after administering the eye drops. During an interview after the medication administration, on 4/7/25 at 4:53 p.m. with LVN F, he confirmed he instilled the drops directly into the inner corner of Resident 3's eyes and did not pull the resident's lower eyelid to make a pocket to instill the medication in during eye drop administration. He further stated he normally administered the eye drop in the center of the eye or pupil [circular black opening in the center of the iris (the colored part of the eye that surrounds the pupil) of the eye]. During a review of Resident 3's physician's order indicated an order, dated 2/26/25 for Brimonidine Tartrate Instill 1 drop in both eyes three times a day for Glaucoma. During an interview on 4/8/25 at 3:13 p.m., with the Director of Nursing (DON), she stated during eye drop administration, the nurses should make a pocket and instill the eye drop in the conjunctival sac (the pocket where eye drops and ointments are typically administered). During phone interview on 4/10/25 at 3:39 p.m., with the Facility Pharmacist Consultant (FPC), the FPC stated for eye drop administration the nurse should wash hands, wear gloves, instruct the patient to look up if the patient cannot follow instruction, they have to hold the eyelid (lower). According to MedlinePlus.gov, a service of the National Library of Medicine (NLM), the world's largest medical library, which is part of the National Institutes of Health (NIH). Indicated the following for Brimonidine Ophthalmic: To instill eye drops, follow these steps: . 5. While tilting your head back, pull down the lower lid of your eye with your index finger to form a pocket . 7. While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove your index finger from the lower eyelid . 9. Place a finger on the tear duct and apply gentle pressure [prevent the medication from draining into the nose and reduces the risk of systemic side effects]. 10. Wipe any excess liquid from your face with a tissue . During a review of the facility's P&P titled 6.0 General Dose Preparation and Medication Administration Revised date 1/1/13, indicated, Applicability: This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications . 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: .Provide the resident with any necessary instructions. 5.8 Follow manufacturer medication administration guidelines . 2. During the medication administration observation on 4/8/25 at 8:36 a.m., Registered Nurse E (RN E), was observed preparing five medications, one liquid medication, four tablets of three different medications, and one powdered medication for Resident 34. The four tablets were one tablet of aspirin (treat mild to moderate pain) 81 milligrams (mg, unit of measurement); two tablets of carbamazepine (used to treat seizures, nerve pain) 200 mg; and one tablet of lithium (treat bipolar disorder, a mental condition in which a person has wide or extreme swings in their mood) 300 mg. The resident was receiving medications via gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). RN E placed the four tablets of three different medications in one small medication cup, then she put it inside the pill crusher pouch and crushed all the three medications together. She put the three crushed medications in one cup of 4 ounces (oz, unit of measurement) of water, which was mixed with 17 grams of polyethylene glycol powder (treat occasional constipation). On 4/8/25 at 8:45 a.m., RN E was observed administering the medication to Resident 34 via G-tube. RN E flushed the G-tube with water and she administered the four mixed medications in one cup using a 60 ml (milliliter, unit of measurement) syringe (commonly used in a wide range of applications, including medication delivery, fluid injections, blood draws, and laboratory testing), then she flushed the G-tube with water. During an interview shortly after the observation, on 4/8/25 at 8:59 a.m., RN E confirmed she crushed the three medications all together and mixed it with 17 gram of polyethylene powder in the cup, total of four mixed medications was administered to Resident 34's G-tube together. The liquid medication was administered separately. RN E stated the three medications should be crushed separately. She stated she should have flushed 15 ml in between each mediation. RN E also stated the four medications should be administered separately. She further stated the medications has different interactions. During an interview on 4/8/25 3:15 p.m., with the DON, she stated during G-tube medication administration, nurses should crush the medication separately and administer the medications separately with flushing in between. During a review of Resident 34's physician's order indicated an order, dated 1/25/24 Enteral Feed (also known as tube feeding) Order every shift flush tube with 15 ml of water in between each medication. During a telephone interview on 4/10/25 at 3:37 p.m., with the Facility Pharmacist Consultant (FPC), the FPC stated for G-tube medicaiton administration, the nurse should administer the medication in separate cups and flush after each medication. She further stated it is a precaution because some drugs might have an interaction. During a review of the facility's P&P titled, ENTERAL THERAPY (Tube Management, Feeding, Medications) Revised date 9/1/13, indicated, . III MEDICATION AND ADMINISTRATION VIA ENTERAL TUBE A. Procedure for Administering Medication: . 4. Administer each medication one at a time, with water flushes prior to administration, due to risk for physical and chemical incompatibilities, potential for tube obstruction, and potential for altered therapeutic drug response . 3. During the medication administration observation on 4/8/25 at 9:04 a.m., Registered Nurse I (RN I), was observed preparing five medications for Resident 139. Included in the medications was tamsulosin (used in men to treat the symptoms of an enlarged prostate [prostate is a gland in the male reproductive system]) 0.4 mg 2 capsules. The medication was not in the cart and RN I stated she will check the medication room for tamsulosin. RN I came back without the tamsulosin and she stated the medication is not available. She further stated she will call the pharmacy. During an interview on 4/8/25 at 1:18 p.m., when RN I was asked whether she was able to give tamsulosin to Resident 139, RN stated it was not given and the pharmacy will deliver the medication later in afternoon. During a review of Resident 139's physician's order indicated an order for Tamsulosin capsule 0.4 mg give 2 capsule by mouth one time a day for BPH (benign prostatic hyperplasia, condition when the prostate gland is larger than normal), dated 5/29/24. During a review of Resident 139's Medication Administration Record (MAR) indicated the 4/8/25 9 a.m. administration for tamsulosin 0.4 mg give 2 capsule was marked 18 meaning medication not available. During an interview of 4/9/25 at 3:36 p.m., with the DON, she stated medication should have been ordered on time and stated medications should be available. She further stated Resident 139 did not receive the medication tamsulosin yesterday. During a review of the facility's P&P titled, MED PASS, MEDICATION ADMINISTRATION ESSENTIALS Revised date 9/1/13, indicated, . 2. The licensed nurse administers medications within one hour before or one hour after the scheduled administration time. E. Medication Rights Licensed nurses are to follow the seven rights of medication: 4. The right time.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Opened multi-dose vials/inhalers had no open date; 2. Expired medications were not removed from active stock; 3. A treatment cart was left unlocked and unattended. These failures had the potential for residents to receive medications with reduced efficacy and had the potential for residents to access the unlocked and unattended treatment cart. Findings: 1. During an inspection of a medication cart on 4/7/25 at 3:31 p.m., with Registered Nurse D (RN D), one opened bottle of Pepto Bismol (indication include diarrhea, heartburn, indigestions, nausea, and stomach upset) was identified. The bottle had an expiration of 3/2025. RN D confirmed Pepto Bismol was expired on 3/2025. She further stated it should not be in the cart and should not be used. During an interview on 4/8/25 at 3:27 p.m., with the Director on Nursing (DON), the DON stated any expired medication should not be in the cart because the efficacy of the medication is not the same. 2. During an inspection of another medication cart on 4/7/25 at 3:46 p.m., with Registered Nurse E (RN E), RN E confirmed the following findings: a. One opened multi-dose vial of insulin did not have an open date. A review of the manufacturer's label on the insulin vial indicated it must be discarded 28 days after opening. RN E stated insulin should have an open date and discard 28 days after opening. b. A Wixela (medication to treat breathing problems such as asthma) inhaler had an open date of 3/5/25. A review of manufacturer's label indicated to discard one month after opening. RN E stated it should be discarded. c. A Breyna (medication to treat breathing problems such as asthma) inhaler was undated with the open date. A review of manufacturer's label with RN E indicated, to discard three months after opening. RN E stated Breyna should have an open date and be discarded in three months. During an interview on 4/8/25 at 3:33 p.m. with the Director of Nursing (DON), the DON stated the expired Wixela inhaler should not be in the medication cart, the Breyna inhaler should have an open date, and the multi-dose vial of insulin should have an open date to know when it should be discarded. During a review of facility's policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles revised date 6/30/17, indicated, . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommendation by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or return to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the dated opened on the medication container when the medication has as shortened expiration once opened. 38087 3. During a wound treatment observation, on 4/9/25 at 8:15 a.m., the treatment nurse (TXN) prepared supplies to perform a wound treatment for Resident 98. The TXN left the treatment cart unlocked, entered Resident 98's room, and closed the door. The treatment cart was left unlocked in the hallway, outside of Resident 98's room. During an interview, on 4/9/25 at 8:22 a.m., the TXN confirmed he left the treatment cart unlocked and stated it should be locked. During an interview with the director of nursing (DON) on 4/10/25 at 7:30 a.m., she confirmed the treatment cart should be locked when not in use. The DON further added the treatment cart should always be within view of the user when unlocked. The facility's policy, General Dose Preparation and Medication Administration, revised 1/1/13 indicated, Facility should ensure that medication carts are always locked when out of sight or unattended.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. A table mounted can opener had brownish colored substances; 2. Six food trays had black substances inside the corners of the trays; and 3. The back and side of a food cart parked inside the kitchen had whitish substances outside food cart surfaces. These failures had the potential to cause foodborne illnesses for residents. Findings: 1. During an initial tour in the kitchen on 4/7/25 at 8:44 a.m., with Registered Dietitian 2 (RD 2), a table mounted can opener had brownish colored substances on the top and sides. RD 2 confirmed the observation and stated the can opener needed to be cleaned and free from rust. 2. During a concurrent observation and interview on 4/7/25 at 8:52 a.m., with RD 2, she confirmed two trays with three loaves of bread were stored in each tray. One tray with 15 bowls, one tray with 27 bowls, and two empty trays were stored together inside a cart. There were black substances inside the corners of each tray. RD 2 stated they will clean the trays now. 3. During a concurrent observation and interview on 4/7/25 at 8:59 a.m., with RD 1 and RD 2, there was a food cart parked inside the kitchen and had whitish substances outside the back and side surface. RD 1 and RD 2 acknowledged the above observation and stated they will clean the food cart now. According to the FDA Food Code 2017, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Review of the facility's undated policy and procedure, titled, Pot and Pan Washing indicated pots and pans will be properly sanitized. The preferred method is to run all pots and pans through the dish machine.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for two of 32 residents when: 1. Maintenance staff intervened while staff attempted to de-escalate Resident 62's angry outburst. 2. Resident 88's urinal was on his bedside table next to food items. These failures had the potential to affect the emotional well-being of the residents. Findings: 1. During an observation on 4/7/25 at 1:31 p.m., there were two maintenance staff working on a handrail in the hallway, close to the nurse's station. Resident 62 was in his wheelchair banging on the door to the nurse's station. One of the maintenance workers, maintenance staff M (MS M) was repeatedly telling Resident 62 to stop banging on the door. MS M stood up from his position fixing the handrail, walked to Resident 62 at the nurse's station, and stood behind Resident 62's wheelchair. MS M continued to tell Resident 62 to stop banging on the door. MS M then grabbed Resident 62's wheelchair and pulled the resident backward. Resident 62 swung his right arm behind him and hit MS M in the face. Review of Resident 62's face sheet indicated he was admitted to the facility with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 62's care plan indicated he has repetitive anxious concerns/complaints, demands juice, burritos, popsicles, and does not allow ample time for staff to accommodate requests. The care plan also indicated Resident 62 bangs on office and nurse's station doors. The care plan interventions included to explain all procedures to the resident before starting and allow the resident time to adjust to changes. Review of the report sent to the Department on 4/11/25 indicated the following: On 4/7/2025, at approximately [1:30 p.m.], staff observed Resident 62 repeatedly banging on the . nursing station window. While CNA [certified nursing assistant] was assisting Resident 62, one maintenance staff intervened and loudly verbalized to [Resident 62] to stop banging on the window. Maintenance staff attempted to redirect [Resident 62] by pulling [Resident 62]'s wheelchair backward towards [his] room. Maintenance staff was behind [Resident 62]'s wheelchair. [Resident 62] responded to maintenance staff by suddenly punching staff using his [Resident 62] right fist to hit the staff member's right eye. Two nurses remained with Resident 62 until he [calmed] down . During an interview on 4/7/25 at 1:45 p.m. licensed vocational nurse N (LVN N) stated he saw the incident with Resident 62. LVN N stated Resident 62 is constantly banging on the window. He stated he saw MS M try to take the resident back to his room and Resident 62 hit MS M on the right side of his face. During an interview on 4/10/25 at 1:43 p.m., the maintenance supervisor O (MS O) stated he heard about the incident with Resident 62 and MS M. The MS O stated he supervises four staff members. He stated he expects maintenance staff to be considerate to residents. The MS O stated if there was a situation related to nursing, he would expect maintenance staff to find someone appropriate to help. When asked about whether maintenance staff should be involved in a resident's disruptive behavior, the MS O stated maintenance staff do not get involved in those types of interactions. When asked what he thought about MS M pulling backwards on Resident 62's wheelchair from behind, the MS O stated, I don't feel that that was the best approach. During an interview on 4/11/25 at 3:38 p.m. with the administrator (ADM) and director of nursing (DON), the DON stated Resident 62 has a behavior of banging on the door of the nursing station. She stated staff is aware how to handle Resident 62. The DON stated staff does not have to go close to Resident 62 to redirect him because he can get aggressive. She stated MS M attempted to redirect Resident 62 and pulled his wheelchair backwards. The DON stated Resident 62's reaction to his wheelchair being moved was to swing and Resident 62 hit MS M's right eye. Both the DON and ADM stated MS M should not have been involved in that type of situation. Review of the facility's policy and procedure, Adequate Staffing/Workplace Composition, revised 8/2023 indicated, Staff will participate in de-escalation training. Review of Crisis Prevention Institute's Nonviolent Crisis Intervention Training Participant Workbook, (training the facility provides) indicated, Always respond with respect, empathy, and compassion. The workbook also indicated, Interpret distress behaviors and address the cause of the behavior to de-escalate the situation and Manage your own emotional responses to distress behavior. 38087 2. Review of Resident 88's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and need for assistance with personal care. Review of Resident 88's minimum data set (MDS, an assessment tool), dated 3/20/25, indicated his cognition was moderately impaired and he needed partial/moderate assistance for toileting hygiene. During an observation on 4/7/25 at 9:47 a.m., Resident 88's bedside table had several drink items on the table including a glass of milk, a cup of coffee, and a glass with a pink liquid. Next to the drinks, on Resident 88's bedside table, was a plastic urinal that contained a yellow liquid. When Resident 88 was asked about the items on his bedside table he stated, That's the remnants of my breakfast I am finishing. Resident 88 further stated he does not like the urinal next to his food but stated, I can't do anything about it. During an observation on 4/7/25 at 9:50 a.m., the activities director (AD) was removing Resident 88's urinal from his bedside table. During a concurrent interview with the AD, he stated, It should not be on the bedside table next to the food. The AD removed the urinal and returned with a plastic urinal holder which he placed on the left side of Resident 88's bedframe. During an interview with the director of nursing (DON) on 4/10/25 at 7:30 a.m., she stated a urinal should not be placed on the bedside table during the meal service or when any food items are on the bedside table. The DON further stated staff should empty urinals after each use and then store in holders on the side of the resident's bed. Review of the facility's policy titled, Use of Bedpans and Urinals indicated, Avoid storing on any surface used for eating, such as the rolling bedside table.

