Every finding on record at Imperial Crest Health Care Center

Based on observation, interview and record review, the facility failed to ensure one of 2 sampled residents (Resident 2) was received shower as scheduled. This failure resulted in a poor quality care as evidenced by very poor grooming state, oily hair and presence of dandruff on the resident's hair, and the potential to affect the resident's quality of life.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dependence on respirator (ventilator, machine that breaths/assist with breathing) status metabolic encephalopathy (disease or brain not working properly). During a review of Resident 2's Care Plan titled Activities of Daily Life (ADL) function, dated 7/9/2024, the interventions indicated to assist with ADLs as needed. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2025, the MDS indicated Resident 2 was not able to understand and be understood by others. The MDS indicated Resident 2 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, and tub/shower transfer. During a review of Resident 2's Daily Body Check Report form, for the month of June to July 2026, the Daily Body Check Report form did not indicate Resident 1 received a shower, except for 6/29/2026. During a review of Resident 2's Documentation Survey Report (a document containing records of shower bath), for the month of 6/2026, the documentation did not indicate Resident 2 received a shower for the month except on 6/18/2026. During a concurrent observation and interview on 7/8/2026 at 12:18 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 2's hair was oily and dandruff were all over Resident 2's head. LVN 1 stated it looked like Resident 2 had not had a shower in a while. During a concurrent observation, interview and record review on 7/8/2026 at 12:43 p.m., with Certified Nurse Assistant (CNA) 1, the Daily Shower Report from 6/1/2026 to 7/6/2026 was reviewed. CNA 1 stated the Reports from 6/1/2026 to 7/6/2026 indicated that Resident 1 was only showered on 6/29/2026. CNA 1 stated there were no documented showers for Resident 1 on her scheduled shower days on 6/1/2026, 6/4/2026, 6/8/2026, 6/11/2026, 6/15/2026, 6/22/2026, 6/25/2026, and 7/6/2026. CNA 1 stated Resident 1 had not been showered all those days. CNA stated she had not washed Resident 1's hair (date unspecified). CNA 1 stated Resident 1's hair was oily and had dandruff. CNA 1 checked Resident 1's drawers for hair products and CNA 1 stated there was no shampoo, conditioner or any other hair products for the resident to use. CNA 1 stated the family did not bring any hair products for Resident 1. CNA 1 stated all residents were supposed to get a shower twice a week even if they were bedridden or had a tracheostomy (small opening in the neck directly into windpipe that assist with breathing). CNA 1 stated Resident 1 was bedridden, and the staff could use a Hoyer lift (device to transfer individuals with limited mobility) to take her to the shower with the assistance of a Respiratory Therapist (specialist that cares for patients with lung/breathing disorders). CNA 1 stated providing residents showers on scheduled days were important to thoroughly clean their body with soap and water. During an interview on 7/8/2026 at 3:13 p.m., with Family Member 1 (FM 1), FM 1 stated every time she went to the facility, she would ask staff to shower Resident 1, but staff (unidentified staff) would tell FM 1 that Resident 1 received shower twice a week. FM 1 stated Resident 1 always looked as if she had not been showered for months and Resident 1's hair was oily and had dandruff. During a concurrent record review and interview on 7/8/2026 at 4:15 p.m., with Director of Nursing (DON), Resident 1's Documentation Survey Report for the month of June 2026 was reviewed. The DON stated the documentation indicated Resident 1 had showered once for the month of June 2026. The DON stated all residents were supposed to have a shower unless they were stable. During a review of the facility's Policy & Procedure (P&P) titled, Activities of Daily Living, dated 3/2018, the P&P indicated the facility should ensure that residents who were unable to carry out activities of daily living independently, will receive the services necessary to maintain good grooming and personal hygiene.

Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of three sampled residents (Resident 1) by failing to: Implement Resident 1's care plan titled, Incontinence which indicated interventions of assisting with toileting needs and/or provide incontinence (inability to control the flow of urine from the bladder or the escape of stool from the rectum) care after incontinent episodes. Follow the physician orders to monitor and document Resident 1's output (all liquids that leave the resident's body to monitor for issues such as kidney complications) in milliliters (mls- measurement of volume) every shift for 30 days. These failures had the potential to result in unidentified urinary retention (bladder doesn't empty properly), worsening pressure ulcers/wounds and urinary tract infection (UTI-an infection in any part of the urinary system) for Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), overactive bladder (a condition in which the bladder squeezes urine out at the wrong time), and anxiety disorder (excessive fear or worry that interfere with daily activities).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and was able to understand others. The MDS indicated Resident 1 was always incontinent with urine and bowel and required substantial (helper does more than half the effort) assistance with oral hygiene, toileting hygiene and upper body dressing.During a review of Resident 1's Bowel and Bladder Program Screener, dated 05/16/2026, the Bowel and Bladder Program Screener indicated Resident 1 was immobile, forgetful, followed commands and was never aware of the need to toilet. The Bowel and Bladder Program Screener indicated Resident 1 had a decubitus (pressure ulcer- localized damage to the skin and/or underlying tissue usually over a bony prominence) stage 3 (full-thickness loss of skin. Dead and black tissue may be visible), stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone). During a review of Resident 1's Documentation Survey Report for the months of 5/2026 and 6/2026, the Documentation Survey Report indicated on 5/17/2026, 5/21/2026, 5/22/2026, 5/25/2026 and 5/26/2026 during the day shifts (7:00 a.m.- 3:30 p.m.), on 5/23/2026 during the night shift (11:00 p.m. - 7:00 a.m.), on 6/1/2026 during the evening (shift (3:00 p.m. -11:00 p.m.) and 6/3/2026 during the evening (3:00 p.m.- 11:00 p.m.) shifts, Resident 1's bowel and bladder elimination intervention/task were blank. During a review of Resident 1's Physician's Order dated 5/15/2026, the Physician's order indicated to monitor the resident's output every shift for 30 days and document output in mls.During a record review of Resident 1's Medication Administration Record (MAR), for the months of 5/2026 and 6/2026, the MAR indicated on 5/16/2026-5/31/2026 during the day and night shifts and on 6/1/2026 through 6/5/2026 during the evening shifts, Resident 1 had two episodes of urinating. The MAR did not indicate Resident 1's (urine) output was measured in mls. During a review of Resident 1's care plan titled, Incontinence dated 6/3/2026, the care plan indicated Resident 1's incontinence was not a new onset with diagnoses of cerebral vascular accident (CVA- stroke, loss of blood flow to a part of the brain), morbid obesity (a severe form of obesity characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health complications and over active bladder). The care plan goals indicated Resident 1 will be able to have bladder/bowel adequately emptied without complications through appropriate interventions and will be kept clean, dry and odor free. The care plan nursing interventions included assisting Resident 1 with toileting needs and/or provide incontinence care, monitor bladder incontinent episodes, assess for signs/symptoms of UTI and notify the Physician if the resident had a change in condition (COC). During an interview on 6/10/2026 at 1:18 p.m., with the Director of Staff development (DSD), the DSD stated (Resident 1's) urine incontinence were documented in the number of episodes, not in mls. The DSD stated failure to provide incontinence care could cause skin damage and infections. During a review of the facility's P/P titled, Urinary Continence and Incontinence-Assessment and Management, dated 8/2022, the P/P indicated staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.During a review of the P/P titled Fluid Intake & Output the P/P purpose indicated the facility will monitor intake and output as ordered. The P/P indicated daily intake and output shall be recorded for a minimum of 30 days as ordered by physician.

Based on observation, interview and record review, the facility failed to follow its Policy and Procedure (P/P) titled, Sharps Disposal which indicated to remove and replace Sharps Disposible containers when 75% to 80% full, in 1 of 2 shower rooms (shower room [ROOM NUMBER]). This failure had the potential to cause injuries, accidents and infections to residents in the facility. Findings:During a concurrent observation and interview on 06/10/2026 at 12:17 p.m., with Certified Nursing Assistant (CNA) 1, in shower room [ROOM NUMBER], one Sharps Disposal container was observed to be full, with two blue razors sticking out of the lid opening. CNA 1 stated the housekeeper normally replaced the Sharps Disposal when full. Having an overflowing Sharps container had the potential to cause accidents or injuries, and increased risk of infections for residents. During an interview on 06/17/2026 at 2:40 p.m., with the Central Supplies staff (CS), the CS stated he and nursing staff were responsible for changing the Sharp Disposable containers. The CS stated he would wait until the Sharp Disposable container was full (greater than 80%) before replacing it. The practice of changing the sharps disposal when full had the potential to cause accidents and injury to residents. During a review of the facility's P/P titled, Sharps Disposal dated 2012, the P&P indicated the facility shall discard contaminated sharps into designated containers. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitary food storage and preparation practices were maintained in the kitchen, by failing to:Ensure one container of Italian dressing was labeled with an opened date and/or use-by date. Maintain cold food items at safe temperatures when three-bean salads measured 57 to 66 degrees Fahrenheit ( F, a scale of temperature) during meal service.Ensure bowls of vanilla mousse were properly immersed in an iced-holding bin or storage, to maintain a safe, cold holding temperatures of 41 F and below during tray line pre-service handling. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 54 medically compromised residents who received food from the kitchen.Findings:During a concurrent observation and interview on 5/19/2026 at 8:55 a.m., with the Registered Dietitian (RD), one container of Italian dressing was observed stored in the kitchen refrigerator without an opened and/or use-by date. The RD stated that all food items should be labeled with the date opened and use-by date to identify when the item was opened and to determine when it was no longer safe for consumption. The RD stated that without an opened date and use-by date, kitchen staff would be unable to determine how long the item had been stored in the refrigerator, creating the potential for the item to be used beyond a safe time frame. During a record review of the facility's Spring Menu, dated 5/19/2026, the menu indicated on 5/19/2026, three bean salad and vanilla mousse were scheduled to be served for lunch on 5/19/2026.During a review of the facility's Recipe of Broccoli Salad, dated 2025, the recipe indicated the three-bean salad was to be prepared and refrigerated at 41 degrees Fahrenheit ( F, a scale of temperature) or below until meal service. The recipe indicated the kitchen staff were to serve the three-bean salad on the tray line at the recommended temperature of 41 F or below. During a concurrent observation and interview on 5/19/2026 at 12:00 p.m., with the RD, observed one pre-plated cup of three-bean salad measured at 50 F. In addition, one cup of three-bean salad held in an ice-holding bin measured at 66 F. The RD stated the three-bean salads temperature exceeded 41 F, which created the potential for bacterial growth and foodborne illness if the salads were to be consumed by the residents. During a review of the facility's Recipe of Vanilla Mousse, dated 2026, the recipe indicated the vanilla mousse was to be prepared and kept chilled in the refrigerator at 41 F or below. The recipe indicated the kitchen staff were to serve the vanilla mousse on the tray line at the recommended temperature of 41 F or below. During a concurrent observation and interview on 5/19/2026 at 12:20 p.m., with RD, observed bowls of vanilla mousse held in an ice-holding bin. The ice did not fully surround the bowls to ensure temperature control. The temperature of three randomly selected bowels of vanilla mousse in the ice-holding bin measured 50 F. The RD stated the vanilla mousse was not maintained under 41 F. RD stated the vanilla mousse should be maintained at 41 F or below prior to serving to residents to prevent bacterial growth and the risk for foodborne illness if consumed by residents. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19. Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/2022, the P&P indicated refrigerator foods must be labeled, dated, and monitored to ensure use by their use-by date.During a review of the facility's P&P titled Menu Service, undated, the P&P indicated salads and desserts must be served at 40 F or below.

Based on observation, interview, and record review, the facility failed to ensure one of eleven residents (Resident 49) observed during medication administration (MedPass) was administered Humalog insulin (a fast-acting prescription medication used to lower blood sugar [BS] in people with diabetes- a chronic condition in which the body either does not produce enough insulin [a hormone that removes excess sugar from the blood] or cannot use insulin effectively, resulting in high levels of blood sugar) within 15 minutes of a meal and injection site rotated after each injection, as ordered and in accordance with manufacturer's specifications. This deficient practice increased the risk of Resident 49 experiencing harmful effects from uncontrolled blood sugar, which could lead to dizziness, confusion, unconsciousness, coma, and hospitalization. The facility's failure to alternate or rotate Resident 49's insulin injection site created the potential of scar tissue build up which may decrease medication absorption and therapeutic effectiveness of the medication's ability to prevent adverse reactions (harmful or unwanted effects) from both the insulin medication and the diabetes disorder. Findings:During a review of Resident 49's admission Record ( a document containing diagnostic and demographic information), the admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus (DM2), long term use of insulin, hypertension (high blood pressure), and long term use of oral hypoglycemic (lowering blood sugar level) drugs. During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 49's cognitive skills for daily decisions making was intact. During a review of Resident 49's care plan focus indicated, the resident has Diabetes and is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to Diabetes Mellitus.care plan dated 4/29/2025, Resident 49's care plan goals included the resident will have no unrecognized s/s (signs and symptoms) of hypoglycemia and hyperglycemia as evidence by: no tremors, no diaphoresis (excessive sweating), no change in level of consciousness daily. Resident 49's care plan Interventions included; diet as ordered; monitor food intake and record; offer HS (bedtime) snacks as ordered; administer medications as ordered; monitor for s/s of hypoglycemia.monitor s/s of hyperglycemia, polydipsia (excessive thirst), polyuria (excessive urination), increased blood glucose (blood sugar)., deep and rapid breathing., weakness, abdominal pain, general aches. During a review of Resident 49's Order Summary Report, signed by physician on 5/7/2026, included and not limited to the following orders:Humalog (Insulin Lispro) KwikPen (a prefilled insulin injection pen) Injection 100 units per milliliter (ml, unit of measurement), instructions indicated, inject as per sliding scale: if BS0 (zero) -149 = 0 unit;150 -199 = 3 units;200 - 249 = 4 units;250 - 299 = 5 units;300 - 349 = 6 units;350 - 399 = 7 unitssubcutaneously (SQ, injection just under the skin) before meals and at bedtime for DM2. Call MD if BS above 400, or below 70. Give no more than 15 minutes before the meals or give at the beginning of the meal (up to 15 minutes after the start of the meal) and to hold the dose if a meal is skipped. Rotate Site, order date 1/31/2023. During a review of Resident 49's Medication Administration Records (MAR, official documents recording the administration of medications to residents, including drug name, dosage, time, and route) for the Months of April 2026 and May 2026, the MAR for Resident 49 indicated the resident was ordered Humalog to be administered by SQ injection per sliding scale four times a day before meals and at bedtime, scheduled administration times were 6:30 AM, 11:30 AM, 4:30 PM, and 9 PM daily. Licensed nurses documented administration of Humalog scheduled for 11:30 AM administration was administered between 4/26/2026 through 5/20/2026 as follows. On: 4/10/2026- injected 4 units at 11:03 AM04/15/2026 - injected 4 units at 11:43 AM04/17/2026 - injected 4 units at 11:11 AM4/26/2026 - injected 3 units at 10:50 AM5/16/2026 - injected 3 units at 10:47 AM5/20/2026 - injected 4 units at 10:41 AM During a concurrent observation and interview on 5/20/2026, at 10:34 AM, with a Licensed Vocational Nurse (LVN) 4, on Nursing Station 2 at Medication Cart (MedCart) 2, LVN 4 checked Resident 49's BS level and stated the resident's BS was 200 and required four (4) units of Humalog per sliding scale dosing. LVN 4 dialed up 4 units of Humalog. LVN 4 entered the Resident 49's room and stated the insulin was injected into the right upper quadrant (RUQ) of the resident's stomach. There was no meal or snack observed available or offered to Resident 49. During an interview on 5/20/2026 at 2:06 PM, with LVN 4, LVN 4 stated Resident 49 receives lunch at 12:15 PM. LVN 4 stated Resident 49 normally receives Humalog insulin around 10:30 AM and LVN 4 stated the insulin was administered today, 5/20/2026 at 10:41 AM. During a concurrent interview and record review on 5/20/2026 at 2:09 PM with LVN 4, Resident 49's Order Summary Report was reviewed for Humalog. LVN 4 stated that Resident 49's Humalog order indicated to give Humalog per sliding scale no more than 15 minutes before the meal or no longer than 15 minutes after the start of the meal and hold if the meal is skipped. LVN 4 stated that she saw the order but did not remember the insulin must be given with a meal. LVN 4 stated Resident 49's Humalog must be given with a meal to help control the BS level during that meal and if Humalog is given on an empty stomach the resident's BS could drop too low. During a concurrent interview and record review on 5/20/2026 at 2:15 PM, with LVN 4, Resident 49's MAR, Location of Administration Report, was reviewed for 5/20/2026. Resident 49's MAR, Location of Administration Report, indicated the resident's Humalog was injected on 5/20/2026 at 6:36 AM RUQ and at 10:41 AM RUQ. LVN 4 stated that she should not have injected the Humalog insulin into the same injection site (RUQ) as the previous dose and should have rotated the insulin injection site. During a concurrent interview and review of mealtimes and snack/nourishment schedules on 5/21/2026 at 3:14 PM, with the Dietary Supervisor (DS), DS stated Resident 49 was not on the list to receive morning, afternoon or bedtime snacks/ nourishment. DS stated mealtimes are posted and the scheduled mealtimes are:Breakfast was scheduled from 7:15 AM to 8:00 AMLunch was scheduled from 12:15 PM to 1:00 PMDinner was scheduled from 5:15 PM to 6:00 PM During a concurrent interview and record review on 5/21/2026 at 3:32 PM, with the Director of Nursing (DON), Resident 49's Order Summary and MAR for the Month of May 2026 were reviewed. DON stated according to Resident 49's physician orders the insulin injection sites must be rotated for each administration to avoid infection, redness, or swelling at the injection site. DON stated that Resident 49's Humalog insulin is fast acting and must be given with meals, within 10 to 15 minutes of the meals. The DON stated Resident 49's Humalog insulin should not be given an hour before a meal, must be given with meals for resident's safety. DON stated that Resident 49's Humalog was scheduled to administer at 11:30 AM, the resident's lunch was scheduled for 12:15 PM daily and Resident 49's physician order indicated to administer Humalog to the resident 15 minutes before the meal and hold if resident do not eat. The DON acknowledged that licensed nurses documented Resident 49's administration of Humalog scheduled for 11:30 AM as administered as follows. On:5/16/2026 - injected 3 units at 10:47 AM5/20/2026 - injected 4 units at 10:41 AM. The DON stated that Resident 49's evening Humalog insulin injection scheduled for 4:30 PM administration time should have been given with dinner, which was scheduled at 5:15 PM daily. The DON acknowledged that licensed nurses documented Resident 49's administration of Humalog scheduled for 4:30 PM as administered as follows. On:5/12/2026 - injected 3 units at 7:41 PM5/15/2026 - injected 3 units at 6:46 PM5/16/2026 - injected 3 units at 6:40 PM5/20/2026 - injected 3 units at 6:42 PM. DON stated Resident 49's Humalog should have been administered with dinner as ordered. During a concurrent interview and record review on 5/21/2026 at 3:59 PM, with the DON, the DON stated after reviewing Resident 49's MAR Location of Administration for the Month of May 2026, that the resident was documented to have been administered Humalog insulin at the same injection site on 5/16/2026 for three dose into the left lower quadrant (LLQ) of the stomach for the 11:30 AM, 4:30 PM, and 9:00 PM scheduled administration times and for two doses at the same injection site on 5/20/2026 injection into the RUQ of the stomach for the 6:30 AM and 11:30 AM scheduled administration times. DON stated licensed nurses can check the manufacturer labeling to ensure they understand how to administer medication for the safety of the resident and to know how the medication works and they could call the facility's pharmacist as needed for drug information. During a telephone interview on 5/21/2026 at 4:21 PM, with the facility's Consultant Pharmacist (Pharm) 1, in the presence of the DON, Pharm 1 stated, Humalog is a fast-acting insulin and should be taken as a resident starts to eat, the onset of action engages rapidly to help control the BS spikes during a meal. Pharm 1 stated administering Humalog 15 minutes before eating matches the peak action of when the Humalog insulin starts to work. Pharm 1 stated Humalog starts to work in 10 to 15 minutes. Pharm 1 stated that administering Humalog on an empty stomach has a risk that resident may experience hypoglycemia, because Humalog acts quickly and symptoms may include sweating, dizziness, confusion, and affect heart rate. Pharm 1 stated regardless of type of insulin, must alternate the injection site to prevent the development of lumps or scar tissue over time, which may delay or decrease absorption of the medication, creating unpredictable, inconsistent, and potentially not a complete absorption of the medication. According to DailyMed (the official U.S. government website that provides Food and Drug Administration-approved drug labeling and information), the manufacturer's labeling for Humalog dated 1/2026, indicated, Administer Humalog U-100 or U-200 by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Rotate injection sites to reduce risk of lipodystrophy (abnormal loss or buildup of fat tissue) and localized cutaneous amyloidosis (a condition where protein deposits called amyloid build up in the skin at repeated injection sites, leading to lumps or thickened areas).During a review of the facility's policy and procedures (P&P) titled, Insulin Administration, dated 3/2023, the P&P indicated, The nursing staff will have access to specific instructions (from manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use.The three key characteristics of insulin are:Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose;Peak effects - the time when the insulin is at its maximum effectiveness; andDuration of effects - the length of time during which the insulin is effective. Rapid-acting, onset 10-15 minutes.Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm) . Report excessive bruising, swelling, pain, redness, or unusual marks on or around the injection site. During a review of the facility's P&P titled, Administering Medications, dated 3/2023, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include.Enhancing optimal therapeutic effect of the medication. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 22) was provided interpreter to ensure the language used was understood. This deficient practice resulted in the resident not understanding instructions and had the potential to violate respect and dignity. Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes a person to have repeated seizures [brain sends abnormal electrical signals causing shaking, staring spells, confusion, loss of awareness, or unusual movements), hypertension (HTN, high blood pressure), dysphagia (difficulty swallowing), and anxiety disorder (a condition where a person feels very worried, nervous, or fearful more often and more strongly than normal).During a review of Resident 22's History and Physical (H&P) dated 7/22/2025, the H&P indicated Resident 22 had the capacity to make medical decisions.During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 22 was able to understand and be understood by others. The MDS indicated Resident 22's cognition (ability to think and process) was intact. The MDS indicated Resident 22 used a walker and wheelchair and required moderate assistance (helper does less than half the effort) from staff for activities of daily living and mobility. During a concurrent observation and interview on 5/19/2026 at 9:13 a.m. with the Licensed Vocational Nurse (LVN) 3, the LVN 3 called Resident 22 Poppa telling him to take blood pressure medication. Resident 22 was observed saying no while pointing to the two pills. LVN 3, called Resident 22 Poppa again but Resident 22 did not respond. LVN 3 stated she will contact a staff member to interpret and explain the medication to Resident 22. LVN 3 stated the importance in having a translator who speaks Spanish can help explain the type of medications, side effects, benefits, can answer questions in the resident's native language.