Based on observation, interview, and record review, the facility failed to perform interdisciplinary team (IDT, staff from different departments who coordinate the residents care) assessment and obtain a physician order for self-administration of medication for one out of 32 sampled residents (Resident 78) when Resident 78 had over-the-counter medication (OTC, can be purchased without a prescription from medical doctor) bottle of expired Vicks VapoRub (used to treat to relieve coughs, congestion and minor pains) on the bedside tray table. This failure had the potential for unsafe and improper administration of OTC medication. Findings: Review of Resident 78's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 78 was admitted to facility on [DATE]. Resident 78's FS also indicated diagnoses included congestive heart failure (a condition when heart is unable to pump blood efficiently), chronic obstructive pulmonary disease (a progressive lung disease characterized by airflow limitation and lung tissue destruction), and depression (a condition of persistent feeling of sadness, and loss of interest or pleasure in daily activities). Review of Resident 78's minimum data set (MDS, clinical and functional assessment tool) dated [DATE] indicated Resident 78's brief interview for mental status (BIMS, a tool used to assess cognition) score of 15 (score of 0 to 7- severe cognitive impairment, 8 to 12-moderate cognitive impairment, and 13 to 15 - intact cognition). Review of Resident 78's clinical documentation indicated there was no documented evidence of the IDT's assessment for self-administration of medication. Review of Resident 78's physician orders indicated there was no order for OTC Vicks VapoRub for self-administration. During an observation in Resident 78's room on [DATE] at 9:11 a.m., a bottle of OTC medication Vicks VapoRub was on the tray table next to Resident 78's bed. This bottle had about one-fourth of the medication left and was labeled with an expiration date ,d+[DATE]. During a concurrent interview, Resident 78 stated he used this medication himself most of the days for his nose and was not aware of the expiration date. Resident 78 also stated his son gave this bottle long ago and nursing staff was aware of him using this medication often. During an interview with licensed vocational nurse B (LVN B) on [DATE] at 12:42 p.m., LVN B confirmed the bottle of Vicks VapoRub OTC medication was left on Resident 78's tray table and was expired. LVN B also stated there was no physician order for this medication for self-use for Resident 78. LVN B stated this medication should not have been left in the room for Resident 78. During an interview with facility's director of nursing (DON) on [DATE] at 10:55 a.m., the DON stated she was not aware of Resident 78 self-administering OTC medication. The DON also stated the IDT should have assessed Resident 78 for safely self-administering the medication and nursing staff should have obtained a physician order for Vicks VapoRub for self-administration for Resident 78. Review of facility's policy and procedure (P&P) titled, Self Administration of Medications, last revised dated [DATE], the P&P indicated, Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and appropriate. Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for advance directive (AD, written instructions, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for three of six sampled residents (Resident 17, 10, and 117). These failures could lead to the delivery of unnecessary or inappropriate medical services against a resident's goals and wishes. Findings: Review of Resident 17's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 17 was admitted to facility on 8/13/2019. Review of Resident 17's POLST form date prepared on 2/3/2025 indicated section D for AD was incomplete and left blank. Review of Resident 17's clinical record indicated there was no documented evidence the facility verified, offered, or assisted Resident 17 to execute an AD. Review of Resident 10's FS indicated Resident 10 was admitted to facility on 1/31/2002. Review of Resident 10's POLST form prepared undated indicated section D for AD incomplete, left blank. Review of Resident 10's clinical record indicated there was no documented evidence the facility verified, offered, or assisted Resident 10 to execute an AD. Review of Resident 117's FS indicated Resident 117 was admitted to facility on 9/15/2021. Review of Resident 117's POLST form prepared date 7/13/2021, section D for AD indicated, No Advance Directive. Review of Resident 117's clinical record indicated there was no documented evidence the facility offered or assisted Resident 117 to execute an AD. During an interview with the facility's social service director (SSD) on 4/9/2025 at 2:05 p.m., the SSD confirmed above findings. The SSD stated facility should have completed POLST form for section D for AD for Residents 17 and 10. The SSD also stated social service staff should have verified, discussed, offered, and assisted to execute AD for Residents 17, 10, and 117. During an interview with the director of nursing (DON) on 4/11/2025 at 10;29 a.m., the DON stated nursing staff should have verified and completed all sections of POLST form for residents. The DON also stated social service staff should have verified, offered, and assisted Residents 17, 10, and 117 to execute an AD. Review of facility's P&P titled, Advance Directives, revised 9/1/2013, the P&P indicated, When admitted , the resident/client is asked if he or she has executed an Advance Directive. If the answer is Yes, a copy of the Advance Directive is obtained and placed in the clinical record. Social Services may provide information on preparing an Advance Directive and contacts the local Ombudsman (independent advocate acts as a point of contact between the resident and nursing facility, ensuring fair solutions related to care, safety, and services) for assistance. Review of facility's P&P titled, POLST (Physician Orders for Life Sustaining Treatment), revised 9/1/2013, the P&P indicated, The admitting nurse will note the existence of the POLST form on admission and review the form for completeness .

Based on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality for one of five sampled residents (Resident 34) when Resident 34's personal information and care instructions were posted in the room visible to roommate and visitors. This failure had the potential to compromise resident's rights. Finding: During an observation on 4/7/2025 at 10:52 a.m., inside Resident 34's room, Resident 34 was sharing a room with one other resident. Resident 34 was awake and there were two care instructions posted at the wall above Resident 34's head of bed (HOB). One care instruction indicated, SPLINT INSTRUCTION, type of splint: Resting hand splint, The purpose of your splint: Maintain skin integrity and joint ROM (range of motion), When to wear your splint: 4-6 hours daily 5x [times]/week, how to wear splint: apply splint . The second care instruction indicated, Feeding Safely 1. Slow rate of feeding, 2. [Resident 34] need cues to chew thoroughly! 3. Every 3 bites of food - sip of liquid, 4. Check mouth for pocketing. During a concurrent observation and interview with Registered Nurse J (RN J) on 4/7/25 at 3:25 p.m., inside Resident 34's room, the care instructions were still posted. RN J confirmed the above observation and stated the facility put the care instruction for communication. RN J further stated Resident 34's care instruction should have been covered for privacy. During an interview on 4/9/25 at 3:31 p.m., with the Director of Nursing (DON), the DON stated care instructions should have been covered for resident privacy and confidentiality. During a review of facility's policy and procedure (P&P) titled RESIDENT RIGHTS revised date 1/15/07, indicated, .RESIDENT RIGHTS UNDER FEDERAL REGULATIONS . 30. The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of the family and Resident groups .

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) was administered per physician's order for one of three sampled residents (Resident 79) when Resident 79 was receiving 5 liters per minute (LPM) of oxygen. This failure had the potential to affect Resident 79's respiratory health. Finding: During an observation on 4/7/25 at 10:47 a.m., Resident 79 was lying in bed with oxygen concentrator (a device which concentrates the oxygen from ambient air) in used at 5 LPM via nasal cannula (NC, device placed in the nostril used to deliver oxygen). During a review of Resident 79's physician's order indicated an order, dated 5/28/24, Administer oxygen at 3LPM/NC continuously to maintain oxygen saturation [the percentage of oxygen in the blood] > [greater than] 92%. every shift. During an observation on 4/7/25 at 1:54 p.m., inside Resident 79's room. Resident 79 was sleeping with a NC and the O2 concentrator on and set at 5 LPM. During a concurrent observation and interview on 4/7/25 at 3:22 p.m., with Registered Nurse J (RN J), inside Resident 79's room, RN J checked Resident 79's oxygen concentrator and she confirmed it was set at 5 LPM. RN J stated the order is 3 LPM and it should not be at 5 LPM. During an interview on 4/9/25 at 3:27 p.m., with the Director of Nursing (DON), the DON stated the nurses should be following the physician's order for oxygen. The DON further stated the resident can affect the breathing if they are getting too much oxygen. During a review of facility's policy and procedure (P&P) titled, Oxygen Management revised date 9/01/13, indicated, It is the policy of this facility to provide oxygen support in a safe manner to prevent accidents, to maintain adequate oxygenation to the resident . During a review of facility's policy and procedure (P&P) titled, Labeling of Oxygen Cannula/Tubing revised date 9/01/13, indicated, 4. Procedure: Before use: Verify the physician's order for oxygen therapy, including the flow rate . During use: . Adjust the flow rate as ordered by the physician . Documentation: Document, including the flow rate, duration and patient's response .

Based on interview and record review the facility failed to provide dialysis services consistent with professional standards for one of one resident (Resident 100) when: 1. Communication with the dialysis facility was not properly coordinated when Resident 100's dialysis communication records (DCR) were not completed; 2. Resident 100's dialysis care plan did not have a person-centered intervention and 3. Staff was not trained on emergency care for residents with renal diseases, dialysis care, and there was no emergency dialysis kit available. These failures may affect the quality of dialysis care being provided to the residents and had the potential to cause resident health complications. Findings: 1. Review of Resident 100's clinical record indicated he was readmitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 5 (CKD, a condition in which the kidney no longer functions normally to filter waste and excess water from the blood as urine) and dependence on renal dialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function) and diabetes mellitus (DM) type 2 (A chronic condition that affects the way the body processes blood sugar). He was scheduled for dialysis every Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 4/9/25 at 11:09 a.m., with the minimum data sheet coordinator (MDSC), he reviewed Resident 100's DCR's records dated 2/11/25, 2/13/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/11/25, 3/13/25, 3/18/25, 3/22/25, 3/25/25, 3/27/25, and 3/29/25 were not completed by a dialysis center. He stated that facility licensed nurses should have followed up with Resident 100's dialysis center and completed the DCR's post dialysis assessment for Resident 100's continuity of dialysis care. The MDSC further stated that there was no documentation in the nurse's notes indicating that the licensed nurse called the dialysis clinic to inquire about Resident 100's special instructions, pre and post-dialysis weight and condition while at the dialysis clinic. During a concurrent interview and record on 4/9/25 at 11: 32 a.m., with the MDSC, He confirmed that Resident 100's clinical record revealed DCR's dated 2/11/25, 3/4/25, 3/15/25 and 3/29/25 DCR's post dialysis assessment was not completed by the facility. MDSC stated that the facility licensed nurses should have completed the Dialysis Assessment Communication Form prior to Resident 100's dialysis treatment and should have completed the assessment after he returned to the facility. Review of the facility's policy and procedure revised 9/1/13, titled, Dialysis, Care for a Resident/Client on indicated, Residents/clients receiving dialysis are cared for in a manner that limits or prevents complications. Exchange of information useful and necessary for the care of the resident/client is documented in the medical record . When dialysis treatments are provided at an outside agency, the agency has direct responsibility for the supervision and care of the resident during the entire treatment process including assessment, access device care, prevention of infections, immediate post-dialysis assessment, administration of treatments and medications etc. while the skilled facility, the facility has direct responsibility for the care of the resident, including customary standard care and the following: Assessment of the resident, including monitoring of vital signs post dialysis, monitoring of shunt site, monitoring for post dialysis complications, providing and monitoring any special diets and etc. Review of the facility's Skilled Nursing Facility (SNF) Dialysis Assessment Communication Form (DACF) indicated, The dialysis unit should complete the dialysis unit section of the Dialysis Communication Form and return the form to the facility and the information shall be shared between the facility and the dialysis unit. Prior to dialysis the SNF Nurse shall complete the Dialysis Communication Form including resident condition, status of the dialysis access site, vital signs, weight diet etc. and send with resident to dialysis for each treatment and complete back of form when resident returns from dialysis. 2. During an observation on 4/8/25 at 9:43 a.m., and 4/9/25 a.m. at 10:28 a.m., Resident 100 had a permacath (long, flexible tube inserted into a vein most commonly in the neck and into the heart to allow dialysis to occur) in place. Review of Resident 100's physician's order, dated 2/7/25, indicated he had a hemodialysis catheter for dialysis via right chest permacath and was scheduled to go to a dialysis facility three times a week. During a concurrent interview and record on 4/9/25 at 3: 13 p.m., with the assistant director of nursing (ADON), She reviewed Resident 100's care plan dated 2/7/25 indicated Resident 100 has right upper chest permacath for dialysis related to diagnosis of Type 2 DM and CKD stage five and one of the interventions was to check for thrill (vibration over an arteriovenous [AV] fistula or graft [types of accesses used for dialysis] and bruit (whooshing sound heard over an AV fistula or graft). ADON stated that the care plan did not have a person-centered intervention because for chest permacath, there would be no monitoring of the thrill and bruit. ADON further stated that she will revise the dialysis care plan to reflect the Resident 100's status. Review of the facility's policy and procedure revised 1/22/20, titled, Care Planning indicated person-centered care plans are prepared by an Interdisciplinary Team with input from the person served, to meet individual needs and preferences . Begin with identifying the person's served strengths, needs, abilities, preferences, considering cultural needs and addressing challenges to care. Problems experienced by the persons served are care planned to use three main care plan components: Problem Statement, Goals, Interventions. 3. During a concurrent observation and interview on 4/9/25 at 10:52 a.m., with registered nurse I (RN I) and licensed vocational nurse S (LVN S) both stated that they don't have a current training about taking care of Resident 100 that was on dialysis care. Both further stated that there was no emergency dialysis kit in the unit, medication room, medication cart, and crash cart.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure when Registered Nurse I (RN I) did not use a pair of gloves while preparing a hazardous drug (medications that pose potential health risks to individuals who handle them). This failure had the potential to expose RN I to hazardous drug. Findings: During the medication administration observation on 4/8/25 at 9:04 a.m., Registered Nurse I (RN I), was observed preparing five medications for Resident 139. One of the medications was finasteride (used to treat symptoms of Benign Prostatic Hyperplasia (BPH, a benign [not cancerous] condition in which the prostate gland [prostate is a gland in the male reproductive system] is larger than normal) 5 mg (milligrams, unit of measurement). The finasteride medication blister pack (packaged doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles.) was labeled with a red sticker stating, Hazardous drug. RN I prepared the finasteride medication without using gloves. During a concurrent interview and record review after the observation on 4/8/25 at 9:26 a.m., RN I confirmed the finasteride medication blister pack red sticker indicated hazardous drug. She stated she did not wear gloves when preparing the medication. She further stated she should have used gloves when preparing finasteride. During an interview on 4/10/25 at 8:35 a.m., with the Director of Nursing (DON), the DON stated when preparing finasteride, the nurse should wear gloves. During an interview on 4/10/25 at 3:35 p.m., with the Facility Pharmacist Consultant (FPC), the FPC stated they [nurse] should wear gloves when preparing finasteride. The FPC further stated finasteride can affect women. During a review of facility's policy and procedure titled, Hazardous Drug/Chemicals and Safety Data Sheets (MSDSs) revised date 1/1/13, indicated, .2. Facility staff preparing, infusing administering or removing a hazardous drug/chemical from its packaged should use protective equipment such as gloves or masks to protect themselves from exposure to aerosolized fluids or particles per Facility Policy. According to Drugs.com Finasteride can be absorbed through the skin. Finasteride can cause birth defects if a woman is exposed to it during pregnancy. The tablets should not be handled by a woman who is pregnant or who may become pregnant.

Based on observation, interview and record review, the facility failed to ensure to provide adaptive equipment (a device specifically designed to assist with drinking/eating) with meals to one of two sampled residents (Resident 10). This failure had the potential to affect the swallowing ability, fluid intake, health, and well-being of Resident 10. Findings: Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 1/31/2002 with diagnoses including dysphagia (difficulty swallowing). Review of Resident 10's physician orders indicated, Nosey cup TID (three times per day) with meals for adaptive equipment . dated 11/5/2021. Review of Resident 10's meal tray card for lunch on 4/8/2025 indicated, Nosey Cup (an adaptive drinking cup with a U-shaped cut out on one side, designed to maintain proper head and neck position when drinking for safe swallowing liquids) highlighted in yellow color. During lunch meal observation and interview with certified nursing assistant K (CNA K) in Resident 10's room on 4/8/2025 at 12:30 p.m., there was a regular plastic cup provided with Resident 10's meal tray. There was no nosey cup on Resident 10's tray. CNA K confirmed there was no nosey cup with Resident 10's meal tray. Resident 10 drank a strawberry health shake (supplemental nutritional liquid filled with nutrients) by herself from the regular plastic drinking cup and it spilled out of Resident 10's mouth. During this observation other liquid supplements also spilled out of Resident 10's mouth while drinking with the plastic cup. CNA K stated Resident 10 drinks liquids comfortably with a nosey cup and liquids will not spill out of her mouth. CNA K also stated Resident 10 frequently did not receive a nosey cup with her meal tray. During an interview with assistant dietary supervisor (ADS) on 4/8/2025 at 3:07 p.m., ADS stated dietary staff should have read the lunch tray card and provided a nosey cup with each meal tray for Resident 10. During an interview with registered dietitian 1 (RD 1) and RD 2 together on 4/8/2025 at 3:11 p.m., RD 1 stated kitchen staff should have provided a nosey cup with lunch meal tray on 4/8/2025 for Resident 10. RD 1 also stated kitchen staff will receive education for extra attention for tray cards with adaptive equipment. During a second observation of a lunch meal on 4/9/2025 at 12:45 p.m., Resident 10 was able to drink liquids from nosey cup without spilling and there were no swallow concerns. During a third observation along with CNA L during breakfast meal on 4/10/2025 at 7:45 a.m., Resident 10 was able to drink liquids from nosey cup with no concerns. CNA L stated nosey cup helps to drink liquids for Resident 10. CNA L stated the kitchen was not sending a nosey cup with meal trays once in a while for Resident 10. During an interview with the assistant director of nursing (ADON) on 4/10/2025 at 10:03 a.m., the ADON stated kitchen staff should have provided a nosey cup for Resident 10 with each meal. During an interview with occupational therapist (OT) on 4/10/2025 at 10:37 a.m., OT stated nosey cup facilitates drinking liquids for residents. During an interview with speech therapist (ST) on 4/10/2025 at 10:51 a.m., ST stated nosey cup facilitates drinking, helps with swallowing liquids, prevents spilling out of the mouth, and helps to increase fluid intake for Resident 10. During an interview with director of nursing (DON) on 4/11/2025 at 10:48 a.m., DON stated kitchen staff should have provided nosey cup for Resident 10 with each meal. Review of facility's undated policy and procedure (P&P) titled, Self-Feeding Devices, the P&P indicated, Devices commonly used, such as divider plates and feeding cups, will be kept in stock. The Food & Nutrition Services Department will store self-feeding devices. Residents needing devices will receive them with each meal or snack, on their meal trays.

Based on interview and record review, the facility failed to follow up on diagnostic results timely for two of three residents (Resident 1 and 2) when: 1. Resident 1's dual-energy x-ray absorptiometry (DEXA or DXA, bone density scan used to diagnose osteoporosis [bone disease that causes a loss of bone density, weakens bones, and increases the risk of fractures]) scan results were not followed up timely. 2. Resident 2's order to schedule a DEXA scan was not followed up timely. This failure resulted in Resident 1's DEXA scan results not reported to the physician timely and a delay in starting medication to treat Resident 1's osteoporosis. This failure had the potential to result in Resident 2 not receiving necessary treatment/medication timely. Findings: 1. Review of Resident 1's clinical record indicated she was admitted to the facility with schizophrenia disorder that affects a person's ability to think, feel, and behave clearly) and benign neoplasm (abnormal but noncancerous tumor) of meninges (membranes that protect the brain and spinal cord). Review of Resident 1's Change of Condition - Initial Note, dated 10/24/23 indicated, . during skin observation, resident noted with discoloration on left hand (palm) and left-hand swelling (back) . NP [nurse practitioner] examined resident and gave an order for x-ray. Review of Resident 1's Radiology Report of the left hand, dated 10/24/23 indicated, There is a complete oblique fracture [broken bone at an angle] through the proximal [closer to the center] fourth metacarpal [ring finger] . There is diffuse osteopenia [reduced bone density]. Review of Resident 1's Progress Note, created by Resident 1's physician, dated 10/25/23 indicated, She likely has underlying osteoporosis . just to get a handle on how osteoporotic she is, I am going to go ahead and get a DEXA scan. Review of Resident 1's physician orders indicated she had an order, dated 10/26/23 for Dexa Scan Referral ASAP [as soon as possible]. Review of Resident 1's left hand complete oblique fracture care plan, dated 10/24/23 indicated, Obtain and monitor lab/diagnostic work as ordered. Report results to MD/NP and follow up as indicated. Review of Resident 1's Nurses Note, dated 12/1/23 indicated Resident 1 left the facility for Dexa Scan Bone Density appointment. There was no documentation in Resident 1's clinical record that indicated the facility followed-up on the DEXA scan results. Review of Resident 1's Change of Condition - Initial Note, dated 2/7/24 indicated During ADL care, resident noted with discoloration on right 4th finger. Review of Resident 1's Radiology Report of the right hand, dated 2/7/24 indicated, There is an acute appearing fracture of the fourth middle phalanx [bones in the fingers] with minimal displacement [not aligned] extending to the distal [away from the center] IP [interphalangeal, joints between adjacent phalanges] joint . The bony structures appear osteopenic. Review of Resident 1's DXA Scan results, dated 12/1/24, faxed to the facility on [DATE] indicated, The patient [Resident 1] has osteoporosis. Review of Resident 1's physician orders indicated she had an order, dated 2/26/24 for Alendronate Sodium Oral Tablet 70 milligrams (mg, unit of measurement). During an interview with Resident 1's physician (MD) on 7/26/24 at 10:36 a.m., the MD stated he would expect DEXA scan results to be provided to him in two to three weeks and certainly within a month. During an interview on 7/26/24 at 12:10 p.m., the director of nursing (DON) confirmed that the facility received Resident 1's 12/1/23 DEXA scan results on 2/26/24. The DON stated the facility does not get results timely but they try their best to contact the service or hospital for the results. Review of the facility's policy, Radiology Services, dated 9/1/13 indicated, Radiology services will be provided and results reported to the physician in a timely manner to meet the needs of residents. 2. Review of Resident 2's clinical record indicated she was admitted to the facility with diagnosis including hemiplegia and hemiparesis (complete paralysis, partial paralysis or muscle weakness on one side of the body) and hypertension (high blood pressure). Review of Resident 2's physician orders indicated she had an order, dated 12/20/23 to Schedule DEXA SCAN. Review of Resident 2's Nurses Note, dated 4/26/24 indicated, Referral request form for Dexa scan and additional documents faxed . There was no documentation that a referral for a DEXA scan for Resident 2 was sent prior to 4/26/24. During an interview on 7/26/24 at 12:10 p.m., the director of nursing (DON) stated she was not able to find Resident 2's DEXA scan referral before 4/26/24. The DON stated if a nurse sent a referral, they still have to document that it was done. Review of the facility's policy, Radiology Services, dated 9/1/13 indicated, Orders for radiology tests shall be noted promptly. Orders, including the reason for the test, shall be submitted to the radiology service. The orders shall be telephones and/or sent electronically to the radiology service.