Based on observation, interview and record review, the facility failed to conduct monthly Medication Regimen Review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) of one of five sampled residents' (Resident 50) medical record. This failure had the potential for the facility to not identify irregularities, significant risks, or actual or potential adverse consequences which may result from or be associated with the resident's current medication. This failure had the potential to affect in maintaining the resident's highest practicable level of physical, mental and psychosocial wellbeing.Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes a person to have repeated seizures [abnormal electrical activity in the brain]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), transient ischemic attack (condition when blood flows to part of the brain is blocked for a short time), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 50's History and Physical (H&P) dated 8/12/2025, the H&P indicated Resident 50 had the capacity to understand make medical decisions. During a review of Resident 50's [NAME] Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 50 was able to understand and be understood by others. The MDS indicated Resident 50's cognition (ability to think and process) was intact. The MDS indicated Resident 50 required substantial assistance (helper does more than half the effort) from staff for activities of daily living and mobility. During a concurrent interview and record review on 5/21/26 at 9:28 a.m. with Registered Nurse Supervisor (RNS 1), Resident 50's medical record was reviewed. RNS 1 stated Resident 50's Medication Regimen Review was not conducted in January 2026, February 2026, March 2026, and April 2026 for the Fluoxetine (medication for depression) 30 milligram (mg, metric unit of measurement, used for medication dosage and/or amount), Trazadone (medication for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] insomnia and depression) 50 mg, Risperidone (medication for mood disorder and for extreme fear) 1mg, and Risperdal (a medication for psychosis and mood disorder) 0.5mg. RNS 1 stated Resident 50's antipsychotic medications should have been reviewed by the Pharmacy Consultant to ensure gradual dosage reduction (GDR) was discussed, medication dosage was therapeutic (helps a person heal, recover, or feel better physically, mentally, or emotionally), behaviors laboratory levels were monitored to ensure efficacy (a measure of how effective something is doing and what it is supposed to do) of the medications. During a review of the facility's policy and procedure (P&P) titled, IIIA1a: Medication Regimen Review (Monthly Report), dated 6/2021, the P&P indicated the facility is committed to evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. The P&P indicated the consultant pharmacist reviews the MRR of each resident at least monthly, or a more frequent MRR may be deemed necessary if the medication regimen is thought to contribute an acute change in condition or adverse consequence, and recommendations are acted upon and documented by the facility staff and / or the prescriber.

Based on interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for five (5) of 5 sampled residents (Residents 59, 1, 22, 50 and 92), by failing to ensure a comprehensive care plan was developed and implemented for:Resident 59's peripheral intravenous (IV) catheter (a thin, flexible tube inserted into a peripheral vein [small vein] to administer IV fluids and medications).Resident 1's heparin (blood thinner medicine) medication.Resident 22's influenza vaccine (shots to prevent infections) refusal and a care plan to address the resident's psychosocial needs identified in the comprehensive assessment. Resident 50 and Resident 92, who refused to wear the facility's identification (ID) bands. This failure had the potential for Residents 59, 1, 22, 50 and 92 to not receive the care and services necessary for safety and the potential to affect in maintaining the highest practicable physical and psychosocial wellbeing.Findings: 1). During a review of Resident 59's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 59 had diagnoses including encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), History of infectious (capable of being spread from one organism to another, usually caused by germs like viruses, bacteria, or fungi entering the body) and parasitic diseases (an illness caused by an organism that lives on or inside another organism and gets its nutrients at the host's expense), Cerebral Infarction (a condition where blood flow to the brain is interrupted, leading to damage or death of brain cells) , Thrombocytopenia (a medical condition characterized by an abnormally low number of platelets in your blood), and Dementia (loss of thinking, remembering, and reasoning). During a review of Resident 59's Minimum Data Set (MDS- a resident assessment tool), dated 3/1/2026, the MDS indicated Resident 59's cognitive skills for daily decision making were severely impaired. Resident 59 was dependent on staff for eating, oral and toileting hygiene, bathing, upper & lower body dressing, and personal hygiene. During a review of the Care Plan Report, dated 3/16/2026, the Care Plan Report did not indicate any care plans for Resident 59's peripheral IV (PIV). During a review of the Resident 59's Order Summary Report, dated 5/11/2026, the Order Summary Report did not indicate an order to maintain or discontinue Resident 59's PIV and had no order for IV hydration. During a review on 5/21/2026 at 11:51 am, Resident 59's admission Orders, dated 5/11/2026 did not include an order for PIV care, use, or monitoring. During a concurrent interview and record review on 5/19/2026 at 2:30 p.m., at the Station 2 desk, with Registered Nurse Supervisor (RNS) 2, Resident 59's Care Plan Report dated 3/16/2026, was reviewed. RNS 2 stated Resident 59 had no care plan for the PIV upon admission to ensure the PIV site was monitored for infection, swelling or pain. RNS 2 stated if there was no care plan, there was a risk that care would not be provided to Resident 59. RNS 2 stated care plans are important to guide staff on what to assess and to achieve the goal of therapy. 2. During a review of Resident 1's Face Sheet, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated Resident 1's diagnoses included chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), dysphagia (difficulty swallowing), pneumonia (an infection/inflammation in the lungs) and encephalopathy (damage or disease that affects the brain). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/30/2026, the MDS indicated Resident 1's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 1 was dependent on staff members with Activities of Daily Living (ADLs). During a review of Resident 1's History and Physical form (H&P), dated 5/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's physician orders, dated 5/15/2025, the physician orders indicated Heparin Sodium 5000 units per milliliter, to inject 5000 international units subcutaneously two times a day for deep vein thrombosis (a serious condition characterized by the formation of a blood clot in a deep vein) prophylaxis. During a review of Resident 1's care plan, there was no care plan noted for Resident 1's Heparin medication. During a concurrent interview and record review, on 5/21/2026 at 11:05 a.m., with Registered Nurse 1 (RN 1), Resident 1's care plan for heparin was reviewed. RN 1 stated she did not see a care plan for Resident 1's heparin medication. RN 1 stated the risk for not initiating a care plan for the heparin use could result in not being able to monitor for any complications and/or not following the protocol for medications. 3). During a review of Resident 22's Face Sheet, the Face Sheet indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including epilepsy (a neurological disorder characterized by recurring, unprovoked seizures), anxiety (a feeling of fear and dread), and hypertension (HTN-high blood pressure). During a review of Resident 22's History and Physical (H&P), dated 7/22/2025, the H&P indicated Resident 22 had the capacity to make medical decisions. During a review of Resident 22's Minimum Data Set (MDS – a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 22's cognition (the ability to think and process information) was intact. The MDS indicated Resident 22 was independent (resident completes the activity by themselves) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). 3a) During a concurrent interview and record review on 5/20/2026 at 1:15 p.m. with the Director of Staff Development (DSD), Resident 22's medical record was reviewed. The DSD stated the Resident 22, speaks Spanish, did not have a care plan to address the resident's language and psychosocial needs. The DSD stated the interdisciplinary team (healthcare professionals who work together to plan, provide, and evaluate a resident's care) should have addressed and evaluated the care plan to ensure interventions are present to meet Resident 22's communication needs. 3b) During a review of Resident 22's physician order, dated 8/18/2023, the physician order indicated to administer influenza vaccine annually between October and March. During a concurrent interview and record review on 5/21/2026 at 10:37 a.m., with the Infection Preventionist (IP), Resident 22's immunization record for the 2025- 2026 influenza season was reviewed. The immunization record did not indicate Resident 22 received the annual influenza vaccine for the 2025 -2026 influenza season. The IP stated Resident 22's immunization record indicated the resident refused the influenza vaccine. The IP stated when a resident refuse the influenza vaccine, licensed staff should develop a comprehensive person-centered care plan with measurable interventions specific for the resident's needs. During a concurrent interview and record review on 5/21/2026 at 11:00 a.m., with the IP, Resident 22's care plan, dated 2025 to 2026, for influenza vaccine and/or influenza vaccine refusal was reviewed. The IP stated there was no care plan developed for Resident 22's influenza vaccine refusal. The IP stated Resident 22 should have an individualized care plan for influenza vaccine refusal, with interventions developed to guide nurses on how to provide education, monitor for continued refusal, and implement infection prevention measures as appropriate. The IP stated this failure had the potential to place Resident 22 at risk for influenza infection and related complications, including respiratory illness, dehydration, hospitalization, and increased risk of serious illness or death. 4. During an interview on 5/20/2026 at 8:15 a.m. with the Admissions Director (AD), the AD stated during rounds (routine checks made by a manager to observe residents, staff, and the environment to ensure safety, quality of care, and proper operations) on 5/8/2026, the AD observed Resident 50 and Resident 92 who were sitting on bed in their respective resident's room had no ID band. The AD stated Resident 50 and Resident 92 had refused to wear an ID band on the wrist but did not inform nursing staff or Social Services regarding the resident's refusal. The AD stated nursing should have been informed because an ID band was required as a patient identifier for medication administration and treatments. Social Services should have been notified for alternatives, document the refusal, and develop a comprehensive plan of care for accurate resident identification, timely delivery of care address resident's preferences and respected while reducing the risk of error. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes a person to have repeated seizures [brain sends abnormal electrical signals causing shaking, staring spells, confusion, loss of awareness, or unusual movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), transient ischemic attack (condition when blood flows to part of the brain is blocked for a short time), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 50's History and Physical (H&P) dated 8/12/2025, the H&P indicated Resident 50 had the capacity to understand make medical decisions. During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 50 was able to understand and be understood by others. The MDS indicated Resident 50's cognition (ability to think and process) was intact. The MDS indicated Resident 50 required substantial assistance (helper does more than half the effort) from staff for activities of daily living and mobility. During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 92's diagnoses included encephalopathy (a condition where the brain is not working normally because it has been affected by an illness, injury, infection, lack of oxygen, or problems with the body's organs), emphysema (a lung disease that damages the lungs and makes it difficult to breathe), hypertension (HTN, high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 92's H&P dated 12/19/2025, the H&P indicated Resident 92 does not have the capacity to understand and make decisions. Resident 92 was able to make decisions for activities of daily living. During a review of Resident 92's MDS, dated [DATE], the MDS indicated Resident 92 was able to understand and be understood by others. The MDS indicated Resident 92's cognition (ability to think and process) was intact. The MDS indicated Resident 92 used a walker and wheelchair and require supervision or touching assistance (helper provides verbal cues and/or touching) may be provided from staff for activities of daily living and mobility. During a concurrent interview and record review on 5/20/26 at 1:34 p.m. with Registered Nurse Supervisor (RNS 1), Resident 50's medical record was reviewed. RNS 1 stated there was no documentation by Social Services Director (SSD), the Minimum Data Set Coordinator Director (MDS), and nursing about Residents 50 and 92's refusal to wear an ID band. RNS1 stated the importance of knowing if a resident refuses wearing an ID band can lead to medication administration errors, treatment and procedure errors, delay in care, and lack of consistent staff approach. During an interview on 5/20/2026 at 8:55 a.m. with the SSD, the SSD stated she was not informed of Residents 50 and 92's refusal to wear an ID band. The SSD stated when informed of a residents' refusal to wear an ID band, the SSD meets with the resident to explain the benefits and identify an alternative method to identify the resident. The SSD stated the residents' refusal is discussed during the plan of care meeting and documented in the progress notes in the resident's medical record. During an interview on 5/20/2026 at 9:00 a.m. with the MDS, the MDS stated she did not update Residents 50 and 92's care plan regarding the resident's refusal to wear an ID band on 5/8/2026 and was updated on 5/19/2026. The MDS stated that when a resident does not wear an ID band, it creates safety concern because staff may misidentify the resident, which can lead to medication administration errors, treatment errors and an incomplete plan of care. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person- Centered, revised 3/2023, the P&P indicated the facility should develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment.