Based on interview, facility document and policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to retransmit Minimum Data Set (MDS) assessments within required timeframes for 8 (Residents #86, #67, #121, #108, #136, #22, #56, and #65) of 29 residents reviewed for MDS requirements. Findings included: A review of a facility policy titled, MDS, Minimum Data Set/Resident Assessment Instrument, effective on 05/27/2015, revealed, It is the policy of this facility to complete the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) in accordance with the regulations, timeframes and guidelines set forth by OBRA [Omnibus Budget Reconciliation Act]-required and Medicare-required assessments. A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, revised in October 2023, revealed in Chapter 2: Assessments for the RAI that a Significant Correction to a Prior Quarterly (SCQA) must be transmitted no later than the MDS Completion Date + [plus] 14 calendar days, with the MDS Completion Date defined as the 14th day after determination that significant error in prior quarterly assessment occurred. The manual further specified, a Significant Correction to Prior Comprehensive (SCPA) must be transmitted no later than the Care Plan Completion Date + 14 calendar days, with the Care Plan Completion Date defined as the CAA(s) Completion Date [Care Area Assessments, the 14th calendar day after determination that significant error in prior comprehensive assessment occurred] + 7 calendar days. A review of an MDS 3.0 Final Validation Report revealed the following MDS assessments were Rejected on 11/04/2023: - Resident #86's quarterly MDS, with an Assessment Reference Date (ARD) of 10/25/2023; - Resident #67's quarterly MDS, with an ARD of 10/24/2023; - Resident #121's quarterly MDS, with an ARD of 10/26/2023; - Resident #108's annual MDS, with an ARD of 10/24/2023; - Resident #136's quarterly MDS, with an ARD of 10/27/2023; - Resident #22's quarterly MDS, with an ARD of 10/25/2023; - Resident #56's quarterly MDS, with an ARD of 10/26/2023; and - Resident #65's quarterly MDS, with an ARD of 10/26/2023. During an interview on 12/13/2023 at 9:10 AM, the MDS Coordinator stated the facility received a validation report from CMS when they transmitted MDS assessments to let them know if there were any errors. He stated if there were any errors, they should be corrected and retransmitted right away. The MDS Coordinator said in October 2023, there was an issue when the MDS system changed, and he had to resubmit several MDSs. He further stated he missed resubmitting the rejected MDS assessments for Residents #86, #67, #121, #108, #136, #22, #56, and #65. During an interview on 12/13/2023 at 2:16 PM, the Administrator stated she expected MDS assessments to be submitted timely.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure podiatry care, specifically toenail care, was provided for 1 (Resident #130) of 2 sampled residents reviewed for activities of daily living (ADLs). Findings included: A review of a facility policy titled, Fingernails and Toenails, Care of, effective 09/01/2013, revealed, Fingernails and toenails are cleaned and trimmed regularly. Only podiatrists, physicians or licensed nurses provide nail care to diabetic residents, or residents with severe circulatory impairment. A review of an Admission Record revealed the facility admitted Resident #130 on 09/27/2023. According to the Admission Record, the resident had a medical history to include a diagnosis of need for assistance with personal care. The Admission Record did not reflect a diagnosis of diabetes, circulatory impairment, or any nailbed abnormalities. A review of Resident #130's Care Plan revealed a Focus area, initiated 09/27/2023, that indicated the resident had an ADL self-care performance deficit related to impaired physical mobility. Interventions directed staff to assist Resident #130 with personal hygiene and to check nail length and trim and clean as necessary on bath days. A review of an Order Summary Report, listing active orders as of 12/13/2023, revealed Resident #130 had an active order started on 10/03/2023 to Check resident's Nails and Trim/clip as appropriate, to be done every Tuesday. On 12/11/2023 at 1:35 PM, Resident #130 was observed to have long toenails on both feet. Their big toenails were approximately three quarters of an inch off the tips of the toes, and nails two through four were approximately a quarter of an inch off the tips of the toes. The fifth toenails on both feet were approximately a half an inch off the tips of the toes. During an interview on 12/12/2023 at 1:30 PM, Licensed Vocational Nurse (LVN) #5 stated that residents' nails were trimmed once per week. LVN #5 stated that the certified nursing assistants (CNAs) conducted nail care unless a resident had diabetes, noting nail care fell to the podiatrist for residents with diabetes. During an interview on 12/12/2023 at 1:40 PM, LVN #6 stated residents had their toenails trimmed every Tuesday. LVN #6 stated the CNAs were responsible for trimming the residents' toenails. During an observation on 12/13/2023 at 11:31 AM, LVN #2 checked Resident #130's feet and stated that their toenails were too long. During an interview on 12/13/2023 at 12:36 PM, the Assistant Director of Nursing (ADON) stated the nurses or podiatrist trimmed the toenails of diabetic residents and confirmed Resident #130 did not have a diagnosis of diabetes. The ADON confirmed staff could trim Resident #130's toenails.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the head of bed (HOB) was elevated 30 degrees during the infusion of enteral feeding as ordered by a physician for 1 (Resident #68) of 2 sampled residents reviewed for tube feeding management. Findings included: A review of a facility policy titled, Enteral Therapy (Tube Management, Feeding, Medications), effective on 09/01/2013, revealed, POLICY Enteral nutrition is provided in a safe and effective manner to promote nutritional well-being and prevent complications of enteral therapy, as ordered by the physician. The section of the policy titled II. Administration of Enteral Feeding / Nutrition, C. Procedure for Feeding Pump Method: specified, 3. Ensure head of bed is elevated minimum of 30-45 degrees before starting the feeding. A review of an Admission Record revealed the facility admitted Resident #68 on 01/20/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2023, revealed a Staff Assessment for Mental Status (SAMS) concluded Resident #68 had a short- and long-term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS, Resident #68 received 51 percent or more of their daily calories through a parenteral or tube feeding and 501 cubic centimeters per day or more of their average daily fluid intake per day by intravenous line or tube feeding during the entire seven-day assessment look-back period. A review of an Order Summary Report, listing active orders as of 12/13/2023, revealed a physician's order dated 09/19/2023 to Elevate HOB 30 degrees during feeding and one hour after feeding. On 12/13/2023 at 8:23 AM, Resident #68 was in bed while their tube feeding infused. Per the observation, the resident's HOB did not appear to be at the proper level. During an interview on 12/13/2023 at 8:58 AM, Licensed Vocational Nurse (LVN) #6 stated that the HOB should be elevated to prevent aspiration. LVN #6 stated that staff frequently checked the HOB by eyeballing it to ensure it was elevated appropriately. During an interview on 12/13/2023 at 9:06 AM, LVN #6 stated Resident #68's HOB was too low. During an interview on 12/13/2023 at 9:10 AM, LVN #2 stated that, during tube feedings, a resident's HOB should be elevated between 30 and 90 degrees beginning an hour before the tube feeding until an hour after the tube feeding was stopped. LVN #2 said staff checked the angle of the HOB visually and said if the HOB was not elevated high enough, there was a risk for aspiration. On 12/13/2023 at 1:38 PM, the Director of Nursing (DON) and Administrator were interviewed concurrently. They stated that when a tube feeding was given, the resident's HOB should be elevated 30 to 45 degrees. They stated the nurses did not measure the angle of a resident's HOB, but rather became familiar with what 30 degrees looked like. They stated that the nurses were supposed to check the elevation of a resident's HOB frequently.

Based on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) from abuse. The facility was aware Resident 2 had episodes of wandering behavior to other resident's room. This failure resulted to Resident 1 being touched inappropriately. Findings: Review of SOC 341 (a form used to report suspected abuse) sent to the California Department of Public Health (CDPH) dated 5/3/23, indicated on 5/3/23 around 8:20 p.m., Resident 2 was seen by certified nursing assistant A (CNA A) during rounds sitting at Resident 1's edge of the foot of the bed with his pants and brief down while touching Resident 1's bilateral thighs (both thighs). Review of Resident 1's clinical record, indicated she was admitted on [DATE] with diagnoses including dementia (mental disorder caused by brain disease or injury), Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anoxic brain damage (the brain is deprived of oxygen), anxiety disorder (medical condition includes symptoms of intense anxietyor panic that are directly caused by a physical health problem.), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and legal blindness. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 3/31/23 indicated her brief interview for mental status (BIMS, cognition level) score was 3 (severely impaired cognition). Review of Resident 1 incident note dated 5/3/23 indicated, on 5/3/23 around 8:20 p.m., Resident 2 was seen by certified nursing assistant A (CNA A) inside Resident 1's room. Resident 2 was observed with pants and brief down while touching Resident 1's bilateral (both) thigh. Resident 1 indicated He's trying to f**k me! Review of Resident 2's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to think, remember and make decisions) and Alzheimer's disease (progressive disease that destroys memory and mental functions). Review of Resident 2's Wandering Assessment, dated 4/26/23 indicated he had a score of 9 (moderate risk for wandering). Review of Resident 2's Wandering Assessment, dated 4/28/23 indicated, he had a score of 15 (high risk for wandering). Review of Resident 2's care plan regarding elopement dated 4/28/23 indicated, he had episodes of wandering out of his room and walking into other residents ' room. The facility's intervention includes monitoring Resident 2's whereabouts. Further review of Resident 2's care plan indicated on 5/2/23, Resident 2 had an episode of wandering into other residents' room and found sleeping in other residents' empty bed. During an interview with CNA A on 7/17/23 at 10:52 a.m., CNA A confirmed she witnessed the incident between Resident 1 and Resident 2 on 5/3/23. CNA A stated she saw Resident 2 with his pants and brief down while touching Resident 1's bilateral thigh (front area). Review of Resident 2's Monitoring Tool, dated 5/3/23 indicated, at 8:15 p.m. Resident 2 was wandering and ambulating (walking). During an interview with the nursing supervisor (NS) on 7/17/23 at 12:40 p.m., the NS stated CNA A reported to her the incident between Resident 1 and Resident 2. The NS stated on 5/3/23 at around 8:20 p.m., she saw Resident 2 with his pants and brief down while touching Resident 1's bilateral thigh and immediately separated the residents. During an interview and record review on 7/18/22 at 10:55 a.m., with the minimum data set coordinator (MDSC), the MDSC reviewed Resident 2's MDS dated [DATE] and confirmed Resident 2 had a BIMS score of 1 (severely impaired cognition) and had a behavior of wandering that could significantly intrude other's activities or privacy. The MDSC stated Resident 2 could walk independently across his room where Resident 1's room was located. During a concurrent interview and record review on 7/18/23 at 11:56 a.m., with the social services director (SSD), the SSD reviewed Resident 2's Wandering Assessment, dated 4/26/23, the SSD indicated Resident 2 had a score of 9 (moderate risk for wandering) and on 4/28/23 he had a core of 15 (high risk for wandering). The SSD reviewed her notes dated 4/28/23 and confirmed staff observed Resident 2 had episodes of wandering out of his room and walking into other resident's room. During a concurrent interview and record review on 7/18/23 at 11:18 a.m., with the MDSC, he reviewed Resident 2's clinical record and stated Resident 2's wandering behavior care plan was initiated on 4/26/23 and updated on 4/28/23 had an intervention of monitoring resident's whereabouts. The MDSC confirmed on 5/2/23, Resident 2 had another wandering episode into other residents' room and was found sleeping in other residents' empty beds. There was no new intervention regarding the behavior on 5/2/23. At 11:30 a.m., the MDSC reviewed Resident 2's care plan dated 5/3/23, indicated Resident 2 was seen touching Resident 1's bilateral thighs [front area]. At 11:55 a.m., the MDSC reviewed nurses notes dated 4/28/23 and confirmed Resident 2 had episodes of wandering out of his room and lying in other residents' beds. The MDSC reviewed nurses notes dated 5/3/23 for 5/2/23 indicating Resident 2 had an episode of wandering into other residents room and found sleeping in other residents' empty beds. The MDSC reviewed the CNA's every 15 minutes monitoring tool form 4/26/23 to 5/3/23 and could not provide evidence licensed nurses (LN) monitored Resident 2's whereabouts every shift as indicated in the care plan. During a concurrent interview and record review with the director of nursing (DON) on 7/18/23 at 12:18 p.m., the DON reviewed Resident 2's clinical record and confirmed LNs did not have monitoring for Resident 2's whereabouts every shift. The DON stated the LNs started to monitor Resident 2's whereabouts was started on 5/4/23, after the incident on 5/3/23. Review of the facility's policy titled, Policy and Procedure on Elderly and Dependent Adult Abuse/Suspicion of a crime, revised 1/10/2019 indicated, [facility name] culture will not tolerate abuse or neglect of any kind, at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident or person served. Each resident and person served has the right to be free from any form of abuse. The policy further indicated, Sexual abuse is non-consensual sexual contact of any type with a resident .It includes, but is not limited to: sexual harassment, sexual coercion, or sexual assault .