Based on interviews and record reviews, the facility failed to ensure care plans for two of ten residents (Resident 41 and Resident 58) were reviewed and updated quarterly as indicated in the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Plans.This failure had the potential to affect the residents' care and interventions to address the problems will not be implemented.Findings: 1). During a review of Resident 41's Face Sheet, the Face Sheet indicated Resident 41 had chronic respiratory failure (long-term, ongoing condition where the lungs cannot properly exchange oxygen and carbon dioxide), history of pneumonia (an infection that inflames the air sacs in one or both lungs), and a tracheostomy (surgical opening in the neck airway to establish airway). During a review of Resident 41's History & Physical (H&P), dated 3/14/2026, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 41 was dependent on staff for personal hygiene, toileting hygiene, bathing, rolling left to right and back, and getting dressed. During a review of Resident 41's Care Plan Report titled, Respiratory Care, initiated on 10/11/2022, the care plan was last revised on 7/1/2024 and had a target date of 6/24/2026. 2). During a review of Resident 58's Face Sheet, the Face Sheet indicated Resident 58 was admitted to the facility on [DATE], with diagnoses including schizophrenia (a chronic, severe brain disorder that causes people to interpret reality abnormally, often resulting in hallucinations, delusions, and disorganized thinking) and dementia (loss of thinking, remembering, and reasoning). During a review of Resident 58's H&P dated 9/7/2025, the H&P indicated Resident 58 does not have the capacity for medical decision making due to mild cognitive (mental processes involved in knowing, learning, and understanding) impairment of uncertain or unknown etiology (the cause, set of causes, or origin of a disease or condition). During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had moderate cognitive impairment. The MDS indicated Resident 58 was dependent on staff for eating, personal hygiene, upper/lower body dressing, and rolling left to right in bed. During a review of Resident 58's Care Plan Report, the report indicated the following: The care plan titled, Behaviors. Alteration in behavior patterns, initiated on 6/12/2024, was last revised 4/3/2025. The care plan had a target date of 6/14/2026. The care plan titled, GT Feeding. At risk for aspiration, dehydration, weight fluctuation, nausea and vomiting, abdominal distention, intolerance to feeding and GT site infection, initiated 4/3/2025, was last revised on 1/20/2026. The care plan had a target date of 6/14/2026 During an interview on 5/21/2026 at 1:32 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated care plans should be updated/ revised every three months, upon admission and readmission to provide continuity of care. If there were increase in resident's behavioral episodes, or residents' behaviors were resolved, the care plan should be updated of the resident's current condition. If care plans were not updated of the resident's current condition, resident care will be affected and will not be addressed. During a concurrent interview and record review on 5/21/2026, at 2:06 p.m., with the MDS Coordinator, Resident 41's care plan titled Respiratory Care, initiated on 10/11/2022, last revised 7/1/2024 with a target date of 6/24/2026 and Resident 58's care plans titled Behaviors. Alteration in behavior patterns, initiated 6/12/2024, last revised 4/3/2025, with a target date of 6/14/2026 and GT Feeding. At risk for aspiration, dehydration, weight fluctuation, nausea and vomiting, abdominal distention, intolerance to feeding and GT site infection, initiated 4/3/2025, last revised 1/20/2026 with a target date of 6/14/2026 were reviewed. The MDS Coordinator stated Resident 41's and Resident 58's care plan were not updated quarterly. The MDS coordinator stated if the residents' care plans were not updated, the residents' plan of care and appropriate interventions would be affected. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Plans, dated 3/2022, the P&P indicated, the interdisciplinary team should review and update the care plan at least quarterly.

Based on observation, interview and record review, the facility failed to ensure effective communication services and language assistance were provided to one of five sampled residents (Resident 22). This deficient practice had the potential to prevent accurate communication between Resident 22 and facility staff, resulting in unmet needs, delayed intervention, and increased risk for resident harm. Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes a person to have repeated seizures [brain sends abnormal electrical signals causing shaking, staring spells, confusion, loss of awareness, or unusual movements), hypertension (HTN, high blood pressure), dysphagia (difficulty swallowing), and anxiety disorder (a condition where a person feels very worried, nervous, or fearful more often and more strongly than normal). During a review of Resident 22's History and Physical (H&P) dated 7/22/2025, the H&P indicated Resident 22 had the capacity to make medical decisions. During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 22 was able to understand and be understood by others. The MDS indicated Resident 22's cognition (ability to think and process) is intact. The MDS indicated Resident 22 used a walker and wheelchair and required moderate assistance (helper does less than half the effort) from staff for activities of daily living and mobility. During a concurrent observation and interview on 5/19/2026 at 9:13 a.m. with Licensed Vocational Nurse (LVN) 3, the LVN 3 was arguing with Resident 22 to take blood pressure medication. Resident 22 was saying no, while pointing to the two pills. LVN 3 stated that she (LVN3) understands Spanish and Resident 22 understands English. Resident 22 stated in Spanish to the LVN he does not recognize the two pills. LVN 3 stated she did not understand what Resident 22 said. Resident 22 did not respond to LVN 3. LVN 3 stated she will contact a Spanish speaking staff member to interpret. The Spanish speaking staff member interpreted and explained the medications to Resident 22. LVN 3 stated it was important to have a translator who speaks Spanish to help answer questions, explain to the Spanish speaking resident (Resident 22) the type of medications, side effects, and the benefits in the language Resident 22 understands. During an interview an interview on 5/21/2026 at 10:14 a.m. with the Director of Nursing (DON), the DON stated she was not aware LVN 3 was not utilizing the facility's resources to communicate to residents who speak Spanish. The DON stated Social Services provides a communication board. The DSD conducts staff training on the available resources such as an in-house interpreter, and a phone application to assist staff to interpret. The DON stated that when staff do not use the facility's resources, it can compromise the resident's ability to communicate choices and concerns which can violate a resident's rights to dignity and self-determination. During a record review of the facility's policy and procedure (P&P) titled, Policy: Accommodation of Needs Related to Communication Deficits, undated, the P&P indicated the facility is committed to identifying communication needs and appropriate interventions. The facility will assess the communication needs of residents by means of a psychosocial assessment form to identify language spoken, and a care plan will be developed, updated quarterly and as indicated to reflect accurate, current assessments related to communication needs.

Based on interview and record review, the facility failed to ensure pain medication one of seven sampled residents (Resident 11), were available and did not miss four doses of scheduled pain medications.This deficient practice had the potential to result in the resident not receiving pain medicine timely, pain not being managed and placing the resident at risk for severe pain, including hospitalization.Findings: During a review of Resident 11's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 11 was initially admitted on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included colon cancer (a disease where cells in the large intestine grow out of control and form tumors), polyneuropathy (a medical condition where many nerves outside the brain and spinal cord (the peripheral nerves) are damaged at the same time), chronic pain syndrome (persistent pain lasting longer than 3 to 6 months) and sepsis (a life-threatening blood infection).During a review of Resident 11's History and Physical form (H&P), dated 8/18/2025, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 11's cognitive (thinking) skills were cognitively intact. The MDS indicated Resident 11 required substantial assistance from staff members with Activities of Daily Living (ADLs). During a review of Resident 11's current physician orders, the physician orders indicated the following:Administer Suboxone 8-2 milligrams (mg, a unit of measurement), sublingually (under the tongue) two times a day (9:00 a.m. and 6:00 p.m.) for chronic pain syndrome. Administer Pregabalin 25 mg three times (10:00 a.m., 2:00 p.m. and 10:00 p.m.) by mouth for chronic neuropathic pain. During a review of Resident 11's electronic MAR for the months of April and May 2026, the MAR indicated on 4/16/2026 and 4/25/2026, Resident 11 did not receive 10:00 a.m. and 2:00 p.m. doses of Pregabalin 25mg and the 2:00 p.m. dose on 5/1/2026. During a review of Resident 11's progress notes, dated 4/16/2026 and 4/25/2026, the progress note indicated Resident 11 did not receive the Pregabalin 25mg because the medication was unavailable. The facility was waiting for delivery from the pharmacy. During a review of Resident 11's electronic Medication Administration Review (MAR-an official, legal document used in healthcare facilities to track all the drugs administered to a patient) for the month of 5/2026, the MAR indicated on 5/11/2026, Resident 11 did not receive the 6 p.m. dose of Suboxone. During a review of Resident 11's progress notes, dated 5/18/2026, the progress note indicated Resident 11 did not receive the 6 p.m. dose of Suboxone. The progress notes indicated Suboxone was unavailable and the facility was waiting for pharmacy delivery. During a concurrent interview and record review, on 5/21/2026 at 11:25 a.m., with Registered Nurse 1 (RN 1), RN 1 stated if there's a new physician's order of pain medication, the facility will notify the pharmacy. RN 1 stated the facility protocol is that if a resident ran out of pain medications and the resident was in pain, the licensed nurse should call the pharmacy to obtain code to open the facility's emergency kit. RN 1 stated when Resident 11's pregabalin was not available and not administered to Resident 11 for 4 doses, the e-kit was not opened. The pregabalin was not administered to Resident 11 for 4 doses. RN 1 stated pain medications should have been refilled a week prior to running out. RN 1 stated the risk of not refilling routine pain medications prior to running out could result in a resident to suffer unrelieved pain and emotional. During a review of the facility's policy and procedures (P&P), titled Pain Management, dated 3/2023, the P&P indicated drugs and biologicals that are required to be refilled, must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for three of three sampled residents (Residents 103, 41, and 54) by failing to ensure:1). Humidifier bottles (devices used with oxygen to add moisture to the oxygen being delivered, enhancing comfort and effectiveness during oxygen therapy) and oxygen tubings were dated when changed. 2). Resident 54, who had a tracheostomy (a surgical opening in the neck for an airway) tube and with mouth open, had a room free of flies.These failures had the potential to cause cross contamination and placed Residents 103, 41, and 54 at risk for infections.Findings: During an observation and interview on 5/19/2026 at 10:01 a.m., in Residents 103 and 41's room, with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the residents' humidifier bottles and tubing were not dated. RNS 2 stated if the humidifier bottle and tubing were not dated, the facility staff would not know when to change them. RNS 2 stated the humidifier bottles and tubing should be changed weekly. If they are not changed, organisms could grow and the resident could be at risk for an infection. a). During a review of Resident 103's Face Sheet, the Face Sheet indicated Resident 103 had the diagnoses of sleep apnea (temporary suspension of breathing), diaphragmatic hernia (condition in which abdominal organs push through an abnormal opening in the diaphragm into the chest cavity, potentially impairing lung development and function) and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures). During a review of Resident 103's History & Physical (H&P), dated 5/18/2026, the H&P indicated Resident 103 had the capacity to understand and make decisions. b). During a review of Resident 41's Face Sheet, the Face Sheet indicated Resident 41 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated Resident 41 had Chronic Respiratory Failure, history of pneumonia (lung infection), and a tracheostomy. During a review of Resident 41's H&P, dated 3/14/2026, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognitive skills for daily decision making was severely impaired. Resident 41 was dependent with staff for personal, oral hygiene, toileting hygiene, shower and bathing self, upper and lower body dressing, and in putting on/ taking off footwear. c). During a review of Resident 54's Face Sheet, the Face Sheet indicated Resident 54 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 54's diagnoses included chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy tube, gastronomy tube (a soft medical tube inserted directly through a small opening in the belly into the stomach) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 54's H&P dated 3/20/2026, the H&P indicated Resident 54 did not have the capacity to understand and make decisions. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 8 was dependent on staff with ADLs. During an observation, on 5/19/2026 at 10:39 a.m., in Resident 54's room, a housefly was observed in the room and landed on Resident 54's right hand and left side of the cheek near her mouth. Resident 54 who was non-verbal (unable to speak) and bedbound, was observed with mouth wide open, had a tracheostomy tube and gastronomy tube. During a concurrent observation and interview, on 05/20/2026 at 1:30 p.m., with the Respiratory Therapist 1 (RT 1), in the Conference Room, RT 1 confirmed a housefly was observed flying around the conference room. RT 1 stated houseflies were known to carry bacteria, viruses and potential parasites and had the potential to cause infections to residents with tracheostomy and gastronomy tubes by laying eggs, causing maggots to form in the openings. During a review of the facility's policy and procedures (P&P), titled Policies and Practices- Infection Control, dated 10/2018, the P&P indicated the facility should maintain a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. During a review of the facility's policy and procedures (P&P), titled Pest Control, dated 5/2008, the P&P indicated the facility should maintain an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained to keep the peripheral intravenous (PIV) line, of one of ten residents (Resident 59), and ensure the IV dressing was dated.This failure placed the resident at risk for IV site infection.Findings:During a review of Resident 59's Face Sheet, the Face Sheet indicated Resident 59 had diagnoses including encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of infectious and parasitic diseases (illnesses caused by organism that lives in or on an organism of another species (its host) and benefits by deriving nutrients at the other's expense), cerebral infarction (stroke), thrombocytopenia (a condition characterized by an abnormally low number of platelets in the blood) and dementia (a progressive state of decline in mental abilities). During a review of Resident 59's Minimum Data Set, MDS, dated [DATE], the MDS indicated Resident 59's cognitive (mental processes involved in knowing, learning, and understanding) skills for daily decision making was severely impaired. Resident 59 was dependent on staff's assistance for eating, oral and toileting hygiene, bathing, upper & lower body dressing, and personal hygiene. During a review of Resident 59's Order Summary Report, dated 5/11/2026, the Order Summary Report did not indicate an order to maintain or discontinue Resident 59's PIV. Resident 59 did not have a physician's order for IV infusions. During an observation on 5/19/2026 at 10:41 a.m., in Resident 59's room, Resident 59 was observed with a PIV on the right hand, with an undated IV dressing. During a concurrent observation and interview on 5/19/2026 at 1:39 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 59's room, LVN 1 stated Resident 59's PIV dressing was not dated. LVN 1 stated the licensed staff should monitor the PIV site for signs of infiltration, skin discoloration due to the risk of infection. During an observation and interview on 5/19/2026 at 2:27 p.m., with RNS 1, Registered Nurse Supervisor (RNS 1), RNS 1 stated it was important to know when the IV dressing was changed to prevent an infection. During a review of the Medication Administration Record (MAR), for the month of 5/2026, the MAR indicated Resident 59 completed the order of Dextrose with Sodium Chloride Intravenous Solution 5-0.45% started 5/5/2026, on 5/7/2026. The MAR indicated checking the IV site every shift was discontinued on 5/8/2026. During an interview on 5/22/2026 at 11:31 a.m. with the DON, the DON stated facility staff should have obtained a physician's order to keep the PIV, assess and to monitor for signs of infections. During a review of the facility's policy and procedure (P&P) titled, General Policies for IV Therapy, dated 3/2023, the P&P indicated IV peripheral sites will be rotated when clinically indicated (e.g. unresolved complication, discontinuation of infusion therapy or when no longer necessary for the plan of care). Dressing change is performed at least every 7 days and when needed.

Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 4) an accusation of sexual abuse was reported within two hours. This deficient practice of not reporting the accusation of sexual abuse by Resident 4 had the potential to cause psychosocial harm (factors that could harm someone ' s mental health). Findings: During a review of Resident 4 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 4 diagnoses dementia (a progressive state of decline in mental abilities), depressive disorder (a mental condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that can significantly impair daily functioning), and transient cerebral ischemic attack (a lack of blood flow to the brain). During a review of Resident 4 ' s History and Physical (H&P), dated 6/4/2024, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4 ' s Minimum Data Set ([MDS]- a resident assessment tool), dated 5/9/2025 the MDS indicated Resident 4 ' s cognition (ability to learn, reason, remember, understand, and make decisions) had the ability to understand. The MDS indicated Resident 4 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. During a review of facility ' s Social Services Notes, dated 5/16/2025, the Social Services Notes indicated Centinela Hospital Social Worker called to notify that resident reported she had been sexually assaulted at the facility. During a concurrent interview and record review on 5/21/25 at 1:49 p.m. with Social Service Director (SSD), Resident 4 ' s Social Services Notes were reviewed. The Social Services Notes indicated Centinela Hospital Social Worker called to notify that resident reported she had been sexually assaulted at the facility. The SSD stated the Social Worker from Centinela Hospital Social Worker had called and told her Resident 4 had stated she was sexually assaulted at the facility. The SSD stated when Resident 4 had returned on 5/20/2025 I had asked her was she sexually abused and she had said Yes,. The SSD stated accusation of sexual assault is considered abuse. The SSD stated she was a mandated reporter when there was an accusation of sexual abuse. The SSD stated she did not notify the Administrator when she had received the call from Centinela Hospital about the sexual allegation. The SSD stated that when there is an abuse allegation we are to report within two hours even if the resident is confused, start the investigation, and take care of Resident 4 as fast as possible. The SSD stated not initiating the investigation sooner could make Resident 4 feel dismissed and cause psychological harm. During an interview on 5/21/2025 at 4:00 p.m. with the Administrator (ADM), the ADM stated the staff is to report Abuse of any kind. The ADM stated the process is to report anytime the staff suspects, hears anything, and they are to report within 2 hours. The ADM stated it was important to report within 2 hours to prevent the behavior from continuing which could cause more abuse. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 3/2023, the P&P indicated all reports of resident abuse findings of all investigations are documented and reported. The P&P indicated abuse was suspected it must be reported immediately to the administrator and to other officials. The P&P indicated immediately is defined as within two hours of an allegation involving abuse.