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. The Housekeeper (HK) did not perform hand hygiene after removing gloves; 2. Licensed Vocational Nurse A (LVN A) did not perform hand hygiene after disposal of lancet (device used for testing blood sugar); 3. There was a Foley Catheter (F/C, flexible tube that passes through the urethra and into bladder to drain urine) drain privacy bag (bag is equipped with adjustable straps that keep the urine bag in place to maintain resident's dignity) touching the floor; 4. There were unlabeled urinals and wash basins in multiple resident's bathrooms and on a bedside table; 5. The Physical Therapist (PT) did not perform hand hygiene after removing gloves; 6. LVN A wore surgical mask below the nostril; and 7. The Dietary Aide (DA) did not perform hand hygiene in between tasks. These failures had the potential to result in transmission and spread of infection to the residents and staff in the facility. Findings: 1. During an observation with the Infection Preventionist (IP) on 2/6/23, at 10:02 a.m., while in the hallway, the HK had gloves on, mopped the floor, then touched and disposed the dirty cloth. The HK removed his gloves, touched the cart, then applied a new pair of gloves. The HK proceeded to clean the resident's side table in room A. The HK did not perform hand hygiene after removing gloves and proceeding to a new task. During an interview with the IP on 2/6/23, at 1:28 p.m., the IP confirmed the above observation and stated the HK should perform hand hygiene after removing gloves and prior to starting a new task. 2. During an observation and concurrent interview with LVN A on 2/6/23, at 11:00 a.m., LVN A disposed the lancet in the sharps container and did not perform hand hygiene. LVN A stated she just checked Resident 2's blood sugar. LVN A further stated she should perform hand hygiene after touching and disposing used lancet. During an interview with the IP on 2/6/2023, at 1:35 p.m., the IP was informed of the above observation and stated the LVN should have performed hand hygiene after touching and disposing of used lancet. 46552 3. During an observation in resident room G on 2/6/23 at 10:09 a.m., Resident 1's f/c drain bag was placed in a privacy bag and anchored to his bed frame and was touching the floor. During an observation and concurrent interview with the IP on 2/6/23 at 10:12 a.m., the IP came to room G and confirmed the above observation. The IP further stated, f/c drain privacy bag should not touched the floor. Review of the facility's policy and procedure titled, Foley Catheter Care, dated 9/1/2013 indicated, Do not allow catheter tubing, bag or spigot to touch the floor. 4. During an observation on 2/6/23, at 10:24 a.m., resident room A bathroom had one unlabeled wash basin. At 10:30 a.m., resident room B bathroom had one empty unlabeled wash basin. At 10:35 a.m., resident room C bathroom had one unlabeled urinal and was on top of a commode. At 10:40 a.m., resident room D had one unlabeled urinal left on the bedside table. At 10:45 a.m., resident room E's bathroom had one unlabeled wash basin on top of a resident commode. During an interview with certified nursing assistant B (CNA B) on 2/6/23 at 10:50 a.m., CNA B acknowledged the wash basins, and urinals were not labeled. He further stated wash basins, and urinals should be labeled with resident's initials and room number. During an interview with the IP on 2/6/23 at 1:25 p.m., the IP stated all wash basins and urinals should be labeled with resident's initials, and room number to maintain infection control standards. He further stated it was the facility's policy and procedure to label urinals and should also apply for labeling wash basin. Review of facility's policy and procedure titled, Bedpan &Urinals, Use of, dated 09/01/13 indicated, Urinal - provide upon admission and label with resident/client's name. 4. During an observation 2/6/23 at 11:00 a.m., the PT was observed in the hallway removing her gloves and discarded the gloves to the garbage bin attached to medication cart. The PT proceeded to the rehabilitation office without performing hand hygiene. During an interview with the PT on 2/6/23 at 11:05 a.m., the PT confirmed she did not perform hand hygiene after she removed her gloves. She further stated she should have cleaned her hands after removing gloves. During an interview with the IP on 2/6/23 at 1:25 p.m., the IP stated all staff should perform hand hygiene upon removing gloves to prevent transmission of infections. 6. During concurrent observation and interview with LVN A on 2/6/23 at 11:10 a.m., LVN A's surgical face mask was below her nostrils. LVN A confirmed the observation and stated the surgical face mask should cover the nose and mouth all the time. During an interview with IP on 2/6/23 at 1:25 p.m., he stated surgical face mask should cover the mouth and nose. The IP further stated staff should wear the surgical face mask properly while in the facility for infection control practices. Review of the facility's policy and procedure titled, Coronavirus (Covid-19) Prevention and Management, revised on 1/31/23 indicated, All staff in all Crestwood Behavioral Health programs are required to wear procedural masks. 7. During a kitchen observation on 2/6/23 at 11:19 a.m., the DA was preparing juice cups and placing water cups to resident's lunch trays with gloves on. The DA removed her eyeglasses, cleaned the eyeglasses using a tissue and placed eyeglasses back on, with gloves on. The DA proceeded with her task preparing residents lunch trays without changing or removing her gloves. During a concurrent interview with the DA, she acknowledged the above observation and stated gloves should be removed and hand hygiene should be performed in between task. During an interview with the IP on 2/6/23 at 1:25 p.m., the IP stated the DA should remove her gloves and perform hand hygiene in between task. The IP further stated the DA should have wear new gloves before returning to her task. Review of facility's policy and procedure titled, Hand Hygiene, revised August 2014 indicated, Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves.

Based on interview and record review, the facility failed to follow their policy and procedure for influenza (Flu-A common viral infection affects lungs, nose, and throat), and pneumococcal (PNA- an serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccines (a preparation that is used to stimulate the body's immune response against diseases) for two out of six residents (Resident 2, and 3) when: residents responsible party (RP, person designated to make healthcare and/or financial decisions on behalf of a resident) were not provided with education regarding risk versus benefits, did not develop care plan and did not re-offer the vaccines. These failures put Resident 2 and 3 at risk of contracting flu and PNA. Findings: Review of Resident 2's clinical record indicated; she received the PNA vaccine on 12/25/12. Review of Resident 2's immunization record indicated, Resident 2's RP refused flu and PNA vaccine on 1/9/20. There was no evidence Resident 2's RP was provided with education regarding the risk versus benefits of flu and PNA vaccines. Further review of Resident 2's clinical record, did not indicate a care plan was developed to address the refusal of flu and PNA vaccines and there was no evidence the vaccines were re-offered to the RP. Review of Resident 3's clinical record indicated; her RP refused the PNA vaccine on 12/17/19. Review of Resident 3's immunization record indicated, her RP refused flu and PNA vaccines. There was no evidence Resident 3's RP was provided with education regarding the risk and benefits of flu and PNA vaccines. Further review of Resident 3's clinical record, did not indicate a care plan was developed to address the refusal of flu and PNA vaccines, and there was no evidence the vaccines were re-offered to the RP. During an interview and concurrent interview with the infection preventionist (IP) on 2/7/23 at 1:25 p.m., the IP reviewed Resident 2 and 3's clinical record and confirmed their RPs were not provided with education regarding the risk versus benefits of flu and PNA vaccines. The IP acknowledged; care plan was not developed to address the refusal of the vaccines. During an interview with the director of nursing (DON) on 2/7/23 at 1:40 p.m., the DON stated care plan regarding vaccine refusal should have been developed when both RP refused the vaccines. During an interview with the IP on 2/7/23 at 1:45 p.m., the IP confirmed the facility did not re-offer the flu and PNA vaccines to Resident 2 and 3's RP. The IP further stated the vaccines should have been offered again. According to the current Center for Disease Control and Prevention (CDC) recommendation titled, Pneumococcal Vaccine Timing for Adults, dated 4/1/22, the CDC recommends PNA vaccination for adults [AGE] years and older and adults [AGE] years through [AGE] years old with certain underlying medical conditions or other risk factors. For those who have never received a pneumococcal vaccine or those with unknown vaccine history, administer one dose of PCV 15 or PCV 20. If PCV 20 is used, their pneumococcal vaccinations are complete. Review of facility's policy, Influenza Vaccine dated August 2016 indicated, The facility shall provide pertinent information about the significant risk and benefits of vaccines to residents (or resident's legal representatives). Review of facility's policy, Pneumococcal Vaccine, dated August 2016 indicated, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The resident, or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Review of facility's policy, Care Planning dated 9/1/13 indicated, Care planning shall include review of clinical issues, potential discharge planning, coordination of care and management of resources.

Based on observation, interview, and record review, the facility failed to follow the operating manual regarding a wheelchair lift (platform lift was a fully powered device designed to raise a wheelchair and its occupant in order to overcome a step) used in the facility's van for one of three sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a laceration (a deep cut), nail damage, and a [MEDICAL CONDITION] big toe. Findings: Review of Resident 1's clinical record indicated he was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/8/18 indicated Resident 1 was cognitively intact (no memory problem), required assistance for transfer, bed mobility, locomotion off unit (walk in the corridor), toileting, and personal hygiene. Review of Resident 1's progress note dated 10/31/18, indicated Resident 1, who used a wheelchair went with the facility's van to his appointment on 10/31/18 at the acute hospital accompanied by the restorative nursing assistant A (RNA A). After the appointment Resident 1 sat in his wheelchair and was placed on the lift's ramp of the van with his feet facing towards the door of the van. When the driver lifted the ramp up, Resident 1's left foot was caught between the floor of the van's door entrance and the wheelchair lift. Review of the Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) dated 10/31/18 indicated on 10/31/18, Resident 1's left big toe was swollen with bluish discoloration on the nail, minimal bleeding, skin tear, and nail avulsion (the excision of the body of the nail plate from its primary attachments). Resident 1 was transferred to the acute hospital. Review of the Resident 1's discharge instructions from the acute hospital on [DATE] indicated a laceration, nail damage, nail avulsion, and closed displaced [MEDICAL CONDITION] great toe. During an observation and concurrent interview with Resident 1 on 11/7/18 at 1:45 p.m., Resident sat on his bed with a white dressing around his left foot. Resident 1 stated he had an appointment on 10/31/18 at the acute hospital, upon returning to the facility, he was lifted on the ramp up to the facility van and his left big toe was squeezed between the floor of the van and the wheelchair lift. Resident 1 stated it was so painful and happened too fast. He stated he was facing towards the door of the van when he entered the wheelchair lift and caught his big toe in between the floor of the van and the wheelchair lift. During an interview with the RNA A on 11/15/18 at 2:35 p.m., she stated she accompanied Resident 1 to his appointment on 10/31/18 and it was the facility driver (FD) who pushed Resident 1 on the wheelchair lift. RNA A confirmed Resident 1 was facing towards the door of the van when Resident 1 entered the wheelchair lift and his left big toe was caught in between the plates. She stated Resident 1 was wearing a sock and was not wearing a shoe on his left foot. During an interview with the FD on 11/15/18 at 3:30 p.m., he stated he pushed Resident 1, who was faced towards the door of the van, and when he turned the wheelchair lift on, Resident 1's left big toe was caught in between the two plates. FD stated he was trained by the previous facility driver in 2014 to place a resident facing towards the door of the van when a resident would enter the wheelchair lift. FD acknowledged he never read the operation manual for the wheelchair lift. During an interview with the maintenance supervisor (MS) on 11/15/18 at 3:00 p.m., he stated he helped the FD when transporting the residents to their appointments. MS stated he was not sure who trained FD how to use the wheelchair lift. There was no evidence of an in-service or training was provided to FD regarding the proper use of the wheelchair lift. MS also stated when taking residents to their appointments, residents were always facing towards the door of the van when they entered the wheelchair lift. During an interview and concurrent record review with the administrator (ADM) on 11/15/18 at 3:50 p.m., she acknowledged Resident 1 was facing towards the door of the van when Resident 1's left big toe was caught between the floor of the van and the wheelchair lift. ADM confirmed the operation manual for the use of the wheelchair lift indicated a resident should be faced outward to prevent a feet being caught between the facility's van and the wheelchair lift. She acknowledged Resident 1 should have been faced outward during his incident. The ADM also stated FD should have read the operation manual for the use of the wheelchair lift, so he would have been aware how to prevent accidents. Review of the, Operator Manual for Personal Use Wheelchair Lift dated 9/2001, indicated under General Safety Precaution to read and thoroughly understand operating instructions before attempting to operate. Wheelchair occupant should face outward when entering and exiting the vehicle. Carefully place wheelchair centrally on platform, and facing outward. Review of the facility's policy 9/2013, Transporting Resident to Appointment, indicated the residents will be transported to appointments at an off site (different location) location in a safe manner.