Based on record review and interview, facility licensed staff failed to ensure the Medical Director (a licensed physician who oversees and manages the medical aspects of a healthcare organization or facility) was notified after licensed staff could not reach the primary physician for one out of three sampled residents (Resident 1). This deficient practice resulted in facility staff had to call 911 to transport the resident to the General Acute Care Hospital (GACH) . Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (COPD, a chronic lung disease causing difficulty in breathing), obstructive uropathy (refers to any condition where the normal flow of urine is blocked or impeded within the urinary tract), and anemia (a condition where the body doesn ' t have enough healthy red blood cells). During a review of Resident 1 ' s History and Physical (H&P), dated 4/22/2025, the H&P indicated Resident 1 did not follow commands, was non-responsive (a patient who is not reacting or responding to external stimuli, such as verbal commands, touch or pian, and non-verbal (communication that conveys messages without using spoken or written words and involves facial expression). During a review of Resident 1 ' s change of conditions (COC) interact assessment form, dated 4/26/2025, the COC indicated at 8:00 p.m. Resident 1 had no significant urine output and to transfer the resident tothe GACH. The COC indicated GACH had no available beds. The COC indicated at 10:00 p.m. the physician was made aware with no reply. The COC indicated Resident 1 blood pressure ([BP] -the force of circulating blood on the walls of the arteries) was 118/72 millimeters of mercury ([mm/hg] -a unit of pressure commonly used to measure blood pressure). During a review of Resident 1 ' s COC, dated 4/27/2025, the COC indicated Resident 1 had hematuria (the presence of blood in the urine) with reduced urine output and an order from the physician to transfer resident to the GACH. The COC indicated Resident 1 could not be transferred to GACH and 911 was called at 8:27 a.m. The COC indicated at 8:38 a.m. the physician was informed of the changes in the transfer plans but no response. The COC indicated the BP was 103/60mmhg. During a review of Resident 1 ' s Minimum Data Set (MDS] a resident assessment tool), dated 5/12/2025 the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 1 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 1 had an indwelling catheter (a medical device used to drain urine from the bladder and allow it to flow into a collection bag). During a concurrent interview and record review on 5/19/2025 at 4:14 p.m. with Director of Nursing (DON), Resident 1's COC, dated 4/26/2025 and 4/27/2025 was reviewed. The COC dated 4/26/2025 indicated the COC indicated at 8:00 p.m. Resident 1 had no significant urine output and transferred the resident to the GACH. The COC form indicated the GACH had no available beds. The COC indicated at 10:00 p.m. the physician was made aware with no reply. The COC dated 4/27/2025 indicated Resident 1 had hematuria with reduced urinary output and an order from the physician to transfer resident to the GACH. The COC indicated Resident 1 could not be transferred to the GACH and 911 was called at 8:27 a.m. The COC indicated at 8:38 a.m. the physician was informed of the changes in the transfer plans but no response. The DON stated Resident 1 had hematuria in the urine and it was considered a change of condition. The DON stated the physician did not return the licensed staff call on 4/26/2025 p.m. and on 4/27/2025. The DON stated that when the physician did not return our calls the next step was to call the Medical Director. The DON stated the Medical Director was not called from 10:00 p.m. to 8:27 a.m. and there was a lot that could have happened; the resident could have been bleeding from somewhere in the body. The DON stated 911 was called because the physician did not return our call, and the blood pressure had dropped from 118/72 mm/hg to 103/60 mm/hg. During a telephone interview on 5/20/2025 at 2:25 p.m. with the Medical Director, the Medical Director stated staff should have called him if the primary physician did not return their call. The Medical Director stated the facility can call anytime of the day or night if the physician does not call back. The Medical Director stated the facility needed to have followed the protocol once the physician had not returned their call and the resident is not doing well. During a review of facility ' s policy and procedures (P&P) titled, Change of Condition, date unknown, the P&P indicated the facility is to ensure proper assessment and follow through for any resident with change of condition. The P&P indicated upon a change of condition for any reason, nursing staff members are to take the following if for some reason physician cannot be reached, alternative physician shall be contacted. The P&P indicated if alternate cannot be reached, the Medical Director is to be contacted.

Based on observation and interview, the facility failed to ensure three dumpsters (trash container) were kept closed. This deficient practice had the potential to result in rodents and insects being attracted to the facility and cause contaminations and infections. Findings: During a concurrent observation and interview on 4/1/2025 at 8:41 a.m. with the [NAME] in the parking lot, three dumpsters were noted with the lids off. The [NAME] stated the dumpsters should be closed to prevent possible contamination. The [NAME] stated if there were food inside it could attract animals. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated dumpsters should be kept closed and free of surrounding litter. Dumpsters must be kept covered when stored or not in continuous use.

Based on observation and interview, the facility failed to ensure the juice connectors for the apple, grape, and pineapple juice was free of sticky residue. This deficient practice had the potential to result in cross contamination (movement of bacteria from one place to another) in the kitchen. Findings: During a concurrent observation and interview on 4/2/2025 at 9:20 a.m. with the Dietary Supervisor (DS), the connectors for the apple, grape, and pineapple juice was observed with a sticky substance. The DS stated the connectors contained dust and sticky residue that can cause cross contamination resulting in infection. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated food services staff should maintain clean food storage areas. Non-refrigerated foods should be kept clean.

Based on observation, interview, and record review, the facility failed to: 1). Ensure expired one opened bottle of vitamin B1 (one of the B vitamins) medication was not kept in the medication cart 1. This deficient practice had the potential to result in administering expired medication to the residents with orders. 2). Label with an opened date, the Ipratropium with Albuterol Solution (a combined inhalation solution to treat and prevent shortness of breath) pouch in medication cart 1 for Resident 33, that had a pharmacy fill date of 7/3/2024. 3). Ensure expired one pouch of Ipratropium with Albuterol Solution for Resident 83 was not kept in medication cart 1. These failures had the potential for the affected residents to receive expired medications. These failures placed the medications at risk of bacterial growth and less potent, which can fail to treat shortness of breath and chest congestion for Resident 33 and Resident 83's shortness of breath or wheezing, when needed. Findings: 1). During a concurrent observation and interview on 4/2/2025 at 11:08 a.m., of the medication cart one with Licensed Vocational Nurse 2 (LVN 2), found one opened bottle of expired vitamin B1. LVN 2 stated the vitamin B1 was labeled with an opened date on 3/23/2025 and the expiration date printed on the bottle was 2/25/2025. LVN 2 stated it was the responsibility of the licensed nursing staff to check the expiration date of all the medications in medication cart 1. LVN 2 stated giving expired medication to residents could cause poison and untoward side-effects (an effect of the drug beyond its desired effect). 2). During a review of Resident 33's Admission Record, the Admission Record indicated, Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included respiratory failure (a medical condition that makes it difficult to breathe on your own), dysphagia (difficulty of swallowing), and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement. During a review of Resident 33's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/23/2025, the MDS indicated, Resident 33's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 33 was totally dependent (helper does all of the effort) from staff with toileting hygiene, upper/lower body dressing, and personal hygiene. During a review of Resident 33's Order Summary Report, dated 4/2/2025, the Order Summary Report indicated an order of Ipratropium with Albuterol Solution 0.5-2.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount)/ 3 milliliter ([ml] - unit of volume), inhale orally every 4 hours as needed for shortness of breath and chest congestion. During a concurrent observation and interview on 4/2/2025 at 11:09 a.m., of the medication cart 1 with LVN 2, observed one opened and expired ipratropium with albuterol inhalation foil pack for Resident 33 stored at room temperature. The opened foil pack was not labeled with a date. LVN 2 stated the ipratropium with albuterol solution for Resident 33 indicated a pharmacy fill date of 7/3/2024. LVN 2 stated it was unknown at this time when the ipratropium with albuterol solution foil pack for Resident 33 was opened since it was unlabeled. LVN 2 stated each medication has a specific date on how long it would be effective. LVN 2 stated she will dispose immediately the unlabeled ipratropium with albuterol solution for Resident 33. 3). During a review of Resident 83's Admission Record, the Admission Record indicated, Resident 83 was admitted to the facility on [DATE]. Resident 83's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), hypertension ([HTN] - high blood pressure) obstructive sleep apnea (a sleep disorder where the airway collapses during sleep, leading to pauses in breathing), and muscle weakness. During a review of Resident 83's MDS, dated [DATE], the MDS indicated, Resident 83's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 83 required substantial assistance (helper does more than half the effort) from staff with oral hygiene and personal hygiene. During a review of Resident 83's Order Summary Report, dated 4/2/2025, the Order Summary Report indicated an order of Ipratropium with Albuterol Solution 0.5-2.5 mg/3 ml to inhale orally every 6 hours as needed for shortness of breath or wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs). During a concurrent observation and interview on 4/2/2025 at 11:14 a.m., of the medication cart 1 with LVN 2, observed one opened and expired ipratropium with albuterol inhalation foil pack for Resident 83 stored at room temperature. LVN 2 stated the ipratropium with albuterol solution for Resident 83 indicated a pharmacy fill date of 1/17/2025. LVN 2 stated the ipratropium with albuterol inhalation foil pack for Resident 83 was opened on 2/25/2025. LVN 2 stated giving expired medication would affect the potency of the medication and no longer be effective to the resident. During a review of the facility's policy and procedure (P&P), titled Labeling of Medication Containers, dated 4/2019, the P&P indicated, all medications maintained in the facility should be properly labeled in accordance with current and federal guidelines and regulations. During a review of the facility's P&P, titled Storage of Medications, dated 3/2023, the P&P indicated, the facility should store all drugs and biologicals in a safe, secure, and orderly manner. The P&P indicated, discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destructed as indicated. During a review of the ipratropium with albuterol inhalation solutions manufacturer's instructions for storage and labeling, indicated that opened foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 and 77 degrees Fahrenheit and used or discarded within two weeks of opening the foil cover.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 52) had a call light (call bell) device within easy reach. This deficient practice had the potential to result in the resident being unable to alert health care workers for assistance for activities of daily living and care needs. Findings: During a review of Resident 52's Admission Record (Face Sheet), indicated the facility readmitted the resident on 3/29/2025 with diagnoses including functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and unspecified dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS - (a resident assessment tool), dated 2/7/2025 indicated Resident 52 had functional limitation in range of motion in both upper extremities. During a review of Resident 52's care plan report, initiated on 3/31/2025 indicated the following goals: assistance in calling for help, in being kept clean, dry, and odor free by placing the call light device within easy reach. The care plan report indicated interventions including: call light should be within easy reach of the resident for staff to know when to assist the resident with activities of daily living/self-care and to notify staff of hygienic needs. During an observation on 4/1/2025 at 10:24 a.m., Resident 52 was not able to access the call light device, which had fallen between the bed mattress and the upper left side rail. During a concurrent observation and interview, on 4/1/2025 at 10:31 a.m., there was no visible call light device within the resident's reach. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 4 entered Resident 52' room and found the call bell device between the bed mattress and the upper left side rail. During an observation on 4/2/2025 at 2:21 p.m., in Resident 52's room, the call light device was pinned to the upper right side of the resident's pillow. Resident 52 stated the call light device was not within reach. During a concurrent interview and observation on 4/2/2025 at 2:27 p.m., Licensed Vocational Nurse (LVN) 2 stated Resident 52 could not reach the call light device. LVN 2 stated when the call light was not within reach, the resident will not be able to contact staff for help when needed. During a review of the facility's policy and procedure (P&P), Answering the Call Light, undated, indicated Ensure that the call light is accessible to the resident when in bed or wheelchair in room, from the toilet or shower room if necessary.

Based on interview and record review, the facility failed to ensure the use of an anti-psychotic (a class of drug used to treat mental health conditions) medication was accurately documented in the Minimum Data Set ([MDS] a resident assessment tool) for one of eight sampled residents (Resident 38). This deficient practice resulted in Resident 38's inaccurate medical condition submitted to the Centers for Medicare/Medicaid Services (CMS). Findings: During a review of Resident 38's Admission Record, the Admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 38's History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 38 had the capacity to make decisions for activities of daily living. During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 was dependent on staff for toileting and bathing. The MDS indicated Resident 38 was not taking any anti-psychotic medication. During a review of Resident 38's Order Summary Report for April 2025, the order summary report dated 11/15/2024, indicated Risperdal (an anti-psychotic medication) to be given for schizoaffective disorder. During a concurrent interview and record review on 4/3/2025 at 12:26 p.m. with the Minimum Data Set Nurse (MDSN), Resident 38's MDS was reviewed. The MDSN stated the MDS did not indicate Resident 38 was taking any anti-psychotic medication. The MDSN stated Risperdal is an anti-psychotic. The MDSN stated it was important to document an accurate MDS assessments because this information goes to CMS and the MDS assessment drives the resident's plan of care and quality of care.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure one of three sampled residents (Resident 1) received adequate nutrition when the gastrostomy tube ((GT) tube placed inside the stomach to administer nutrition, water, and medications) was dislodged. This deficient practice resulted in Resident 1 not being fed, receiving water and/or medications via GT for 14 days and worsening pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) which required an admission to the general acute care hospital (GACH) for evaluation, treatment, blood transfusion and surgical debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of the pressure sore wounds. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 4/20/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 7/16/17, indicated the resident required total assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS, dated [DATE], indicated Resident 1 had a feeding tube, open [MEDICAL CONDITION] other than ulcers, rashes, cuts on the body, and was at risk of developing pressure ulcers. A review of Resident 1's Admission Assessment, dated 4/9/16, indicated the resident had pressure ulcers to the left hip measuring 3 by 3 centimeters (cm), right hip measuring 2 cm by 2 cm, left heel measuring 4 cm by 4 cm, left big toe measuring 3 cm by 3 cm, and the right lateral foot measuring 2 cm by 2 cm, none with any depth measurements. A review of Resident 1's care plan, dated 4/10/17, indicated the resident had altered skin integrity. Resident 1's goal was to provide and encourage adequate nutrition to promote wound healing. Another care plan, dated 4/13/17, indicated Resident 1 was receiving [MEDICATION NAME] (tube feeding) at 65 centimeters per hour (cc/hr) for twenty hours a day. The goal was that Resident 1 would have adequate nutrition and decreased risk for weight loss. A review of Resident 1's Dehydration Risk Assessments, dated 4/10/17 and 10/10/17, indicated the resident had a score of 40. The assessment indicated a score of 25-49 was a moderate risk for dehydration (a harmful reduction in the amount of water in the body). A review of Resident 1's physician order, dated 4/8/17, indicated the resident was to have medications crushed and administered via the [DEVICE]. The physician's orders [REDACTED]. A review of Resident 1's Interdisciplinary Team ((IDT) group of disciplines working towards a common goal for a resident) Note, dated 10/24/17, indicated the resident's GT dislodged and the stoma (surgical opening) site was breaking down. The physician assistant (PA) for a wound care company suggested for the resident to have a new GT site placement. The IDT Team also had concerns that Resident 1 was at risk for osteo[DIAGNOSES REDACTED] (bone infection), poor wound healing and lack of nutrition. The resident's physician was notified, but she refused to order hospitalization for a new GT site replacement. A review of Resident 1's physician's orders [REDACTED]. There was no time frame written and there was no order for any other nutritional supplements. A review of a Surgical Consult Note, dated 10/31/17, indicated Resident 1's GT was dislodged and the primary physician did not reorder a replacement. A review of a [MEDICATION NAME] ((GI) physician who specialized in the study of the throat, intestines stomach and anus) Patient Note, dated 11/7/17, indicated Resident 1 was sent for a consultation regarding placement of the GT, since Resident 1 had not received GT feeding for a week. Another GI Patient Note, dated 11/14/17, seven days later, indicated Resident 1 was to have the GT replaced, but needed a consent for the procedure. A review of Resident 1's laboratory (lab) records, from 10/4/17 through 10/10/17, indicated Resident 1's potassium (K) level was low at 3.3 (normal reference range (NRR) 3.5-5.5 mEq/L), BUN/Creatinine Ratio was elevated at 25.9 (NRR 10-20), Calcium level was low at 7.7 (NRR 8.6-10.3), pre-[MEDICATION NAME], which was an indication of the resident's nutritional status, was 5g/dl (NRR 17-34), hemoglobin was low at 6.1 grams per deciliter (g/dl) (NRR 13.7-17.5) and the hematocrit was low at 19.9 percent (%) (NRR 40.1-51.0) A review of the GACH's lab results, dated 11/10/17, indicated Resident 1's potassium level had dropped lower at 2.8 mEq/L, The resident's calcium had decreased to at 7.5 mg/dL and the [MEDICATION NAME] was low at 1.4 g/dl (NRR 3.4-5.0 g/dL), BUN/Creatinine Ratio 10, Troponin 0.56 Nano gram per milliliter (ng/mL), urine color was orange (normal= yellow), turbid (cloudy appearance) urine with protein (normal=clear without protein), BUN/Creatinine Ratio 21. There was no pre-[MEDICATION NAME] level indicated on the lab records. A review of Resident 1's emergency room (ER) physician's progress note, dated 11/10/17, indicated the resident was brought to theER on [DATE]. Resident 1 was assessed to be pale, sweaty, with bedsores ((pressure sores) no measurements provided) and abnormal lab results. The note indicated that the physicians had concerns regarding elder abuse. The physician's progress note indicated Resident 1 was emaciated (abnormally weak or thin due to illness or lack of food), frail and chronically ill looking. According to the ER note Resident 1 was to be admitted and placed on total [MEDICATION NAME] nutrition ((TPN) way of providing nutritional needs of the body through the veins and not through the stomach), and for possible surgical wound debridement of the wounds and a GT replacement. Another ER note, dated 11/10/17, indicated the resident's GT had not been used for food or medications for a week and Resident 1's pressure ulcers were foul-smelling. A GI note, dated 11/11/17, indicated the resident had a large open wound on the abdominal wall at the site of the previous GT requiring a surgical closure. A review of the GACH's progress note, dated 11/12/17, indicated the resident received a unit of packed red blood cells ((PRBCs) red blood cells that have been collected, processed, and stored in bags as blood product units available for blood transfusion purposes when blood count is low) and that the resident was unstable for transfer. The ER note also indicated that Resident 1 could not be fed through the feeding tube because it would leak out of the abdominal wall. A review of the GACH physician progress notes [REDACTED]. A review of the physician progress notes [REDACTED]. The note indicated that there was brown colored drainage from the previous GT site that was damaging Resident 1's skin. According to the GACH's progress note, dated 11/14/17, Resident 1 had a GT replaced through the existing abdominal site. On 11/16/17, at 8:15 a.m., during an interview and a concurrent record review, Registered Nurse 1 (RN 1) stated Resident 1's GT dislodged on 10/18/17 and the physician ordered the resident to have nothing by mouth (NPO) and a GI consult, but failed to indicate which GI physician would see the resident. According to RN 1, he called and scheduled a GI consult for Resident 1 on 11/7/17. RN 1 stated the resident remained NPO from 10/28/17 to 11/10/17, for 14 days, and was only receiving intravenous ((IV) through the vein) fluids infusing 50 centiliters of [MEDICATION NAME] (form of sugar) with sodium chloride (salt solution) ((D5 1/2 NS) a treatment for [REDACTED]. At 8:24 a.m. on 11/16/17, during a subsequent interview, RN 1 stated Resident 1 went for a GI consult on 11/7/17, but his GT was not replaced. RN 1 stated the resident was scheduled for GT placement on 11/14/17 and the GI specialist was made aware the resident remained NPO. RN 1 stated Resident 1's lab results indicated a low Hgb and Hct at 6.1/19.9, but the physician initially refused transferring the resident to the hospital. RN 1 stated that the facility's Director of Nursing (DON) insisted for the resident to be transferred to the hospital before the physician gave the orders. RN 1 stated the physician was aware that Resident 1 was scheduled to have a GT placement on 11/14/17 and that the resident remained NPO. RN 1 also stated that he should have convinced the physician to transfer Resident 1 to the hospital sooner. On 11/16/17 at 9:16 a.m., during an interview, the DON stated the PA recommended for Resident 1 to go to the hospital where a GI consult and insertion could be done, but the physician refused to order the hospital transfer. The DON stated she told the physician that the resident was only receiving IVF (intravenous fluids) and needed some nutrients. The DON stated since the physician continued to refuse a transfer to the GACH, she told the physician that she was going to call the facility's Medical Director for the resident to be transferred to the GACH. On 11/16/17 at 9:32 a.m., during an interview, the DON stated that she was upset because the resident went without food for many days and she was afraid the resident was going to die in the facility. On 11/16/17 at 9:42 a.m., during a telephone interview, the PA stated Resident 1's GT came out many times before and she stated the physician was resisting to order a transfer to GACH. On 11/16/17 at 11:36 a.m., during an interview, the facility's Administrator (ADM) stated that it was surprising the resident went for 14 days without food. He stated that he did not know the magnitude and he should have contacted the physician himself. On 11/16/17 at 11:58 a.m., during an interview, Resident 1's physician stated she was not aware Resident 1 was without GT feeding for 14 days. The physician stated that an alternative would be TPN, but the resident cannot be hospitalized just for TPN. According to the physician, the resident was being well hydrated with IVF, though not an ideal form of nutrition. On 11/16/17 at 1:54 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated a resident should not be left on IVF without feeding for more than 12 hours because of the risk of dehydration and poor wound healing because of the lack of nutrients. A review of the facility's policy titled Dehydration Risk Assessment with a revision date of 1/24/17, indicated the facility would address resident's dehydration risk factors based on each residents' assessment. A review of the facility's policy titled Nutritional Risk with a revised date of 1/24/17, indicated the goal was to increase nutrient consumption without increasing food volume for residents with skin breakdown or other conditions, which increased calorie needs.

Based on observation, interview and record review, the facility failed to provide adequate supervision for Resident 3 by not preventing the resident who had a history of [REDACTED]. Resident 3 was diagnosed with [REDACTED]. As a result of this deficient practice Resident 3 sexually assaulted Resident 1, performed inappropriate sexual behavior toward Resident 2 and potentially exposed the residents to HIV. Findings: a. A review of Resident 3's admission records indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an uncompleted MDS dated [DATE] indicated Resident 3 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) with an impact on others that included, risk for physical injury, significant intrusion on the privacy of others and significantly disrupt care of living environment. A review of Resident 3's physician order [REDACTED]. A review of Resident 3's admission assessment dated on September 16, 2016 indicated the resident was alert, oriented and had slow comprehension. A review of the nurses notes dated on September 25, 2016 indicated Resident 3 was alert and oriented x 2 with impaired decision making. A review of Resident 3's plan of care titled Psychotropic Drug Use related to Haldol for Schizophrenia manifested by constant pacing leading to self-exhaustion dated September 18, 2016 the interventions indicated to monitor behavior as ordered, utilize alternative interventions such as, redirection, activity 1:1 visits needed for behavior management. Psychiatric evaluation or follow-up as needed and report to the physician any behavior decompensation and adverse drug reactions timely. A review of records from SNF 2 dated August 17, 2016 indicated Resident 3 was observed for having inappropriate sexual behavior by entering a female resident's room. Resident 3 was transferred to a general acute care hospital (GACH) after the incident. A review of the psychological consultation records from the GACH dated August 19, 2016 indicated Resident 3 was admitted to the GACH for being a danger to others. The GACH records indicated that Resident 3 had entered a female resident's room and began to have sex with the bed board, when the roommate screamed for help. According to the GACH records Resident 3 would continuously enter female resident's rooms with an effort to seek sex. During an interview on October 4, 2016 at 9:00 a.m., Resident 3's Public Guardian (PG) stated the facility informed her that Resident 3 had been wandering in other residents rooms. Resident 3 was observed with his penis exposed and standing in between the legs of a female resident. The female resident alleged that Resident 3 raped her. The PG stated that Resident 3 had been caught attempting to do the same thing in the past. The PG further stated that the facility did not ask about Resident 3's previous sexual behaviors. During an interview on October 4, 2016 at 9:38 a.m. the Director of Nursing (DON) at Resident 3's previous skilled nursing facility 2 (SNF 2), stated that Resident 3 had behaviors of going into other residents rooms. During an interview on October 4, 2016 at 1:56 p.m., the Administrator stated that the facility did not talk to the conservator about Resident 3's history. The Administrator stated that usually the hospital ' s case manager would have informed the facility about a resident. During an interview on October 4, 2016 at 2:05 p.m., the licensed vocational nurse 2 (LVN 2), charge nurse for the 3pm to 11pm shift, stated that he was not aware that Resident 3 had dropped his pants in front of residents and staff. During an interview on October 4, 2016 at 2:20 p.m., Resident 3's Psychiatrist (PSYMD) stated that he had known the resident for over two years. The PSYMD stated that Resident 3 had been living in nursing homes and explained that the resident was observed going into female residents' rooms in the past. PSYMD stated that Resident 3 was alert and oriented to his name and had a history of [REDACTED]. During an interview on October 5, 2016 at 1:00 p.m., LVN 1stated Resident 3 required frequent re-directing and knew his name and that he resided in the facility. LVN 1 stated that Resident 3 was aware that he had exposed himself. During an interview on October 5, 2016 at 3:35 p.m., certified nurse assistant 5 (CNA 5) stated that a few days prior to the incident Resident 3 was observed in the dining room when the nursing staff constantly told Resident 3 to pull up his pants. During an interview on October 5, 2016 at 3:50 p.m., CNA 6 stated a few days prior to September 29, 2016, Resident 3 dropped his pants in front of her while she was out in the patio during a break. CNA 6 stated that Resident 3's penis was sticking out at me and told the resident to put his pants back on. CNA 6 stated she was not aware of Resident 3's history. During further review of Resident 3 ' s clinical record, there was no documentation about the incident of Resident 3 exposing his penis to her. CNA 6 was asked if she had reported the incident the CNA stated that she did not remember who she told specifically and believed that the resident was looking for someone to hurt . During an interview on October 5, 2016 at 4:20 p.m., the Assistant Director of Nursing (ADON) stated that she was not aware of Resident 3 was exposing himself to residents and staff. The resident would have been seen by a psychiatrist, placed on a one-on-one observation (1:1) and moved closer to the nurse's station. During an interview on October 5, 2016 at 4:20 p.m., the DON stated that she was not aware of Resident 3 ' s behavioral history. The DON further stated an interdisciplinary team meeting (IDT) would have been done to address the resident ' s behaviors. During an interview on November 7, 2016 at 3:15 p.m., the facility ' s previous minimum data set (MDS) nurse stated the facility was aware that Resident 3 had psychological issues. The MDS nurse stated Resident 3 ' s public guardian assistant was present at the facility for an interdisciplinary team (IDT) meeting on September 27, 2016. During the IDT meeting, the facility ' s social services designee (SSD) discussed concerns about feeling uncomfortable around Resident 3. The MDS nurse stated Resident 3 would continuously smile at the female residents and staff in the facility. The MDS nurse further stated that she could not recall if a care plan was developed for Resident 3 after the IDT meeting. During an interview on November 7, 2016 at 3:20 p.m., the SSD stated she informed Resident 3 ' s public guardian assistant that the resident made her feel uncomfortable and the resident would linger when speaking to her or when asking for money. During an interview on November 7, 2016 at 3:30 p.m. the SSD while in the presence of the DON stated that after the IDT meeting there was no care plan or SBAR (situation, background, assessment and recommendation) report created for Resident 3 and there was no documentation of the resident ' s behavior in his clinical record. b . A review of Resident 1's admission records indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the minimum data set (MDS-a comprehensive assessment screening tool) dated July 27, 2016 indicated Resident 1 was able to express ideas and wants, had clear speech and was able to understand others. According to the MDS, the resident's memory was moderately impaired but had the ability to recall. The MDS indicated Resident 1 required total dependence with a one person assistance due to an impairment of one side of the body. A review of the history and physical (H&P) dated April 8, 2016 indicated Resident 1 did not have the capacity to make decisions. A review of the physician ' s progress notes dated September 22, 2016 indicated Resident 1 had right sided weakness A review of the Interdisciplinary Team (IDT) conference records dated July 26, 2016 indicated Resident 1 was alert with confusion and able to make needs known. The IDT notes further indicated that Resident 1 spoke very softly was non-ambulatory and required total assistance. The IDT notes indicated there were no functional changes with the residents ' activities of daily living. A review of the nurses notes dated September 18, 2016 indicated Resident 1was alert, oriented x 1 and responsive. The resident ' s communicative modes of expression were by signs and gestures. During an interview on October 3, 2016 at 11:50 a.m., Resident 1 was able to state her name, date of birth, her present location and her reason/purpose for being at the facility. Resident 1 stated that a man (Resident 3) whom she had never seen before came into her room; she asked the resident what he was doing in her room. Resident 1 stated Resident 3 came towards her and touched her breast. Resident 1 stated Resident 3 did his business and she began to cry and told him to get off her. Resident 1 was asked to explain did his business the resident stated rape. During the same interview, when asked how the incident made her feel, Resident 1 was observed being tearful and stated that she wanted to die while making a gesture with her right index finger sliding across her throat. Resident 1 stated that Resident 3 was tall and black and she was afraid of him. Resident was observed being tearful, agitated and slapping her side her leg using her right hand while recounting events. Resident 1 was asked if she felt safe at the facility, she stated No. During an interview on October 3, 2016 at 1:00 p.m., the social services director (SSD) stated certified nurse assistant 1 (CNA 1) reported that Resident 1's room door was partially closed and upon entering the residents ' room she observed Resident 3 standing at the foot of Resident 1 ' s bed with his penis exposed. The SSD stated Resident 1 was more tearful than normal after the incident. During an interview on October 3, 2016 at 3:50 p.m., CNA 3 stated that she was not present during the time of the incident however she observed Resident 1 crying while explaining the incident. During an interview on October 5, 2016 at 1:00 p.m., licensed vocational nurse 1 (LVN 1) stated that she was working as a charge nurse at the day of the incident when CNA 1 came running out of Resident 1's room and stated that Resident 3 was standing on the side of the bed exposing himself. LVN 1 stated when she entered the room; Resident 1 was making continuous hand gestures, was visibly upset and emotional. During an interview on October 5, 2016 at 1:10 p.m., CNA 2 stated a few minutes after CNA 1 had come out of Resident 1's room she walked in and observed Resident 1 lying on the bed with her diaper off and the lower part of her body was exposed. CNA 2 stated that Resident 1 was crying, trying to catch her breath and trying to explain what happened to her, she stated he raped me, he raped me. During an interview on October 13, 2016 at 12:20 p.m., CNA 1 stated on September 29, 2016 at approximately 10 a.m., she noticed Resident 1's call light was on and the door was closed. CNA 1 stated she knocked on the door and tried to open it but noticed the bedside table was located behind the door. When CNA 1 pushed the door open she heard crying and observed Resident 3 standing with an exposed penis between Resident 1's legs. Resident 1 ' s legs that were hanging off the bed, her diaper was off and lying on the bed. CNA 3 pulled Resident 3 out from the room. CNA 3 further stated that Resident 1 was crying and breathing really hard and stated [***] , [***] , rape, rape. A review of an untimed social services note dated September 29, 2016 indicated that Resident 1 ' s behavior was normally labile prior to the alleged sexual abuse, however on the same day during an interview with social services, Resident 1 stated I was [***] ed. A review of the general acute care hospital (GACH ' s) emergency department physician ' s H&P dated on September 29, 2016 indicated Resident 1 was transferred from facility with complaints of rectal and vaginal pain with a pain score of six out of 10 after an alleged sexual assault. The report further indicated that Resident 1 was sexually assaulted by a gentleman who indicated that he did sexually abuse her, did not use protection and has a history of AIDS and sexual abuse. According to the GACH ' s emergency department report dated on September 29, 2016 indicated Resident 1 was treated with anti-viral medications which included Tenofovir (a medication used to prevent and treat HIV/AIDS) 300 milligrams (mg), Truvada (a medication used to treat HIV) 200 mg and Raltegravir (a medication used to treat HIV) 400 mg all to be taken twice a day. These medications prescribes and administered to Resident 1 are prescribed for individuals [DIAGNOSES REDACTED]. A review if the GACH ' s emergency department physician ' s discharge summary report authenticated on October 6, 2016 indicated a [DIAGNOSES REDACTED]. c. During an interview on October 3, 2016 at 3:30 p.m., Resident 2 was lying on the bed, non-verbal but able to answer questions with hand gestures and head movements. In the presence of the resident's family member and the Director of Nurses (DON), asked Resident 2 if Resident 3 was observed in her room, Resident 2 gestured by touching her right breast. Resident 2 lifted her left arm and kicked out with her left leg then gestured by pressing the call light. Resident 2 was asked the person that touched her breast was an African American man the resident nodded her head up and down, indicating yes. When asked if the man had touched her, she nodded her head up and down, indicating yes. Resident 2 was asked what occurred after the man had touched her, Resident 2 gestured pointing to Resident 1. A review of Resident 2's admission record indicated admission on August 4, 2011 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS dated [DATE] indicated the resident was cognitively intact and required total dependence with transfers and toileting. A review of the IDT notes dated January 26, 2016 indicated Resident 2 had general muscle weakness, a decline functional mobility and activities of daily living (ADL ' s). A review of Resident 2 ' s plan of care titled Communication Needs dated on January 2016 indicated Resident 1 had expressive aphasia related to cerebral vascular accident (no blood flow to the brain that results in minor or major deficits). A review of Resident 2 ' s re-vised care plan titled Self Care Deficits: Total Assistance with ADL ' s and dated on July 20, 2016 the interventions indicated to provide a safe environment and assist resident with ADL ' s as needed. During an interview with CNA 3 on October 3, 2016 at 3:50 p.m., stated that Resident 2 is unable to speak but is alert and oriented with good memory. A review of the facility ' s undated policy titled Assessment Care Planning and Monitoring of Residents indicated the facility shall ensure comprehensive assessments and care planning for residents with needs and behaviors which might lead to conflict or neglect are initiated. Samples of residents with behavioral symptoms and manifestations that may lead to conflict or anger are residents who have wandering behaviors i.e., walks or enters other resident rooms, residents with history of aggressive behavior.