Based on interview and record review, the facility failed to follow the physician's order to administer laxatives (substances designed to loosen stools and increase bowel movements) and to notify the physician for one of three sampled residents (1) when Resident 1 did not have a bowel movement for six consecutive days. These failures resulted in sending Resident 1 to an acute care with a fecal impaction incident with fecal disimpaction (manually removal of feces). Findings: Review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, an assessment tool), dated 7/25/17, indicated Resident 1 was not ambulatory, and was incontinent of urine and bowel. Review of Resident 1's physician orders, dated 8/2017, indicated Resident 1 had orders dated 3/11/16 for [MEDICATION NAME] (a medication used to treat depression) 15 milligrams (mg, a metric unit of mass) at bedtime, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] disorder) 100 mg at bedtime, dated 9/27/16, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] disorder) 10 mg at bedtime, dated 5/1/17, and [MEDICATION NAME] 2.5 mg every day, dated 6/22/17. Resident 1 also had orders for monitoring side effects of these three medications, such as constipation, dated 3/11/16. Review of Resident 1's care plan, dated 3/30/17, indicated Resident 1 had the potential/risk for constipation due to dementia, limited physical mobility, and use of [MEDICAL CONDITION] medications (medication capable of affecting the mind, emotions, and behavior). During an interview with the Registered Dietitian (RD) on 8/24/17 at 2 p.m., she stated Resident 1 had poor bowel movement, so she recommended adding fiber blend (a dietary supplement that helps with the regularity of bowel movements) and Hyfiber (a medical food that provides the nutrients for the dietary management of constipation, hard stools, and irregularity) to his diet for bowel regularity. Review of Resident 1's physician orders, dated 8/2017, indicated Resident 1 had an order for [REDACTED]. Review of Resident 1's Transfer Discharge Notice, dated 8/14/17, indicated Resident 1 was sent to the hospital for difficulty breathing at 3:46 p.m. Review of Resident 1's Emergency Department (ED) Provider Notes, dated 8/14/17, at 4:13 p.m., indicated Resident 1 had a markedly distended abdomen. Resident 1's computed tomography (CT, the use of computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas, allowing the user to see inside the object without cutting) of the abdomen and pelvis indicated Resident 1 had diffuse colonic distention without volvulus and with prominent fecal retention in the distal colon and rectum. The ED physician recommend and the resident was sent to surgery on 8/14/17 for severe dilation and bowel ischemia (a restriction in blood supply to tissues in the bowels) due to chronic constipation. Review of Resident 1's Full Operative Report, created on 8/15/17 at 7:29 a.m., indicated Resident 1 went through an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease), sigmoid colectomy with end [MEDICAL CONDITION] and fecal disimpaction. According to the Full Operative Report, The most remarkable finding was a massively distended left colon .with the colon packed completely full of stool. The facility policy and procedure titled, Bowel Care, Managing constipation, revision dated 9/1/13, indicated Residents/clients are assisted to prevent and relieve bowel constipation or impaction. Upon written order from the physician, the following protocol shall be followed to provide adequate elimination of the bowels for residents/clients who require assistance . Licensed nurses monitor resident/client bowel movements daily with assistance of certified nursing assistants. Bowel care protocol will be indicated for those who have not had a bowel movement in the past three days as follows (per physician order): A. The licensed nurse will administer 30 ml of MOM per physician order (recommend evening shift). B. If no results from MOM by the end of the subsequent shift (i.e., night shift), the licensed nurse will administer a [MEDICATION NAME] suppository per physician order. C. If no results from a suppository by subsequent shift (i.e., morning shift), the licensed nurse will give resident a Fleet Enema per physician order. If no results from Fleet Enema by the end of the same shift, the licensed nurse will check for a possible fecal impaction. If the current bowel care orders are not sufficient to maintain regular evacuation of the bowels, contact the physician to discuss further interventions that may be needed . Review of Resident 1's Bowel Elimination Report for 7/2017 and 8/2017 indicated from 7/31/17 to 8/14/17, within those 15 days, there were 10 days Resident 1 did not have a bowel movement. In addition, Resident 1 did not have a bowel movement for six consecutive days from 7/31/17 to 8/5/17. Review of Resident 1's Medication Administration Record [REDACTED]. The [MEDICATION NAME] suppository was not given until 8/5/17 at 9:30 a.m. by a morning nurse, which was ineffective. MOM, rather than a Fleet Enema was given on 8/5/17 at 6:57 p.m. by registered nurse B (RN B), and it was ineffective. During an interview with LVN A on 8/28/17 at 3:40 p.m., he stated he should have given Resident 1 MOM on 8/2/17 instead of 8/3/17 since Resident 1 did not have a bowel movement since 7/31/17. On 8/29/17 at 12:20 p.m., LVN A stated after he gave Resident 1 MOM on 8/3/17 which was ineffective, and if the subsequent shifts did not give Resident 1 a [MEDICATION NAME] suppository, he should have given it to him on 8/4/17. LVN A stated he did not inform the physician about Resident 1's constipation. During an interview with LVN C on 8/29/17 at 11:50 p.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m., which was ineffective, she did not give Resident 1 [MEDICATION NAME] suppository because she did not know LVN A gave him MOM. LVN C stated she did not give Resident 1 the [MEDICATION NAME] suppository on 8/4/17 either because she did not know the previous shifts did not give it to him. LVN C stated she did not check for a fecal compaction in Resident 1 and did not call the physician because she did not know Resident 1 was constipated. During an interview with LVN D on 8/29/17 at 11:05 a.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m., which was ineffective and LVN C did not give him the [MEDICATION NAME] suppository on the night shift, she should have followed up and given Resident 1 the [MEDICATION NAME] suppository on 8/4/17. LVN D stated she did not check Resident 1's Bowel Elimination Report and did not call the physician. During an interview with RN B on 8/29/17 at 3:10 p.m., she stated after a morning nurse gave Resident 1 a [MEDICATION NAME] suppository on 8/5/17 at 9:30 a.m. which was ineffective, she should have given Resident 1 a Fleet Enema instead of MOM. RN B stated she did not know Resident 1 did not have a bowel movement for six consecutive days, so she did not check for a fecal compaction for Resident 1 and did not notify the physician. During an interview with Resident 1's physician on 8/30/17 at 2:20 p.m., she stated she came to the facility to visit Resident 1 on 8/9/17, but she was not notified about Resident 1's constipation. Resident 1's physician stated the licensed nurses should have informed her about this issue, and if she knew she would have examined Resident 1 and ordered lab tests. During an interview with the director of nursing (DON) on 8/30/17 at 2:50 p.m., she reviewed Resident 1's MAR for 8/2017 and Bowel Elimination Report for 7/2017 and 8/2017, and she stated the licensed nurses did not follow the facility's policy on bowel management.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and toileting to prevent falling consistent with the resident's assessment needs and plan of care for one of 25 sampled residents (10). This resulted in Resident 10 sustaining a concussion with headaches. Findings: Review of Resident 10's clinical record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set (MDS, an assessment tool) dated 9/27/2016 indicated a BIMS (Brief Interview for Mental Status) score of 13, which means cognition is intact but she had indicators of hallucinations and delusions. Resident 10 also required assistance from the nursing staff with her activities of daily living (ADL) especially in toilet use (one person physical assistance). Resident 10 had falls on the following dates: 12/29/15 trying to get on the toilet; 3/29/16 found sitting next to her bed; 6/23/16 fell in the bathroom; 7/25/16 fell by reaching for a soda and 10/9/16 tripped on her foot and fell at nurses station. Review of Resident 10's clinical records indicated Resident 10 had a fall incident on 12/29/15. Review of Resident 10's Interdisciplinary (IDT, team members from different departments who are involved in the care of residents) Progress Notes dated 12/30/15 indicated the IDT reviewed the fall incident on 12/29/15. They reassessed, with the resident present, her bed area and the bathroom environment. IDT recommended putting the resident on a toileting schedule every two hours to assist the resident with toileting as needed; replace the grab bar in the bathroom with a longer one to provide more area of support. Review of Resident 10's clinical record revealed no evidence of Bowel & Bladder Toileting Record was initiated after the fall on 12/29/15. Review of Resident 10's long term care plan for risk for falls initiated 12/30/15 indicated interventions which included encouraging the resident to use grab bars in and outside of bathroom, over-the-toilet commode and transfer pole next to her bed to aid with transfer. Review of Resident 10's clinical record indicated Resident 10 had a fall incident on 3/30/16. Resident 10's IDT note dated 3/30/16 indicated Resident 10 felt very dizzy when she got out of bed, and fell . The IDT recommended installing a transfer pole next to her bed to assist her with her transfers. Review of Resident 10's Change of Condition Follow up Note from 3/29/16 through 4/2/16, and Nurses Note dated 3/29/16 through 4/3/16 did not indicate the two hourly toileting schedule was done, nor were the transfer pole and over-the-toilet commode initiated. Review of Resident 10's clinical record revealed no evidence of Bowel & Bladder Toileting Record was initiated after the fall on 3/29/16. Review of Resident 10's Fall Risk Assessment dated 3/29/16 under the section Systolic Blood Pressure (blood pushed through the arteries to the rest of the body) indicated there was no noted drop of blood pressure between laying and standing positions, but there was no documentation of the recorded blood pressures taken while Resident 10 was in the laying and standing positions. Review of Resident 10's clinical record showed no evidence of any neurological evaluation flow sheet (neuro checks) was initiated after an unwitnessed fall when Resident 10 felt dizzy 3/29/16 at 10:15 a.m. Review of Resident 10's physician's progress notes dated 6/23/16 indicated under chief complaint: fall. I was at nursing station when resident came and informed she had a fall hitting her head. She slipped and fell and hit her head in (sic) the bathroom floor. She was shaky and said she felt very dizzy. She complained of dizziness after the fall h/o trauma to head; send to emergency room for further eval and possible computer tomography head. Review of Resident 10' s acute care emergency department note dated 6/23/16 indicated under HPI (history and physical information) per patient, she tripped over her foot and fell when going to the bathroom, hit the right side of head. Small superficial bump on right scalp. DDX (discharged diagnoses) concussion. Review of Resident 10's physician's progress notes dated 6/27/16 indicated under chief complaint: pain on head. Resident had a fall two days ago and she is still concerned about pain in her head when she touches the scalp where she hit her head. During an observation on 11/1/16, at 11:30 a.m. Resident 10's room did not have a transfer pole installed next to her bed and no over-the-toilet commode in the bathroom. During another observation on 11/2/16, at 7:40 a.m. Resident 10's room did not have a transfer pole next to her bed. During an observation on 11/4/16, at 9:30 a.m. and 1:30 p.m. Resident 10 did not have an over-the- toilet commode in the bathroom. During an interview on 11/2/16, at 1:45 p.m. the assistant director of nursing (ADON) stated when the care plan had an intervention for having a transfer pole and an over-the-toilet commode for Resident 10, it was expected the equipment should be in the resident's room. She also stated if a fall occurs due to dizziness, an orthostatic blood pressure (measure blood pressure in sitting and standing) should be taken. The ADON concurrent checked Resident 10's chart and was not able to find the orthostatic blood pressure results for the dates of the falls. During an interview on 11/4/16, at 8:55 a.m. the ADON stated if a resident was put on a two hourly toileting program a Bowel and Bladder Toileting Record form should be filled out. The toileting should be done for 72 hours and the licensed nurse should evaluate it, and document the outcome. The ADON confirmed no evidence was in the chart that the IDT discussed to stop or continue this intervention. Review of the facility's Fall Prevention and Management policy dated 9/2013 indicated resident is to be placed on observation of vital signs, pain, and other post-fall complications. Fall details, assessment findings, interventions and notifications are to be documented in resident's clinical record and care plan accordingly. Review of the facility's Orthostatic Blood Pressure policy dated 9/2013 indicated the nurse shall perform and document orthostatic blood pressures when any resident experiences signs of orthostatic hypotension (i.e. dizziness when standing, etc.). Documentation of orthostatic blood pressures may be on a special form, medication administration record or nurse's notes in the resident's medical record.

Based on interview and record review, the facility failed to ensure Resident 1 was free from verbal, physical, and sexual abuse. Resident 1 was diagnosed with [REDACTED]. While residing at the facility's locked unit, Resident 1 was subjected to verbal and physical abuse by other residents and had a sexual encounter with a resident. The facility: 1. Failed to assess if Resident 1 was appropriate for their locked unit within a population of aggressive residents. 2. Failed to address Resident 1's significant other's concerns regarding aggressive residents within the lock unit. 3. Determined in error Resident 1 had the capacity to consent to sexual acts with another resident. Due to Resident 1's cognitive impairment, the reasonable person standard was used to determine outcome. These failures did not ensure the facility was protecting Resident 1 from verbal, physical, and sexual abuse. If a reasonable person was subjected to these verbal, physical, and sexual abuses, he/she would be negatively impacted psychologically, which constitutes harm. Findings: Review of Resident 1's face sheet, dated 6/9/15, indicated she was admitted to the facility on [DATE] and had multiple [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, a national standardized clinical assessment of residents), dated 10/17/14, indicated on section C1300 , .the resident . (has) difficulty focusing attention . (was) easily distracted, out of touch or (had) difficulty following what was said. (Resident 1 exhibited) Disorganized thinking (on an ongoing basis).rambling or irrelevant conversation, unclear or illogical flow of ideas. On section E0100, staff assessed Resident 1 had .Hallucinations (perceptual experiences in the absence of real external sensory stimuli).Delusions (misconceptions or beliefs that are firmly held, contrary to reality). On section, staff assessed Resident 1 had physical behavioral symptoms directed toward others (.hitting, kicking, pushing, scratching, grabbing, abusing others sexually). (these behaviors) Significantly interfere with the resident's participation in activities or social interactions. (and) significantly intrude on the privacy or activity of others. During an interview with Resident 1 on 6/17/15 at 2:22 PM when asked if she remembered someone hurting her, she stated Yeah, she's here, but she apologized. Asked if she felt safe here, she stated Yes. During an interview on 7/2/15 at 10:35 AM, the facility's Program Director (PD) stated residents were admitted to the locked unit based on their medical and psychological diagnoses. The PD stated these [DIAGNOSES REDACTED]., and more. The PD stated only conserved residents are considered for the locked unit (California courts may appoint a conservator for adults with serious mental health illnesses who need special care. These conservatorships are used for people who usually need very restrictive living arrangements and require extensive mental health treatment.). The PD stated Resident 1's conservator wanted Resident 1 in the locked unit because there were concerns regarding Resident 1's wandering behavior. Resident 1's conservator was worried Resident 1 would wander out of the facility and harm herself. Review of reportable incidents to the California Department of Public Health for the last six months indicated Resident 1 was involved in four resident to resident altercations and one sexual encounter with a resident. On 12/3/14, Resident 1 complained a resident was hitting her, on 1/1/15, Resident 1 had a sexual encounter with a resident, on 4/17/15 there was a verbal altercation between Resident 1 and another resident, on 5/14/15, a resident attempted to hit Resident 1, and on 5/19/15, a resident hit Resident 1. Review of Resident 1's Interdisciplinary Progress Note, dated 1/2/15 at 10:45 AM, indicated the interdisciplinary team (a health care team consisting of members from various healthcare disciplines), met to discuss sexual activity which occurred with peer on . (1/1/15). Staff found .(Resident 1) undressed in male . (peer's) room. Resident (1) and peer verbalized to staff that they engaged in consensual sexual intercourse. Resident (1) and peer immediately separated (peer moved to new unit). According to a publication by the American Psychological Association, titled Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists, dated 2008, it indicated to determine consensual sex with an older adult with diminished capacity, . the law recognizes three factors that must be analyzed in determining legally sufficient consent: (1) knowledge of the relevant facts relating to the decision to be made; (2) the mental capacity to realize and rationally process the risks and benefits of engaging in sexual activity; and (3) voluntariness, meaning the absence of coercion and the presence of a realistic choice between engaging or refraining from the activity. Review of Resident 1's records titled Social Service Note, dated 1/2/15 at 11:41 AM, indicated Writer met with .(Resident 1) regarding unprotected sexual intercourse with peer. Resident (1) was able to recall incident and did not verbalize any ill effects. Writer reminded .(Resident 1) that the residents here are conserved and counseled her on respecting personal boundaries of others. When asked about relationship with male peer, .(Resident 1) stated 'I like him, I love all men.' Writer proceeded to counsel on risks of unprotected sex and importance of keeping her hands to herself. Due to poor impulse control and sexually inappropriate .(behavior) .(Resident 1) requires frequent cues and redirection away from others. Staff will continue to engage in appropriate activities of choice and redirected to supervised area when in hallways/intrusive. Review of the facility's document titled PSYCHIATRIC NOTES, dated 1/3/15, indicated Resident 1 was assessed by a psychiatrist after her sexual encounter with a male resident. The Psychiatrist documented Resident 1's insight/judgment was poor.she tentatively agreed that she in fact went to other person room thinking that he was her husband.now I know that he was not my husband.Educated about the grave risk .(with) unprotected sex.Follow up (to include) repeatedly educated about not having unprotected sexual contact .(with) others. During an interview on 6/17/15 at 11:39 AM, the Director of Nursing (DON) stated the facility investigated the sexual encounter between Resident 1 and a male resident on 1/2/15. The facility determined the sex was consensual. The DON was asked to provide clinical rationale for their conclusion when Resident 1's MDS, psychiatric notes and IDT (interdisciplinary) team notes indicated she lacked capacity to consent to sexual intercourse. The facility was unable to provide the requested documents. During an interview on 6/17/15 at 2:54 PM, Certified Nursing Assistant (CNA) 1 stated Resident 1 was very touchy feely. Other residents see her coming and they'll say get away from me. During an interview on 6/17/15 at 3:04 PM, CNA 2 stated Resident 1 was very friendly, too friendly. (she) touch(ed) people on the arm .massage(d) (their) shoulders. CNA 2 stated Resident 1 was easily redirectable during these episodes. She has never seen Resident 1 touched breasts or private parts of other residents or staff. CNA 2 stated Resident 1 was not physically violent or verbally abusive. During an interview on 6/17/15 at 1:47 PM, Resident 1's Significant Other (SO) stated I don't know why . (Resident 1) needs to be in a locked unit. She's overly friendly, that's all. I've asked them (staff) about it. I'm afraid of some of the people there in the locked unit. They can be very violent and aggressive to . (Resident 1). During an interview on 7/2/15 at 1:40 PM, the SO stated I don't remember (when I asked staff about moving her out of the locked unit) .it was over a year ago.I talked to the social worker (SO stated the social worker's name). Review of a fax communication from the facility on 7/22/15 at 9:46 AM, indicated while Resident 1 was residing in the locked unit on 6/23/15 Total number of . (Residents) with (a) history of physical/verbal altercations in 2015.21 physical and 2 verbal. According to this document, Resident 1 was living among 21 residents with a potential for physical aggression and 2 residents with a potential for verbal aggression. During an interview on 7/2/15 at 1:15 PM, the DON was asked to provide clinical rationales why Resident 1 was placed in a locked unit when interviews and document reviews indicated Resident 1 was easily redirectable, was not violent and was not actively trying to harm herself or others. Review of resident to resident altercations placed Resident 1 as the victim 75 % of the time in the last six months. The DON was asked to provide documented evidence Resident 1 was actively trying to escape from the locked unit and would be a danger to herself if placed in a less restrictive setting. The facility was unable to provide the requested documents.