Based on observation, interview and record review, the facility failed to ensure Resident 1 and 2 were free from sexual abuse. Resident 1 and 2 were physically touched and exposed to inappropriate sexual behavior by Resident 3 who was diagnosed with [REDACTED]. Resident 3 had been accused of having sex with a bed bound female resident prior to the admission, exhibited wandering behavior (walking around without a purpose) in and out of residents bedrooms and had exposed himself by dropping his pants in front of residents and staff members. On September 29, 2016 at 10:45 a.m., Resident 3 was seen by a Certified Nurse Assistant (CNA 1) standing with an exposed penis between Resident 1's legs. Resident 1's legs were hanging off the bed, her diaper was off and it was lying on the bed. Resident 1 was then heard crying and breathing really hard, saying [***] , [***] , rape, rape. This deficient practice caused Resident 1 to be sexually raped by Resident 3 and had the potential to be exposed [MEDICAL CONDITION].which resulted in Resident 1 feeling emotionally distressed and not feeling safe. Findings: An unannounced visit was conducted on October 3, 2016 at 11:05 a.m., regarding an alleged rape of Resident 1 by Resident 3 on September 29, 2016 at 10:45 a.m. a. A review of Resident 1's admission records indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the minimum data set (MDS, a standardized assessment and care screening tool), dated July 27, 2016 indicated Resident 1 was able to express ideas and wants, had clear speech and was able to understand others. According to the MDS, the memory was moderately impaired but the resident had the ability to recall. The MDS indicated Resident 1 was totally dependent with a one person assistance due to an impairment of one side of the body. A review of the history and physical (H&P), dated April 8, 2016 indicated Resident 1 did not have the capacity to make decisions. A review of the physician's progress notes dated September 22, 2016 indicated Resident 1 had right sided weakness. A review of the Interdisciplinary Team (IDT) conference records dated July 26, 2016 indicated Resident 1 was alert with confusion and able to make needs known. The IDT notes further indicated Resident 1 spoke very softly, was non-ambulatory and required total assistance. The IDT notes indicated there were no functional changes with the residents' activities of daily living. A review of the nurses notes dated September 18, 2016 indicated Resident 1 was alert, oriented x 1 and responsive. The resident's communicative modes of expression were by signs and gestures. During an interview on October 3, 2016 at 11:50 a.m., Resident 1 was able to state her name, date of birth, her present location and her reason/purpose for being at the facility. Resident 1 stated a man (Resident 3) whom she had never seen before came into her room so she asked the resident what he was doing in her room. Resident 1 stated Resident 3 came towards her and touched her breast. Resident 1 stated Resident 3 did his business and she began to cry and told him to get off her. Resident 1 was asked to explain what did his business meant, the resident stated rape. When asked how the incident made her feel, Resident 1 was observed being tearful and stated she wanted to die while making a gesture with her right index finger sliding across her throat. Resident 1 stated Resident 3 was tall and black and she was afraid of him. Resident 1 was observed being tearful, agitated and slapping her right leg using her right hand while recounting events. Resident 1 was asked if she felt safe at the facility, she stated No. During an interview on October 3, 2016 at 1:00 p.m., the Social Services Director (SSD) stated a Certified Nurse Assistant (CNA 1) reported about Resident 1's door being partially closed but upon entering she observed Resident 3 standing at the foot of Resident 1's bed with his penis exposed. The SSD stated Resident 1 was more tearful than normal after the incident. During an interview on October 3, 2016 at 3:50 p.m., CNA 3 stated she was not present during the time of the incident however she observed Resident 1 crying while explaining the incident. During an interview on October 5, 2016 at 1:00 p.m., Licensed Vocational Nurse (LVN 1) stated she was working as a charge nurse on the day of the incident when CNA 1 came running out of Resident 1's room and stated Resident 3 was standing on the side of the bed exposing himself. LVN 1 stated when she entered the room, Resident 1 was making continuous hand gestures, was visibly upset and emotional. During an interview on October 5, 2016 at 1:10 p.m., CNA 2 stated a few minutes after CNA 1 come out of Resident 1's room, she walked in and observed Resident 1 lying on the bed with her diaper off and the lower part of her body was exposed. CNA 2 stated Resident 1 was crying, trying to catch her breath and trying to explain what happened to her, she stated he raped me, he raped me. During an interview on October 13, 2016 at 12:20 p.m., CNA 1 stated on September 29, 2016 at approximately 10 a.m., she noticed Resident 1's call light was on and the door was closed. CNA 1 stated she knocked on the door and tried to open it but noticed the bedside table was located behind the door. When CNA 1 pushed the door open she heard crying and observed Resident 3 standing with an exposed penis between Resident 1's legs. Resident 1's legs were hanging off the bed, her diaper was off and lying on the bed. CNA 3 stated she pulled Resident 3 out from the room. CNA 3 further stated Resident 1 was crying and breathing really hard, saying [***] , [***] , rape, rape. A review of an untimed social services note dated September 29, 2016 indicated Resident 1's behavior was normally labile prior to the alleged sexual abuse, however on the same day during an interview with social services, Resident 1 stated I was [***] ed. A review of the general acute care hospital (GACH's) emergency department physician's H&P dated on September 29, 2016 indicated Resident 1 was transferred from facility with complaints of rectal and vaginal pain with a pain score of six out of 10 (0 being no pain and 10 being the worst pain) after an alleged sexual assault. The report further indicated Resident 1 was sexually assaulted by a gentleman who indicated he did sexually abused her, did not use protection with a a history of AIDS and had prior sexual abuse. According to the GACH's emergency department report dated on September 29, 2016 indicated Resident 1 was treated with anti-[MEDICAL CONDITION] medications [MEDICAL CONDITION].which included Tenofovir (a medication used to prevent and treat HIV/AIDS) 300 milligrams (mg), [MEDICATION NAME] (a medication used to [MEDICAL CONDITION].200 mg and Raltegravir (a medication used to [MEDICAL CONDITION].400 mg all to be taken twice a day. These medications prescribed and administered to Resident 1 were usually prescribed for individuals diagnosed with [REDACTED]. A review if the GACH's emergency department physician discharge summary report authenticated on October 6, 2016 indicated a [DIAGNOSES REDACTED]. b. During an interview on October 3, 2016 at 3:30 p.m., Resident 2 was lying on the bed, non-verbal but able to answer questions with hand gestures and head movements. In the presence of the resident's family member and the Director of Nurses (DON) asked Resident 2 if Resident 3 was observed in her room, Resident 2 gestured by touching her right breast. Resident 2 lifted her left arm and kicked out with her left leg then gestured by pressing the call light. Resident 2 was asked the person that touched her breast was an African American man, the resident nodded her head up and down indicating yes. When asked if the man had touched her, she nodded her head up and down, indicating yes. Resident 2 was asked what occurred after the man had touched her, Resident 2 gestured pointing to Resident 1. A review of Resident 2's admission record indicated admission on August 4, 2011 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS dated [DATE] indicated the resident was cognitively intact and required total dependence with transfers and toileting. A review of the IDT notes dated January 26, 2016 indicated Resident 2 had general muscle weakness, a decline functional mobility and activities of daily living (ADL's). A review of Resident 2's plan of care titled Communication Needs dated on January 2016 indicated Resident 1 had [MEDICAL CONDITION] related to [MEDICAL CONDITION] (no blood flow to the brain that results in minor or major deficits). A review of Resident 2's re-vised care plan titled Self Care Deficits: Total Assistance with ADL's dated on July 20, 2016 the interventions indicated to provide a safe environment and assist resident with ADL's as needed. During an interview with CNA 3 on October 3, 2016 at 3:50 p.m., stated Resident 2 was unable to speak but was alert and oriented with good memory. c. A review of Resident 3's admission records indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an uncompleted MDS dated [DATE] indicated Resident 3 had hallucinations (perceptual experiences in the absence of real external sensory stimuli) with an impact on others that included; risk for physical injury, significant intrusion on the privacy of others and significantly disrupt care of living environment. A review of Resident 3's physician's orders [REDACTED]. A review of Resident 3's admission assessment dated on September 16, 2016 indicated the resident was alert, oriented and had slow comprehension. A review of the nurses notes dated on September 25, 2016 indicated Resident 3 was alert and oriented x 2 with impaired decision making. A review of Resident 3's plan of care titled [MEDICAL CONDITION] drug use related to [MEDICATION NAME] for [MEDICAL CONDITION] manifested by constant pacing leading to self-exhaustion, dated September 18, 2016 indicated the interventions was to; monitor behavior as ordered, utilize alternative interventions such as, redirection, activity 1:1 visits needed for behavior management, psychiatric evaluation or follow-up as needed and report to the physician any behavior decompensation and adverse drug reactions timely. A review of records from SNF 2 dated August 17, 2016 indicated Resident 3 was observed for having inappropriate sexual behavior by entering a female resident's room. Resident 3 was transferred to a general acute care hospital (GACH) after the incident. A review of the psychological consultation records from the GACH dated August 19, 2016 indicated Resident 3 was admitted to the GACH for being a danger to others. The GACH records indicated Resident 3 had entered a female resident's room and began to have sex with the bed bound, when the roommate screamed for help. According to the GACH records, Resident 3 would continuously enter female resident's rooms with an effort to seek sex. During an interview on October 4, 2016 at 9 a.m., Resident 3's Public Guardian (PG) stated the facility informed her Resident 3 had been wandering in other residents rooms and was observed with his penis exposed. The PG stated Resident 3 had a history of [REDACTED]. The PG further stated the facility did not ask about Resident 3's previous sexual behaviors. During an interview on October 4, 2016 at 9:38 a.m. the Director of Nursing (DON) at Resident 3's previous skilled nursing facility 2 (SNF 2), stated that Resident 3 had behaviors of going into other residents rooms. During an interview on October 4, 2016 at 1:56 p.m., the Administrator stated that the facility did not talk to the conservator about Resident 3's history. The Administrator stated usually the hospital's case manager would informed the facility about the resident. During an interview on October 4, 2016 at 2:05 p.m., the Licensed Vocational Nurse (LVN 2), charge nurse for the 3 pm to 11 pm shift, stated he was not aware Resident 3 had dropped his pants in front of residents and staff members. During an interview on October 4, 2016 at 2:20 p.m., Resident 3's Psychiatrist (PSYMD) stated he had known the resident for over two years. The PSYMD stated Resident 3 had been living in a nursing homes and explained the resident was observed going into female residents' rooms in the past. PSYMD stated Resident 3 was alert and oriented to his name and had a history of [REDACTED]. During an interview on October 5, 2016 at 1:00 p.m., LVN 1 stated Resident 3 required frequent re-directing and knew his name and he resided in the facility. LVN 1 stated Resident 3 was aware he had exposed himself. During an interview on October 5, 2016 at 3:35 p.m., Certified Nurse Assistant (CNA 5) stated a few days prior to the incident Resident 3 was observed in the dining room when nursing staff were constantly telling Resident 3 to pull up his pants. During an interview on October 5, 2016 at 3:50 p.m., CNA 6 stated a few days prior to September 29, 2016 Resident 3 dropped his pants in front of her while she was out in the patio during a break. CNA 6 stated Resident 3's penis was sticking out at me and told the resident to put his pants back on. CNA 6 stated she was not aware of Resident 3's history. During further review of Resident 3's clinical recorded, there was no documentation about the incident of Resident 3 exposing his penis to CNA 6. CNA 6 was asked if she had reported the incident, CNA stated she did not remember who she told specifically but believed the resident was looking for someone to hurt. During an interview on October 5, 2016 at 4:20 p.m., the Assistant Director of Nursing (ADON) stated she was not aware Resident 3 was exposing himself to residents and staff members. The ADON the resident resident would have been seen by a psychiatrist, placed on a one-on-one observation (1:1) and moved closer to the nurse's station. During an interview on October 5, 2016 at 4:20 p.m., the DON stated she was not aware of Resident 3's behavioral history. The DON further stated IDT would have been done to address the resident's sexually inappropriate behaviors. During an interview on November 7, 2016 at 3:15 p.m., the facility's previous minimum data set (MDS) nurse stated the facility was aware Resident 3 had psychological issues. The MDS nurse stated Resident 3's public guardian assistant was present at the facility for an IDT meeting on September 27, 2016. During the IDT meeting, the facility's Social Services Designee (SSD) discussed concerns about feeling uncomfortable around Resident 3. The MDS nurse stated Resident 3 would continuously smile at the female residents and staff in the facility and she could not recall if a care plan was developed for Resident 3 after the IDT meeting. During an interview on November 7, 2016 at 3:20 p.m., the SSD stated she informed Resident 3's public guardian assistant about the resident making her feel uncomfortable, lingering when speaking to her or when asking for money. During an interview on November 7, 2016 at 3:30 p.m., the SSD while in the presence of the DON stated after the IDT meeting there was no care plan or SBAR (situation, background, assessment and recommendation) report created for Resident 3 and there was no documentation of the resident's behavior in his clinical record. A review of the facility's undated policy titled Abuse and Mistreatment of [REDACTED]. According to the legal dictionary assault is defined as an act carried out by a threat of bodily harm coupled with an apparent, present ability to cause the harm. The essential elements of assault consist of an act intended to cause an apprehension of harmful or offensive contact that causes apprehension of such contact in the victim. (http://legal-dictionary.thefreedictionary.com/ Assault).

Based on observation, interview and record review, the facility failed to ensure four of 19 sample residents (12, 13, 3, and 17) were assessed, monitored and provided treatment and services as indicated. For Resident 12, the facility failed to: 1) Conduct an assessment into the cause of Resident 12 ' s continuous itchiness and scratching to her chest, abdomen, left arm and back of head 2) Administer [MEDICATION NAME] (medication for itching) as ordered in August 2016, and implement nonpharmacological interventions to decrease itching. 3) Ensure lotion and moisturizer was available to apply to Resident 12 ' s skin after the resident ' s bath. This resulted in continuous intense itching, discomfort and distress to Resident 13 and resulted in her crying. For Resident 13, the facility failed to: 1. Monitor the resident ' s urine for signs and symptoms of urinary tract infection as ordered by the physician. 2. Ensure proper alignment (below the resident ' s bladder) of Resident 13 ' s indwelling catheter to promote proper drainage. For Resident 3, the facility (LVN 20 and LVN 21) failed to conduct a timely assessment of resident 3 ' s complaint of shortness of breath and pain. This had the potential to result in a delay in services and treatment and cause the resident undue respiratory distress and discomfort. For Resident 17, the facility failed to monitor and document the whereabouts of Resident 17 while out on pass. Findings: a. During an initial tour of the facility on August 16, 2016, at approximately 3 pm, the surveyor observed Resident 12 continuously scratching her chest, abdomen and left arm and had a black substance underneath her fingernails. The resident slid her head from side to side across the pillow, in what appeared to be an attempt to scratch the back of her head. The surveyor observed Resident 12 frowning, grimacing, moaned and groaning and looked very uncomfortable. On August 17, at 8:20 am, the surveyor observed Resident 12 scratching her chest and abdomen continuously. At the same time, the resident would slide her head from side to side across the pillow in an attempt to scratch the back of her head. The surveyor also observed Resident 12 frowning, grimacing, moaning and looked uncomfortable. On August 17, 2016, at 10:20 am, during a bed bath, the surveyor observed Resident 12 again scratching continuously. The certified nursing assistant (CNA 15) stated the resident had scratch marks on her chest and under her left breast. The chest area had two to three scratches measuring one to two inches in length. Under the left breast the scratch measured approximately two to three inches in length. In both areas the scratches were reddened and raised. CNA 15 used a liquid soap/body wash to bathe Resident 12, however, the soap was not rinsed off. Upon completion of the bath, the surveyor observed the resident had facial grimacing, was heard moaning and looked very uncomfortable. A physician ' s telephone order dated August 17, 2016, at 2:50 pm, indicated Resident 12 was to receive [MEDICATION NAME] 50 mg via gastrostomy tube every six hours as needed for itching. On August 17, 2016, at 4:35 pm, Resident 12 continued scratching her chest, abdomen and left arm, sliding her head across the pillow looking extremely uncomfortable. CNA 16 asked Resident 12 if she would like lotion applied for the itching, the resident responded yes. CNA 16 checked the resident's drawer and there was no lotion or any type of protective skin barrier to moisturize with. When the itching was reported to the charge nurse CNA 16 was informed [MEDICATION NAME] (anti-itch medication) had been ordered, but had not been delivered from the pharmacy yet. On August 19, 2016, at 9:45 am, Resident 12 was still scratching her chest and abdomen, sliding her head from side to side across the pillow and had tears in her eyes. When asked if the scratching was uncomfortable for her she responded yes. When asked if the staff lotion or moisturize her skin she responded no. Resident 12 was unable to speak in complete sentences. On the same day at approximately 2 pm, when asked how it felt to have shampooed, showered and out of the bed Resident 12 grabbed and held onto the surveyors hand with tears in her eyes. A review of the medical record indicated Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated Resident 12 was totally dependent on the staff for her activities of daily living including bathing and personal hygiene (brushing teeth). (MDS information for Skin and itching) A resident care plan dated August 2, 2016, addressed Resident 12 being on [MEDICAL TREATMENT]. The nursing interventions included providing the resident with good skin care. A review of the Certified Nursing Assistant notes for August 2016, indicated Resident 12 was provided a bed bath most of the time. The label on the shampoo/body wash used by the CNA's to bathe the resident indicated the product should be rinsed off thoroughly. It was documented in the notes Resident 12 was dependent on the staff to provide her with grooming and hygiene. The Multidisciplinary Progress Record (licensed nurses notes) from August 16 through the 19, 2016 failed to provide evidence of the licensed staff evaluating or assessing Resident 12's skin. There was no indication the licensed staff attempted to find out why the resident was itching or attempted to provide non pharmacological methods to decrease or stop the itching. The Multidisciplinary Progress Record (licensed nurse ' s notes) dated August 17, 2016 at 2:30 pm, indicated Resident 12 was observed scratching with complaints of itching. The record indicated the physician ordered [MEDICATION NAME] 50 milligrams (mg) every six hours as needed for itching. However, Resident 12 had a previous order (7/28/16) of [MEDICATION NAME] 25 mg every six hours as needed for itching. There was no documented evidence Resident 12 had been offered or administered [MEDICATION NAME] during the observations conducted August 16 - 19, 2016, prior to the [MEDICATION NAME] being ordered. On August 19, 2016, at 9:30 am, a Family Member 1 at the bedside stated he noticed Resident 12 was always scratching all over and constantly rubbing her head side to side across the pillow. Family Member 1 stated it seems like the resident's head itches a lot and may need to be shampooed. On August 19, 2016, the director of staff development (DSD) observed Resident 12's continuous scratching and the look of discomfort. She stated the CNA's should have reported the continuous itching to the licensed staff and moisturized the resident's skin. The DSD stated she rotates the CNA's providing care for the resident and she could not explain why Resident 12 was receiving such poor care. On August 22, 2016, at 4:05 pm, the director of nursing stated he makes rounds approximately every four to six hours. The DON stated he conducts rounds to see if the residents are comfortable, safe and if basic hygiene is being provided. The DON stated he has observed poor quality of care with some residents but has not discussed the concerns at the quality assurance meetings. The DON could not explain why the licensed staff did not evaluate/assess Resident 12's continuous itching and discomfort. The DON agreed non-pharmacological interventions should have been attempted (moisturizing/repositioning/out of bed) in addition to ordering medication. Refer to Quality of Care F312 b. On August 22, 2016, at 10:15 am, Resident 13 was observed during a shower. The resident had an indwelling urinary catheter with reddish-brown colored urine, full of sediment and a foul odor. After the shower CNA 11 and 12 transferred Resident 13 from the shower gurney to the bed using a mechanical lift. While preparing the resident for the transfer and during the actual transfer Resident 13's catheter drainage bag was placed on her abdomen, held above the resident's bladder and back onto her abdomen. The urine was observed moving up the tubing towards the resident's bladder. While at the bedside the licensed vocational nurse stated Resident 13's urine was reddish-brown, full of sediment and had a foul odor. LVN 19 stated the resident's urine normally does not look like that. A review of the medical record indicated Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident care plan dated April 22, 2016, addressed Resident 13's use of an indwelling urinary catheter. The nursing approaches included maintaining the proper alignment of the catheter to promote proper drainage. The resident care plan dated June 15, 2016, indicated Resident 13 had the potential for unavoidable recurrent urinary tract infection [MEDICAL CONDITION]. The goal of the care plan was to reduce the risk of recurrence of UTI through daily interventions. However, there was no indication the resident developed an actual UTI. A physicians order dated July 7, 2016, indicated to monitor Resident 13's indwelling catheter. It was indicated the color, consistency, odor and hematuria were to be documented on every shift. A review of the Change of Condition Assessment Form dated July 16, 2016, indicated Resident 13 had a previous incident with blood in her urine. The form indicated the physician was left a message, however no return call was made and the concern was endorsed to the upcoming shift. On August 2, 2016, a physicians order was made for Resident 13 to have UTI stat (UTI prevention medication) twice a day. However, there was no evidence of the resident having an actual UTI. On August 22, 2016, a review of the medical record was conducted with two licensed vocational nurses (LVN 17, 18). There was no indication Resident 13's reddish-brown urine had been evaluated or assessed on the previous shift. In addition the change in the urine was not documented in the communication book. A Change of Condition Assessment Form dated August 22, 2016, indicated Resident 13's physician was called to report the change in urine. A return phone call from the physician indicated Resident 13 was to be transferred to the hospital for further evaluation. On August 22, 2016 at 11:05 am, LVN 17 stated the catheter drainage bag had to have been emptied on the night shift. LVN 17 stated when she checked the resident in the morning the drainage bag was already empty and she did not notice any urine in the catheter tubing. LVN 17 stated she did not receive a report from the night shift nurse regarding a change in Resident 13's urine. c. Review of the Admission Record Resident 3 readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) an assessment and care screening tool dated July 13, 2016 indicated the resident's speech was clear and able to make himself understood and understood others. The resident's vision was highly impaired and his cognitive skills for daily decision making were intact. The resident was totally dependent upon the nursing staff with bed mobility (how resident moves to and from lying position and turns side to side and position body while in bed). The resident's range of motion in the upper and lower extremities was impaired on both sides. The resident's pain numeric rating indicated a nine. The pain numeric rating level is from zero to ten. A review of the August 2016 recapitulated physician's orders [REDACTED]. Administer [MEDICATION NAME] Tablet 5/325 milligram (mg) every four hours as needed for moderate pain, Tylenol tablet 640 mg every four hours as needed for mild pain and Dliaudid tablet 2 mg every three hours as needed for severe pain, via the gastrostomy tube (GT (tube placed into the stomach to provide nutrition and medication)). During a tour August 18, 2016, at 7:17 a.m., on Station 2, the surveyor heard Resident 3 calling out for help. The surveyor observed no nursing staff member nearby and knocked on the door and entered the room. The resident was lying on his back in bed with his head on a pillow and wearing a nasal cannula (prongs placed in the nostrils for the mixture of air and oxygen flows and used to deliver supplemental oxygen). The surveyor observed oxygen infusing via a concentrator administering oxygen at 5 LPM. The resident stated to the surveyor he was in pain. The surveyor asked the resident was he able to use the call light. The resident attempted to raise his head off the pillow. The resident stated both my hands are stiff and I cannot use this call light or raise my head up off the pillow. Resident 3 stated I am in pain with spasms and my fingers are stiff and short of breath. The surveyor summoned a licensed vocational nurse to the resident's room. On the same day at 7:19 a.m., the surveyor observed inside the resident's room Licensed vocational nurse (LVN 20) on the 7 a.m., to 3 p.m., shift entered the resident's room. The resident stated to LVN 20 he was in pain and short of breath. LVN 20 stated to the resident she will get his charge nurse from the night shift (11 p.m., to 7 a.m.). LVN 20 left the room and failed to assess the resident for pain or shortness of breath before leaving the resident's bedside. Then, the 11 p.m., 7 a.m., licensed vocational nurse (LVN 21) entered the room and went to the resident's bedside. The resident stated he was in pain and stated not sure if I am short of breath. LVN 21 stated to Resident 3 she had to go get her medication cart. LVN 21 left the resident's room and failed to assess the resident before leaving the bedside. LVN 21 parked the medication cart outside of the resident's room and entered the room. The surveyor remained in the resident's room and observed from 7: 17 a.m., to 7:25 a.m., for 8 minutes before Resident 3 was assessed for pain and shortness of breath. Review of the Change of Condition (COC)/Licensed Progress Notes dated August 18, 2016 at 7:45 a.m., indicated LVN 21 went into the resident's room. The resident stated had shortness of breath. Review of the Change of Condition/Interact Assessment Form dated August 18, 2016 at 7:58 a.m., indicated the resident complained of shortness of breath and the assessment was shortness of breath. During an interview on August 19, 2016 at 6:45 a.m., with LVN 21 she stated the resident should have been assessed before she left the resident's room. LVN 21 stated she had to leave the room to get the medication cart to to take the resident's vital signs and oxygen saturation. LVN 21 stated the resident has arthritis and spasms in both hands that cause him pain and a nasal cannula for oxygen. LVN 21 asked why she did not use the resident's call light to summons a licensed staff member to the room. LVN 21 did not respond. LVN 21 stated she should not have left the resident's room to get the medication cart. During an interview on August 22, 2016 at 7:20 a.m., with LVN 20 on the 7 a.m., to 3 p.m., stated it was not one of those things the resident had to go to the hospital. The resident was talking and she heard the oxygen concentrator (delivers oxygen via tubing to the nasal cannula) was on and did not look at the oxygen setting on the concentrator. LVN 20 stated the resident wanted his medication to be comfortable. LVN 20 stated she left the room to get the resident's 11 p.m., to 7 a.m., shift licensed vocational nurse (LVN 21). The plan of care dated January 14, 2016 indicated the resident potential for alteration in comfort/pain related to [MEDICAL CONDITION] arthritis, muscle spasms and multiple medical conditions. The nursing interventions to assess the resident's pain characteristics, the location, duration, quality, aggravating/alleviating factors, intensity and document. The plan of care dated January 14, 2016, indicated the resident was at risk for respiratory distress, shortness of breath, and irregular respirations (breathing difficulty). The nursing interventions included to assess for shortness of breath, respirations, to apply oxygen as needed, and monitor the oxygen saturation as needed. According to the facility policy titled, Pain Management, not dated, indicated the purpose to provide guidelines for the consistent assessment, management, and documentation of pain or resident, in order to provider maximum and quality of life. d. According to the Admission Records, Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment and care screening tool dated February 21, 2016, indicated the resident's cognitive skills for daily decision making were intact. The resident required extensive assistance from the nursing staff with transfer, dressing and toilet use and limited assistance from the nursing staff with personal hygiene. The resident's mobility device the wheelchair. The resident bowel continent and urinary continence the resident had a indwelling catheter (flexible tube passed through the urethra and into the bladder to drain urine). Review of the August 2016 recapitulated physician's orders [REDACTED]. A Review of a physician's orders [REDACTED]. During an interview on August 19, 2016 at 11:30 a.m., with the assistant director of nursing (ADN), the surveyor requested to review Resident 17's Out on Pass form for the month of March 2016. The ADON stated the facility was unable to locate the March 2016 Out on Pass Form for Resident 17. Review of the Multidisciplinary Progress Record dated March 19, 2016, indicated the resident signed out of the Facility and was Out on Pass beginning March 17, 2016 at 3 p.m. On March 19, 2016, at 11:30 a.m., the facility received a telephone call from a acute hospital emergency room stating that the resident was there. The acute hospital emergency room staff member stated that the resident tested positive for cocaine and was informed the facility would allow the resident to return. During an interview on August 19, 2016, at 11:45 a.m., with the ADON, surveyor requested to review the emergency room records. The ADON stated the facility did not have the resident's emergency room records on file. Review of the Certified Nursing Assistant Activity of Daily Living (ADL) Sheet for March 2016, indicated on March 18, 2017, the resident was provided ADL Care as follows: Personal Hygiene the resident had a Bed Bath on the 7 a.m., to 3 p.m., and the 11 p.m., to 7 a.m., shift. Personal Hygiene Oral care the resident was Assisted on the 11 p.m., to 7 a.m., shift and on the 7 a.m., to 3 p.m., shift, indicated Self. The Mobility/Activity care on the 11 p.m., to 7 a.m., shift indicated Bedrest and on the 7 a.m., to 3 p.m., shift and 3 p.m., to 11 p.m., shift indicated a Wheelchair. The resident's Meal Chart Percentage Ate 65 percent at 7 a.m., and at 12 p.m., zero and at 5 p.m., the resident was out. The resident took a Snack on the 3 p.m.,. to 11 p.m., shift. The resident was repositioned every two hours on the 11 p.m., to 7 a.m., shift and on the 7 a.m., to 3 p.m., shift and the 3 p.m., to 11 p.m., shift documented not applicable. A record review on March 22, 2016 at 8:30 a.m., of the Nursing Sign in Sheet and the Certified Nursing Assistant ADL Sheet dated March 18, 2016, 11 p.m., to 7 a.m., shift with CNA 50 who was assigned to Resident 17. CNA 50 stated yes according to the Nursing Sign in Sheet. CNA 50 stated the resident was in the facility on March 18, 2016 on her shift. CNA 50 stated she told the 11 p.m., to 7 a.m., licensed vocational nurse (LVN 55) the resident was in the facility on March 18, 2016. During an interview on March 22, 2016 at 9 a.m., with the administrator stated he stated LVN 55 was no longer employed at the facility. According to the GACH emergency room record dated March 18, 2016 at 7:03 p.m., indicated the patient complained of a moderate persistent cough of green sputum and congestion for three days. The GACH's laboratory test results dated March 18, 2016 at 7:33 p.m., indicated an Ethyl Alcohol level at 198 milligram/deciliter (mg/dl). An Alcohol serum (blood) toxic level greater than 80 mg/dl. The GACH's final laboratory report dated March 19, 2016 at 3 a.m., indicated presumptive positive for Cocaine. The Emergency Department Course / Medical Decision Making based on patient's history of present illness and physical examination the decision was made to discharge the patient. Impression Patchy Bilateral Atelectasis and [MEDICAL CONDITION]. The Departure Disposition Date March 18, 2016 and Time of Disposition 11:01 p.m. According to the Multidisciplinary Progress Record dated March 19, 2016, indicated resident was Out on Pass on March 17, 2016 at 3 p.m., and returned to the facility on [DATE] at 11:30 a.m. The Resident was out of the facility for thirty-two hours without the licensed nursing staff members monitoring and documenting whereabouts of the resident in the facility or not in the facility. Review of the License Nurse Record dated March 18, 2016 on the 3 p.m., to 11 p.m. shift wrote across the the front of the Record OUT ON PASS and on the back of the record under additional nursing comments no documentation and no nurse's signsture. The 11 p.m., to 7 a.m., License Nurse Record dated March 18, 2016, wrote across the front of the record OUT ON PASS and on the back under additional nursing comments residenty was out on pass this shift, resident out on pass a total of 16 hours two shifts. Review of the clinical record indicated there was no documentation that the licensed staff members monitored the resident's return to the facility on [DATE]. Also there was no documentation at least weekly of the resident's characteristics when going out on pass: The resident was able to actively participate in decision making and independent in locomotion and good recall ability. A plan of care dated March 2016 indicated resident leaving the facility daily, and the nursing interventions to monitor the resident's whereabouts and the resident is to sign out per protocol and notify the probation officer if needed. According to the facility's policy title, Out on Pass, not dated, indicated the residents may go out on pass with physicians' order. Out on pass orders will be obtained from attending physician as follows: May go out on pass/self responsible. If out on pass exceeds 72 hours, (unless a physician's orders [REDACTED]. Residents should have demonstrated the following characteristics when going out on pass: Able to actively participate in decision making. Independent in locomotion. Good recall ability. Nurses periodically document the foregoing charteristics, at least weekly in nurses notes.