Based on observation, interview and record review, the facility failed to provide care and services to prevent the development and worsening of pressure ulcers for Residents 1 and 12, two of 31 sampled residents. 1. For Resident 12, the facility failed to accurately assess her risk for developing pressure ulcers. The facility failed to accurately document pressure ulcer information on her wound sheets.The care plan failed to address the risk factors for developing pressure ulcers. The facility did not assess if current pressure relieving devices and/or other pressure relieving devices were appropriate in providing adequate pressure relieve. The deficient practice resulted to the development of seven avoidable pressure ulcers and the deterioration of three out of seven pressure ulcers. 2. For Resident 1, the facility failed to identify risk factors and develop individualized interventions for a stage II pressure ulcer leading to worsening of that pressure ulcer. The following are pressure ulcer classifications as defined by the National Pressure Ulcer Advisory Panel (NPUAP) on their website (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/): Stage I pressure ulcers: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons. Stage II pressure ulcers: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury Unstageable pressure ulcers/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Findings: 1. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. the joints), and chronic bilateral leg [MEDICAL CONDITION] (long-term swelling of the legs). Record review of Resident 12's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that she had memory problem and was severely impaired in her cognition regarding daily decision making. Staff assessed her as having no episodes of rejecting care. Resident 12 was assessed as always incontinent of urine and there were no episodes of continent voiding. Resident 12 was assessed as totally dependent on the physical assistance of one staff member for bed mobility, transfers, toilet use and personal hygiene. For range of motion, staff documented impairment on both lower extremities for Resident 12. Review of her Braden Scale (a tool used by the facility to assess pressure ulcer risks) dated 5/7/13 indicated that Resident 12 was at moderate risk for developing pressure ulcers. Record review of Resident 12's "WOUND/SKIN HEALING RECORD" indicated she developed seven pressure ulcers from 6/25/13 to 7/29/13 and the following were staff documentation of those pressure ulcers. a) On 6/25/13, Resident 12 developed a 2.5 x 3.2 cm (centimeter) stage II pressure ulcer on her left inner heel. On 7/22/13, the wound nurse documented that the left inner heel wound had deteriorated, had increased in size to a 4 x 4 cm stage II pressure wound and the wound bed was black/brown (eschar). This was a doubling of the wound surface area from 2.5 x 3.2 = 8 square cm to 4 x 4 = 16 square cm. b) On 6/25/13, Resident 12 developed a 1 x 3.3 cm stage II pressure ulcer on her right lateral foot. On 7/26/13, her right lateral foot wound measured 1 x 3 cm and had deteriorated into an unstageable pressure ulcer; the wound nurse documented that the wound bed was black/brown (eschar) "...reabsorbed blood blister fluid filled center." c) On 6/25/13, Resident 12 developed a 1 x 1 cm stage I pressure ulcer on her right 5th metatarsal head (5th toe). On 7/14/13, the wound nurse documented that the right fifth toe wound deteriorated into a 0.7 x 0.7 cm stage II pressure ulcer with scant serosanguineous exudate (discharge containing serum and blood). d) On 7/29/13, Resident 12 developed a 1.5 x 1 cm stage II pressure ulcer on her left buttock. e) On 6/25/13, Resident 12 developed a 2.5 x 3.2 cm stage II pressure ulcer on her right outer heel. f) On 6/29/13, Resident 12 developed a 3 x 3 cm stage I pressure ulcer on her right inner heel. g) On 7/26/13, Resident 12 developed a 0.1 x 0.1 cm stage I pressure ulcer on her right metatarsal. During observation with the nursing supervisor (RN 1) on 7/26/13 at 2:46 p.m., a Nursing Assistant (CNA 2) applied knee braces to Resident 12's left and right knees. Resident 12 had her soft heel lift devices on both feet (heel lift devices are soft cloth covered boot shape appliances with cut outs at the heels to off load pressure at the heels.) During application of the knee braces, even slight attempts to extend the resident's knees elicited grimacing from Resident 12. After application of the knee braces, RN 1 stated that Resident 12 had a history of [REDACTED]. These braces were there to prevent progression of the contractures. After CNA 2 finished applying the knee braces, observation revealed Resident 12 was repositioned on her back. However, due to her knee contractures, the heel area of the heel lift boots (where the cut outs are) were resting on the mattress. In a concurrent interview, RN 1 was asked if CNA 2 had repositioned Resident 12 to provide adequate heel pressure relief and RN 1 stated "No." Closer examination of the heel lift boots revealed that these devices did not provide any pressure relief to the side of the foot or the side of heel. RN 1 stated staff would use pillows to provide pressure relief if Resident 12 was turned on her sides. During an interview on 7/26/13 at 2:52 p.m., RN 1 and the Assistant Director of Nursing (ADON) were interviewed regarding how staff were repositioning Resident 12's feet. The ADON and RN 1 were asked to provide documented evidence that directed staff where to position pillows/pads to provide pressure relief to Resident 12's heels and the side of her foot. RN 1 provided a pre-printed care plan dated 6/25/13 that showed a check mark on "use pads/pillows to reduce pressure and maintain position." RN 1 was asked if this was an individualized care plan which addressed Resident 12's unique risk factors due to her knee contractures, and where and how to position these pads and pillows. RN 1 agreed that these were generic care plans and had not been modified sufficiently to address Resident 12's individualized needs. Furthermore, review of Resident 12's treatment record for July 2013 revealed that staff were not directed to "float ? foot on a pillow" until 7/12/13. This was 23 days after she developed a stage II pressure ulcer on her right lateral foot. During an interview on 7/30/13 at 9:40 a.m. with the Dietitian, she stated that Resident 12 had a history of [REDACTED]. During an interview on 7/26/13 at 2:52 p.m., RN 1 was asked to explain why Resident 12 was assessed as being at moderate risk for developing pressure ulcers when: A. Resident 12 had a history of [REDACTED]. Resident 12 had multiple [DIAGNOSES REDACTED]. C. Resident 12 was totally dependent on staff for bed mobility, transfers, repositioning, and incontinence care D. Resident 12 was unable to verbalize her needs. E. Resident 12 was always incontinent of urine and there were no episodes of continent voiding. RN 1 stated staff used the Braden pressure sore risk assessment tool to determine risk level. He added that the latest Braden assessment dated [DATE] puts Resident 12 at moderate risk. RN 1 was asked how often staff were required to reassess risks. RN 1 stated staff were required to use the Braden tool on admission and on a quarterly basis. RN 1 stated he was unsure if a Braden assessment needed to be performed when residents acquire a new pressure ulcer. Review of facility's policy and procedure for "SKIN MANAGEMENT" dated 7/1/13 indicated "Procedure for Pressure Ulcer Risk Identification: 1. Upon admission, each resident is assessed by a licensed nurse using a pressure ulcer risk assessment tool (i.e. Braden Scale ...Risk assessments are also completed quarterly, annually and sooner if needed with each significant change of condition MDS." Interview with the Director of Nursing (DON) on 7/29/13 at 2:45 p.m. revealed that staff did not reassess the risk factors for residents who developed new pressure ulcers. Failure to re-assess risks factors after development of new pressure ulcers has the potential to led to delay in implementing effective intervention(s). Observation of Resident 12's wound care on 7/30/13 at 9:43 a.m. revealed Resident 12 was resting on a generic mattress provided to the general resident population. Given Resident 12's high risk for developing pressure ulcers and her newly acquired stage II left buttock pressure ulcer on 7/29/13, the MDS nurse (RN 2) was interviewed on 7/30/13 at 9:33 a.m. regarding Resident 12's mattress. RN 2 stated that the facility will provide special pressure relieving mattress when residents are assessed as high risk for developing pressure ulcers and when there is a history of pressure ulcers. The medication nurse (RN 8) then stated she was going to phone the doctor to ask for a special pressure relieving mattress for Resident 12. During an interview with the wound nurse (LN 2) and the Director of Nursing (DON) on 7/29/13 at 3:02 p.m., LN 2 stated that all seven of Resident 12's pressure ulcers were facility acquired and each pressure ulcer was documented on a separate WOUND /SKIN HEALING RECORD form. LN 2 was then interviewed regarding wound documentation issues such as: a) On a WOUND /SKIN HEALING RECORD dated 7/22/13, the site/location was left blank. b) On a WOUND /SKIN HEALING RECORD dated 6/25/13, staff had written "(left) inner heel" (left inner heel) on the site/location. However, the diagram section of the form had conflicting information when staff documented wounds on both the right outer heel and the left inner heel. c) On a WOUND /SKIN HEALING RECORD dated 7/26/13, staff had written "? 1st metatarsal" (right first toe) on the site/location. However, on the diagram section of the form, staff documented the wound was on the left first toe. d) On a WOUND /SKIN HEALING RECORD dated 6/29/13, staff had written "? inner heel" (right inner heel) on the site/location. However, staff documented the wound on the left inner heel on the foot diagram. Additionally, there were two different onset dates documented for the "? inner heel" wound. An onset date of 6/29/13 was documented on page 1 and an onset date of 6/25/13 was documented on page 2. After reviewing these documentation issues, LN 2 agreed that there were problems with the wound documentation and that it could be confusing for a clinician to try and figure out actual wound sites and onset date. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 7/24/13 at 10:45 AM, Resident 1 had a stage II pressure ulcer on the left buttocks. The open wound was dry, shallow, and pink without drainage. Record review of Resident 1's Wound/Skin Healing Record dated 6/26/13 indicated the development of a stage II pressure ulcer with a wound size of 1.3 x 1.3cm. Record review of Resident 1's Wound/Skin Healing Record dated 7/15/13 indicated a wound size of 0.3 x 0.3cm. Record review of Resident 1's Wound/Skin Healing Record dated 7/24/13 indicated a wound size of 1.5 x 1.3cm. In an interview on 7/26/13 at 10:05 AM, Licensed Nurse 1 (LN1) was asked why Resident 1's pressure ulcer enlarged from 7/15/13 to 7/24/13. LN1 stated, "I don't think they wrote is down here." In an interview on 7/26/13 at 10:20 AM, Licensed Nurse 2 (LN2) was asked why Resident 1's pressure ulcer enlarged from 7/15/13 to 7/24/13. LN2 stated, "He likes to pick and scratch it or he doesn't want to be changed. It could be from being soiled, sitting, watching T.V. or since it is a bony prominence." LN2 acknowledged it could be a result of sitting in a chair for [MEDICAL TREATMENT] for a long period of time. In the same interview, LN2 was asked if any of that information was documented to communicate to others. LN2 stated, "I'm sorry, I don't think I have it in here" and acknowledged the [MEDICAL TREATMENT] center was not aware of the pressure ulcer. Record review of Resident 1's care plan for renal function dated 1/3/13 indicated [MEDICAL TREATMENT] (when the kidneys no longer work properly and a machine filters toxins from your blood) treatment "3x (three times) a week". [MEDICAL TREATMENT] is usually done 3 days a week and take 3 to 5 hours a day (www.uwhealth.org). Record review of Resident 1's care plan for skin breakdown dated 7/4/13 did not indicate the resident was on [MEDICAL TREATMENT] or mark the intervention of providing a pressure relieving device for a chair. Record review of Resident 1's care plan for skin breakdown dated 7/6/13 indicated the resident was on [MEDICAL TREATMENT], but did not mark the intervention of providing a pressure relieving device for a chair. In an interview on 7/26/13 at 2:21 PM, LN2 acknowledged the importance of communicating problems causing pressure ulcers to create appropriate interventions and preventions. Record review of the facility's policy and procedure for skin management, dated 7/1/13, indicated "Procedures for Pressure Ulcer Prevention: 1. Residents who are determined to be at risk for pressure ulcer development will have appropriate preventative surfaces for bed and seating in place...Procedures for Existing Pressure Ulcer(s): 1. Procedures for Pressure Ulcer Prevention interventions will be employed as appropriate for residents with existing pressure ulcer(s)...4. An episodic care plan will be developed, including the pressure ulcer site, risk factors that may delay healing if applicable, a time limited measurable goal, and interventions implemented to promote healing."

Based on observation, interview and record review, the facility failed to provide care and services in pressure ulcer management for one of 15 sampled residents (Resident 38). For Resident 38, the facility failed to accurately assess a reddened area to his buttocks. The facility identified a potential risk for developing pressure ulcers but failed to develop individualized interventions to promote the healing of a newly developed pressure ulcer. The following are pressure ulcer classifications as defined by the National Pressure Ulcer Advisory Panel (NPUAP) on their website (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/): Stage I pressure ulcers: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons. Stage II pressure ulcers: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Findings: During a record review of Resident 38's most recent Minimum Data Set (MDS) (an assessment tool) dated 8/8/13, it indicated that he had multiple [DIAGNOSES REDACTED]. Resident 38 was cognitively intact with no memory problem and had no episodes of rejecting care during the assessment period. Resident 38 was assessed as always incontinent of urine and bowel. Resident 38 was assessed as requiring supervision for bed mobility, and extensive assistance of one staff for transfers. Resident 38 required extensive assistance of one staff for toilet use. Review of Resident 38's Braden Scale dated 8/8/13 indicated that Resident 38 was at moderate risk for developing pressure ulcers. Review of Resident 38's records indicated he had a history of [REDACTED]. Review of Resident 38's "NON-PRESSURE SKIN CONDITION REPORT" dated 9/5/13 indicated he developed "redness" around his gluteal cleft (buttocks area). There was no evidence that staff measured the redness. The section of the form titled "SIZE IN CM" was left blank. Additionally, there was no evidence that on the form or in Resident 38's "NURSE'S NOTES" dated 9/5/13 that staff had assessed the redness to determine if it was a stage I pressure ulcer. Two days later, on 9/7/13, staff documented on Resident 38's "WOUND/SKIN HEALING RECORD" that he developed a stage II pressure ulcer on his left inner buttock. During observation of Resident 38 on 9/10/13 at 2:14 p.m. with the Nursing Supervisor (RN 1), Resident 38 was noted to have an open wound on his left buttock and RN 1 confirmed it was a stage II pressure ulcer. During an interview on 9/10/13 at 2:30 p.m., RN 1 was asked about the accuracy of the facility's Braden scale assessment for Resident 38. RN 1 was asked to explain if Resident 38 was not assessed as high risk for developing pressure ulcer, how did he developed a pressure ulcer on 9/7/13. RN 1 stated "I think we can re-do his Braden." RN 1 then pointed out in Resident 38's care plan dated 9/8/13 that resident "refuses to get out of bed (between) meals...(history of) resistive to care..." Review of the nursing care plan dated 9/8/13 found no evidence that staff were to monitor Resident 38 after meals or interventions to re-direct Resident 38 between meals to encourage Resident 38 to reposition himself. RN 1 was asked to provide documented evidence that the facility had developed individualized intervention(s) which specifically address this refusal issue for Resident 38. RN 1 was unable to provide the requested documentation.

Based on interviews and record review, the facility failed to ensure that every resident was free from sexual, physical and mental abuse, when a staff member witnessed incidents of inappropriate touching by a male Certified Nurse Assistant (CNA 1) of one male resident (Resident 1) of ten sampled residents occurred and were not reported to the California Department of Public Health. On 1/19/11 Resident 1 claimed that a CNA touched him inappropriately on his private parts. Failure to identify and report any suspicious, or actual abuse incidents in the facility can lead to increased risk of additional abuse. This deficient practice resulted in the obstruction of abuse investigation and the occurrence of further abuse of Resident 1 by CNA 1. Findings: Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment, dated 12/27/10, indicated the resident had memory problems. Resident 1's speech was clear and he had the ability to clearly express his ideas and needs. Resident 1 required supervision with walking in the room and toileting. The resident needed limited assistance with walking in the corridor, dressing, personal hygiene and bathing. The resident used wheelchair for mobility. During an interview on 2/15/11 at 10:00 AM by the (2) PCB investigators (Professional Certification Branch is responsible for the certification of nurse assistants, home health aides, [MEDICAL TREATMENT] technicians and the licensure of nursing home administrators. The PCB is also responsible for the investigation of allegations involving health care professionals and the enforcement of disciplinary actions.), this surveyor and a CMS surveyor present (Centers for Medicare & Medicaid Services, a branch of the Department of Health & Human Services, employs surveyors to ensure fulfillment of Federal participation requirement by health care facilities), Resident 1 disclosed that on 1/19/11 a male CNA grabbed his genitals and referred to him as a woman in the presence of another CNA (who was a Restorative Nurse Assistant - RNA). Resident 1 stated, "I don't like men touching that (pointing at his genitals). That's disgusting! I can't stand that. It's not good fun! It's disgusting!" When asked by the PCB investigator, if the CNA who touched him was joking, Resident 1 said, "He was serious. I think he was ... and, I didn't like it!" Resident 1 also indicated that before this incident, the CNA grabbing his genitals, he was inappropriately touched once, or twice by the same CNA inside his room. Resident 1 did not remember the CNA's name (CNA 1), when asked by the PCB investigator, but he was able to recognize the name of the RNA and said, "Yeah, I know (RNA's name). I can talk to him." In an interview on 2/15/11 at 2:10 PM the social worker (SW) said he was notified of the incident on 1/19/11 at about 11:30 AM. SW stated he interviewed Resident 1, who complained to him that someone grabbed his balls. Resident 1 described CNA 1 as wearing a black nursing outfit and his height was about his (resident's) height. The CNA had dark skin, he was fit. The SW said nursing and social services staff interviewed Resident 1 and they found him consistent in his allegation. During an interview on 2/15/11 at 2:45 PM the unit manager (UM) stated, on 1/19/11 at 1:35 PM Resident 1 told him that he was touched inappropriately by a CNA. The RNA, who was with Resident 1 at that time confirmed he saw it happening that afternoon. Resident 1 told the UM, "Yeah, they were doing it (referring to inappropriate touching) to me constantly for the past 3 to 4 days, and they always come in two's. The UM said he asked Resident 1 who were these guys, but Resident 1 did not mention names; instead, he described the perpetrator as the CNA wearing black nursing shirt, tall and the other guy was wearing grey nursing shirt. The UM further disclosed, he saw and identified on 1/19/11 CNA 1 and CNA 2 based on Resident 1's descriptions. They were usually seen working together in the unit. UM said that Resident 1 indicated, only CNA 1 was touching him. UM stated he talked to CNA 1, CNA 2 and RNA the afternoon of the incident. The UM asserted that CNA 1 did not write a statement, when asked. CNA 2 told UM that he did not see anything. The RNA did write a statement about the incident. When asked, if CNA 1 had ever been assigned to Resident 1, the UM indicated CNA 1 came from the Open Unit, located in another building and he floated in the Closed Unit since December 2010. The UM also said, CNA 1 was not assigned to Resident 1. He had a regular female CNA (CNA 3). UM indicated after he knew of the incident, he told the staff in the unit, starting with the evening shift, everyone should be on a "buddy system" (assigning additional staff to assist CNA providing care). According to UM the RNA said that he saw CNA 1 touching the private part of Resident 1 in the hallway on 1/19/11. When UM was asked, if a physical examination was done immediately after the incident to check any body injury on Resident 1, UM stated the "body check " on Resident 1 was not done until the following day. UM acknowledged they should have done the physical examination right away. UM was asked if the attending physician was notified of the incident. UM stated the physician was notified. Review of Resident 1's clinical records at the time of the interview with UM contained no language indicating a physician's assessment of Resident 1. The last entry notes of the attending physician on the Progress Record for Resident 1 was on 11/10/10. The UM acknowledged, physician's visit to the resident should be every month, or whenever the resident has a problem. UM said he already called to remind the physician regarding needed visits to Resident 1. UM was asked if a psychiatric consult, or evaluation was provided to Resident 1 after the incident. His answer was "No." UM acknowledged Resident 1 needed psychiatric evaluation and follow-up in conjunction with 72-hour follow-up and support of the social worker, because Resident 1 was subjected to abusive incidents. In an interview on 2/16/11 at 10:35 AM the RNA for Unit 3 said that on 1/19/11 around 11:00 AM he asked Resident 1 about doing his exercises. RNA stated that "out of nowhere" Resident 1 started talking about some guy, who touched him. The RNA thought Resident 1 was talking about another resident, who grabbed Resident 1's neck about 3 or 4 months ago. RNA further stated that after lunch on 1/19/11 he saw Resident 1 in the hallway and Resident 1 told him, "I will turn this guy in. I need your help." The RNA said he asked Resident 1 "What's going on?" Resident 1 pointed at Room (__). The RNA knocked and opened that door. CNA 1 came out of the room and said "Hi" to Resident 1. Resident 1 pointed at CNA 1 and said, "This is him." The RNA went to the Director of Nurses (DON) office to report CNA 1, but the DON wasn't there. The RNA said he went back to Resident 1, who was outside his room sitting in his wheelchair after the walking exercise. CNA 1 suddenly came out of Room (___) and said to Resident 1, "Hey, what's up (name of Resident 1) ? Let's see what you've got there." The RNA indicated, he saw CNA 1 grabbing the penis of Resident 1 (the RNA quickly motioned his hand side-to-side to demonstrate what CNA 1 did to Resident 1). CNA 1 told Resident 1 in a loud voice, "There's really nothing there, (name of the resident). You're a woman (name of the resident). Hahahaha. You're a woman. Hahahaha." CNA 1 was laughing, while walking away from the resident. The RNA said he didn't notice whether, or not there were other people who also saw the incident in the hallway. The RNA wheeled Resident 1 to the nurses station and they reported the incident to the Assistant Director of Nursing (ADON) and to the UM. In an interview on 2/16/11 at 11:10 AM CNA 2 said he knew CNA 1. On 1/19/11 he was working with him. CNA 2 explained, although CNA 1 was not assigned to Resident 1, CNA 1 went into the room of Resident 1 to help CNA 2, who was assigned to provide care for Resident 1's roommate. When asked if he noticed anything unusual going on with Resident 1 and CNA 1 in the unit, CNA 2 looked hesitant to answer and made a lot of pauses. Eventually he indicated that he saw them joking and laughing, once. CNA 2 also said, about a week before the 1/19/11 incident he saw CNA 1 standing in front of Resident 1, who was sitting in a wheelchair in the hallway. CNA 2 stated, he saw CNA 1 waving his hand between Resident 1's legs. CNA 2 said, "Like ... I don't know ... He (referring to CNA 1) was doing like this (waving hand) ... close to his (referring to Resident 1) genital area." When asked, what was the reaction of Resident 1, CNA 2 said that Resident 1 "was backing up in his wheelchair." When CNA 2 was asked if he reported this incident, CNA 2 said, "No" because according to CNA 2 he thought that CNA 1 and Resident 1 were just joking. In an interview on 2/16/11 at 11:45 AM the DON stated, she was not aware that CNA 2 had also seen such incidents, because CNA 2 did not report, or said anything during their inter-facility abuse investigation on Resident 1. DON stated she would further look into this. In another interview on 2/16/11 at 2:15 PM the DON revealed that upon her re-investigation with CNA 2, she discovered that CNA 2 did not report several previous abuse incidents by CNA 1 to Resident 1. DON stated that aside from the incident disclosed to the survey team by CNA 2 this morning, CNA 2 acknowledged that at one time he called CNA 1 to help him with Resident 1's roommate. CNA 1 came to the room with snacks for Resident 1, who was still asleep. CNA 1 woke Resident 1 by touching his thigh close to his genital area. Resident 1 told CNA 1 that he will report him to the nurse if he'd do that again. She said, since CNA 2 failed to report a misconduct he witnessed last month (January 2011) by another male staff to a resident, CNA 2 was sent home and would be suspended from work pending re-opening of the 1/19/11 abuse investigation. DON stated CNA 1 was terminated from work on 1/24/11 upon substantiating the abuse complaint against him. Review of facility's policy and procedure "SUBJECT: ELDER and DEPENDENT ADULT ABUSE" with effective date of 11/1/05 indicated, "2. MANDATED ABUSE REPORTING REQUIREMENTS OF EMPLOYEE, (B) ANY PERSON EMPLOYED BY CRESTWOOD IS REQUIRED BY LAW TO REPORT ELDER OR DEPENDENT ADULT ABUSE IF THEY(1.) Observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse or neglect or (2.) Is told by an elder or dependent adult they have experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect or (3) Reasonably suspects - objectively reasonable suspicion based upon facts that such abuse has occurred."