Based on observation, interview and record review, the facility failed to ensure four of 19 sample residents (12, 13, 3, and 17) were assessed, monitored and provided treatment and services as indicated. For Resident 12, the facility failed to: 1) Conduct an assessment into the cause of Resident 12 ' s continuous itchiness and scratching to her chest, abdomen, left arm and back of head 2) Administer [MEDICATION NAME] (medication for itching) as ordered in August 2016, and implement nonpharmacological interventions to decrease itching. 3) Ensure lotion and moisturizer was available to apply to Resident 12 ' s skin after the resident ' s bath. This resulted in continuous intense itching, discomfort and distress to Resident 13 and resulted in her crying. For Resident 13, the facility failed to: 1. Monitor the resident ' s urine for signs and symptoms of urinary tract infection as ordered by the physician. 2. Ensure proper alignment (below the resident ' s bladder) of Resident 13 ' s indwelling catheter to promote proper drainage. For Resident 3, the facility (LVN 20 and LVN 21) failed to conduct a timely assessment of resident 3 ' s complaint of shortness of breath and pain. This had the potential to result in a delay in services and treatment and cause the resident undue respiratory distress and discomfort. For Resident 17, the facility failed to monitor and document the whereabouts of Resident 17 while out on pass. Findings: a. During an initial tour of the facility on August 16, 2016, at approximately 3 pm, the surveyor observed Resident 12 continuously scratching her chest, abdomen and left arm and had a black substance underneath her fingernails. The resident slid her head from side to side across the pillow, in what appeared to be an attempt to scratch the back of her head. The surveyor observed Resident 12 frowning, grimacing, moaned and groaning and looked very uncomfortable. On August 17, at 8:20 am, the surveyor observed Resident 12 scratching her chest and abdomen continuously. At the same time, the resident would slide her head from side to side across the pillow in an attempt to scratch the back of her head. The surveyor also observed Resident 12 frowning, grimacing, moaning and looked uncomfortable. On August 17, 2016, at 10:20 am, during a bed bath, the surveyor observed Resident 12 again scratching continuously. The certified nursing assistant (CNA 15) stated the resident had scratch marks on her chest and under her left breast. The chest area had two to three scratches measuring one to two inches in length. Under the left breast the scratch measured approximately two to three inches in length. In both areas the scratches were reddened and raised. CNA 15 used a liquid soap/body wash to bathe Resident 12, however, the soap was not rinsed off. Upon completion of the bath, the surveyor observed the resident had facial grimacing, was heard moaning and looked very uncomfortable. A physician ' s telephone order dated August 17, 2016, at 2:50 pm, indicated Resident 12 was to receive [MEDICATION NAME] 50 mg via gastrostomy tube every six hours as needed for itching. On August 17, 2016, at 4:35 pm, Resident 12 continued scratching her chest, abdomen and left arm, sliding her head across the pillow looking extremely uncomfortable. CNA 16 asked Resident 12 if she would like lotion applied for the itching, the resident responded yes. CNA 16 checked the resident's drawer and there was no lotion or any type of protective skin barrier to moisturize with. When the itching was reported to the charge nurse CNA 16 was informed [MEDICATION NAME] (anti-itch medication) had been ordered, but had not been delivered from the pharmacy yet. On August 19, 2016, at 9:45 am, Resident 12 was still scratching her chest and abdomen, sliding her head from side to side across the pillow and had tears in her eyes. When asked if the scratching was uncomfortable for her she responded yes. When asked if the staff lotion or moisturize her skin she responded no. Resident 12 was unable to speak in complete sentences. On the same day at approximately 2 pm, when asked how it felt to have shampooed, showered and out of the bed Resident 12 grabbed and held onto the surveyors hand with tears in her eyes. A review of the medical record indicated Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated Resident 12 was totally dependent on the staff for her activities of daily living including bathing and personal hygiene (brushing teeth). (MDS information for Skin and itching) A resident care plan dated August 2, 2016, addressed Resident 12 being on [MEDICAL TREATMENT]. The nursing interventions included providing the resident with good skin care. A review of the Certified Nursing Assistant notes for August 2016, indicated Resident 12 was provided a bed bath most of the time. The label on the shampoo/body wash used by the CNA's to bathe the resident indicated the product should be rinsed off thoroughly. It was documented in the notes Resident 12 was dependent on the staff to provide her with grooming and hygiene. The Multidisciplinary Progress Record (licensed nurses notes) from August 16 through the 19, 2016 failed to provide evidence of the licensed staff evaluating or assessing Resident 12's skin. There was no indication the licensed staff attempted to find out why the resident was itching or attempted to provide non pharmacological methods to decrease or stop the itching. The Multidisciplinary Progress Record (licensed nurse ' s notes) dated August 17, 2016 at 2:30 pm, indicated Resident 12 was observed scratching with complaints of itching. The record indicated the physician ordered [MEDICATION NAME] 50 milligrams (mg) every six hours as needed for itching. However, Resident 12 had a previous order (7/28/16) of [MEDICATION NAME] 25 mg every six hours as needed for itching. There was no documented evidence Resident 12 had been offered or administered [MEDICATION NAME] during the observations conducted August 16 - 19, 2016, prior to the [MEDICATION NAME] being ordered. On August 19, 2016, at 9:30 am, a Family Member 1 at the bedside stated he noticed Resident 12 was always scratching all over and constantly rubbing her head side to side across the pillow. Family Member 1 stated it seems like the resident's head itches a lot and may need to be shampooed. On August 19, 2016, the director of staff development (DSD) observed Resident 12's continuous scratching and the look of discomfort. She stated the CNA's should have reported the continuous itching to the licensed staff and moisturized the resident's skin. The DSD stated she rotates the CNA's providing care for the resident and she could not explain why Resident 12 was receiving such poor care. On August 22, 2016, at 4:05 pm, the director of nursing stated he makes rounds approximately every four to six hours. The DON stated he conducts rounds to see if the residents are comfortable, safe and if basic hygiene is being provided. The DON stated he has observed poor quality of care with some residents but has not discussed the concerns at the quality assurance meetings. The DON could not explain why the licensed staff did not evaluate/assess Resident 12's continuous itching and discomfort. The DON agreed non-pharmacological interventions should have been attempted (moisturizing/repositioning/out of bed) in addition to ordering medication. Refer to Quality of Care F312 b. On August 22, 2016, at 10:15 am, Resident 13 was observed during a shower. The resident had an indwelling urinary catheter with reddish-brown colored urine, full of sediment and a foul odor. After the shower CNA 11 and 12 transferred Resident 13 from the shower gurney to the bed using a mechanical lift. While preparing the resident for the transfer and during the actual transfer Resident 13's catheter drainage bag was placed on her abdomen, held above the resident's bladder and back onto her abdomen. The urine was observed moving up the tubing towards the resident's bladder. While at the bedside the licensed vocational nurse stated Resident 13's urine was reddish-brown, full of sediment and had a foul odor. LVN 19 stated the resident's urine normally does not look like that. A review of the medical record indicated Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident care plan dated April 22, 2016, addressed Resident 13's use of an indwelling urinary catheter. The nursing approaches included maintaining the proper alignment of the catheter to promote proper drainage. The resident care plan dated June 15, 2016, indicated Resident 13 had the potential for unavoidable recurrent urinary tract infection [MEDICAL CONDITION]. The goal of the care plan was to reduce the risk of recurrence of UTI through daily interventions. However, there was no indication the resident developed an actual UTI. A physicians order dated July 7, 2016, indicated to monitor Resident 13's indwelling catheter. It was indicated the color, consistency, odor and hematuria were to be documented on every shift. A review of the Change of Condition Assessment Form dated July 16, 2016, indicated Resident 13 had a previous incident with blood in her urine. The form indicated the physician was left a message, however no return call was made and the concern was endorsed to the upcoming shift. On August 2, 2016, a physicians order was made for Resident 13 to have UTI stat (UTI prevention medication) twice a day. However, there was no evidence of the resident having an actual UTI. On August 22, 2016, a review of the medical record was conducted with two licensed vocational nurses (LVN 17, 18). There was no indication Resident 13's reddish-brown urine had been evaluated or assessed on the previous shift. In addition the change in the urine was not documented in the communication book. A Change of Condition Assessment Form dated August 22, 2016, indicated Resident 13's physician was called to report the change in urine. A return phone call from the physician indicated Resident 13 was to be transferred to the hospital for further evaluation. On August 22, 2016 at 11:05 am, LVN 17 stated the catheter drainage bag had to have been emptied on the night shift. LVN 17 stated when she checked the resident in the morning the drainage bag was already empty and she did not notice any urine in the catheter tubing. LVN 17 stated she did not receive a report from the night shift nurse regarding a change in Resident 13's urine. c. Review of the Admission Record Resident 3 readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) an assessment and care screening tool dated July 13, 2016 indicated the resident's speech was clear and able to make himself understood and understood others. The resident's vision was highly impaired and his cognitive skills for daily decision making were intact. The resident was totally dependent upon the nursing staff with bed mobility (how resident moves to and from lying position and turns side to side and position body while in bed). The resident's range of motion in the upper and lower extremities was impaired on both sides. The resident's pain numeric rating indicated a nine. The pain numeric rating level is from zero to ten. A review of the August 2016 recapitulated physician's orders [REDACTED]. Administer [MEDICATION NAME] Tablet 5/325 milligram (mg) every four hours as needed for moderate pain, Tylenol tablet 640 mg every four hours as needed for mild pain and Dliaudid tablet 2 mg every three hours as needed for severe pain, via the gastrostomy tube (GT (tube placed into the stomach to provide nutrition and medication)). During a tour August 18, 2016, at 7:17 a.m., on Station 2, the surveyor heard Resident 3 calling out for help. The surveyor observed no nursing staff member nearby and knocked on the door and entered the room. The resident was lying on his back in bed with his head on a pillow and wearing a nasal cannula (prongs placed in the nostrils for the mixture of air and oxygen flows and used to deliver supplemental oxygen). The surveyor observed oxygen infusing via a concentrator administering oxygen at 5 LPM. The resident stated to the surveyor he was in pain. The surveyor asked the resident was he able to use the call light. The resident attempted to raise his head off the pillow. The resident stated both my hands are stiff and I cannot use this call light or raise my head up off the pillow. Resident 3 stated I am in pain with spasms and my fingers are stiff and short of breath. The surveyor summoned a licensed vocational nurse to the resident's room. On the same day at 7:19 a.m., the surveyor observed inside the resident's room Licensed vocational nurse (LVN 20) on the 7 a.m., to 3 p.m., shift entered the resident's room. The resident stated to LVN 20 he was in pain and short of breath. LVN 20 stated to the resident she will get his charge nurse from the night shift (11 p.m., to 7 a.m.). LVN 20 left the room and failed to assess the resident for pain or shortness of breath before leaving the resident's bedside. Then, the 11 p.m., 7 a.m., licensed vocational nurse (LVN 21) entered the room and went to the resident's bedside. The resident stated he was in pain and stated not sure if I am short of breath. LVN 21 stated to Resident 3 she had to go get her medication cart. LVN 21 left the resident's room and failed to assess the resident before leaving the bedside. LVN 21 parked the medication cart outside of the resident's room and entered the room. The surveyor remained in the resident's room and observed from 7: 17 a.m., to 7:25 a.m., for 8 minutes before Resident 3 was assessed for pain and shortness of breath. Review of the Change of Condition (COC)/Licensed Progress Notes dated August 18, 2016 at 7:45 a.m., indicated LVN 21 went into the resident's room. The resident stated had shortness of breath. Review of the Change of Condition/Interact Assessment Form dated August 18, 2016 at 7:58 a.m., indicated the resident complained of shortness of breath and the assessment was shortness of breath. During an interview on August 19, 2016 at 6:45 a.m., with LVN 21 she stated the resident should have been assessed before she left the resident's room. LVN 21 stated she had to leave the room to get the medication cart to to take the resident's vital signs and oxygen saturation. LVN 21 stated the resident has arthritis and spasms in both hands that cause him pain and a nasal cannula for oxygen. LVN 21 asked why she did not use the resident's call light to summons a licensed staff member to the room. LVN 21 did not respond. LVN 21 stated she should not have left the resident's room to get the medication cart. During an interview on August 22, 2016 at 7:20 a.m., with LVN 20 on the 7 a.m., to 3 p.m., stated it was not one of those things the resident had to go to the hospital. The resident was talking and she heard the oxygen concentrator (delivers oxygen via tubing to the nasal cannula) was on and did not look at the oxygen setting on the concentrator. LVN 20 stated the resident wanted his medication to be comfortable. LVN 20 stated she left the room to get the resident's 11 p.m., to 7 a.m., shift licensed vocational nurse (LVN 21). The plan of care dated January 14, 2016 indicated the resident potential for alteration in comfort/pain related to [MEDICAL CONDITION] arthritis, muscle spasms and multiple medical conditions. The nursing interventions to assess the resident's pain characteristics, the location, duration, quality, aggravating/alleviating factors, intensity and document. The plan of care dated January 14, 2016, indicated the resident was at risk for respiratory distress, shortness of breath, and irregular respirations (breathing difficulty). The nursing interventions included to assess for shortness of breath, respirations, to apply oxygen as needed, and monitor the oxygen saturation as needed. According to the facility policy titled, Pain Management, not dated, indicated the purpose to provide guidelines for the consistent assessment, management, and documentation of pain or resident, in order to provider maximum and quality of life. d. According to the Admission Records, Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment and care screening tool dated February 21, 2016, indicated the resident's cognitive skills for daily decision making were intact. The resident required extensive assistance from the nursing staff with transfer, dressing and toilet use and limited assistance from the nursing staff with personal hygiene. The resident's mobility device the wheelchair. The resident bowel continent and urinary continence the resident had a indwelling catheter (flexible tube passed through the urethra and into the bladder to drain urine). Review of the August 2016 recapitulated physician's orders [REDACTED]. A Review of a physician's orders [REDACTED]. During an interview on August 19, 2016 at 11:30 a.m., with the assistant director of nursing (ADN), the surveyor requested to review Resident 17's Out on Pass form for the month of March 2016. The ADON stated the facility was unable to locate the March 2016 Out on Pass Form for Resident 17. Review of the Multidisciplinary Progress Record dated March 19, 2016, indicated the resident signed out of the Facility and was Out on Pass beginning March 17, 2016 at 3 p.m. On March 19, 2016, at 11:30 a.m., the facility received a telephone call from a acute hospital emergency room stating that the resident was there. The acute hospital emergency room staff member stated that the resident tested positive for cocaine and was informed the facility would allow the resident to return. During an interview on August 19, 2016, at 11:45 a.m., with the ADON, surveyor requested to review the emergency room records. The ADON stated the facility did not have the resident's emergency room records on file. Review of the Certified Nursing Assistant Activity of Daily Living (ADL) Sheet for March 2016, indicated on March 18, 2017, the resident was provided ADL Care as follows: Personal Hygiene the resident had a Bed Bath on the 7 a.m., to 3 p.m., and the 11 p.m., to 7 a.m., shift. Personal Hygiene Oral care the resident was Assisted on the 11 p.m., to 7 a.m., shift and on the 7 a.m., to 3 p.m., shift, indicated Self. The Mobility/Activity care on the 11 p.m., to 7 a.m., shift indicated Bedrest and on the 7 a.m., to 3 p.m., shift and 3 p.m., to 11 p.m., shift indicated a Wheelchair. The resident's Meal Chart Percentage Ate 65 percent at 7 a.m., and at 12 p.m., zero and at 5 p.m., the resident was out. The resident took a Snack on the 3 p.m.,. to 11 p.m., shift. The resident was repositioned every two hours on the 11 p.m., to 7 a.m., shift and on the 7 a.m., to 3 p.m., shift and the 3 p.m., to 11 p.m., shift documented not applicable. A record review on March 22, 2016 at 8:30 a.m., of the Nursing Sign in Sheet and the Certified Nursing Assistant ADL Sheet dated March 18, 2016, 11 p.m., to 7 a.m., shift with CNA 50 who was assigned to Resident 17. CNA 50 stated yes according to the Nursing Sign in Sheet. CNA 50 stated the resident was in the facility on March 18, 2016 on her shift. CNA 50 stated she told the 11 p.m., to 7 a.m., licensed vocational nurse (LVN 55) the resident was in the facility on March 18, 2016. During an interview on March 22, 2016 at 9 a.m., with the administrator stated he stated LVN 55 was no longer employed at the facility. According to the GACH emergency room record dated March 18, 2016 at 7:03 p.m., indicated the patient complained of a moderate persistent cough of green sputum and congestion for three days. The GACH's laboratory test results dated March 18, 2016 at 7:33 p.m., indicated an Ethyl Alcohol level at 198 milligram/deciliter (mg/dl). An Alcohol serum (blood) toxic level greater than 80 mg/dl. The GACH's final laboratory report dated March 19, 2016 at 3 a.m., indicated presumptive positive for Cocaine. The Emergency Department Course / Medical Decision Making based on patient's history of present illness and physical examination the decision was made to discharge the patient. Impression Patchy Bilateral Atelectasis and [MEDICAL CONDITION]. The Departure Disposition Date March 18, 2016 and Time of Disposition 11:01 p.m. According to the Multidisciplinary Progress Record dated March 19, 2016, indicated resident was Out on Pass on March 17, 2016 at 3 p.m., and returned to the facility on [DATE] at 11:30 a.m. The Resident was out of the facility for thirty-two hours without the licensed nursing staff members monitoring and documenting whereabouts of the resident in the facility or not in the facility. Review of the License Nurse Record dated March 18, 2016 on the 3 p.m., to 11 p.m. shift wrote across the the front of the Record OUT ON PASS and on the back of the record under additional nursing comments no documentation and no nurse's signsture. The 11 p.m., to 7 a.m., License Nurse Record dated March 18, 2016, wrote across the front of the record OUT ON PASS and on the back under additional nursing comments residenty was out on pass this shift, resident out on pass a total of 16 hours two shifts. Review of the clinical record indicated there was no documentation that the licensed staff members monitored the resident's return to the facility on [DATE]. Also there was no documentation at least weekly of the resident's characteristics when going out on pass: The resident was able to actively participate in decision making and independent in locomotion and good recall ability. A plan of care dated March 2016 indicated resident leaving the facility daily, and the nursing interventions to monitor the resident's whereabouts and the resident is to sign out per protocol and notify the probation officer if needed. According to the facility's policy title, Out on Pass, not dated, indicated the residents may go out on pass with physicians' order. Out on pass orders will be obtained from attending physician as follows: May go out on pass/self responsible. If out on pass exceeds 72 hours, (unless a physician's orders [REDACTED]. Residents should have demonstrated the following characteristics when going out on pass: Able to actively participate in decision making. Independent in locomotion. Good recall ability. Nurses periodically document the foregoing charteristics, at least weekly in nurses notes.

Based on observation, interview, and record review, the facility failed to ensure all residents were free from verbal or mental abuse that included a "hostile" environment according to one of 19 sampled residents (15), three of eight alert and oriented residents who attended the group meeting, and for other residents who requested anonymity (not to be identified). This deficient practice resulted in the continued mental and physical abuse to Resident 15, who is blind, and other residents who were provided care by two certified nursing assistants (CNA 15 and CNA 16). Resident 15 cried when he explained how he felt whenever CNAs 15 and 16 provided care to him, stating he was always rushed during his care, which created feelings of great anxiety. The anonymous residents stated they felt afraid, rushed during care, and felt that their environment was hostile when CNA 15 and CNA 16 were around. Findings: a1. During an observation on February 1, 2014, at 9:00 a.m., Resident 15 had over grown facial hair and crumbs on his face. During an interview on February 1, 2014, at 10:10 a.m., he stated he was not happy with the service provided to him by the nursing staff. He said he is always rushed to do everything which causes him great anxiety because he is blind. Resident 15 began to cry and requested assistance to deal with two staff (CNA 15 and CNA 16) that are particularly insensitive to him. He said these two CNAs rush while providing care to him, demanding he hurry and complete tasks. He said he felt vulnerable because these staff were difficult to deal with. He stated that he reported this to staff, but CNA 15 and CNA 16 have continued to be assigned to provide care to him. According to the admission record Resident 15 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 22, 2013 indicated the resident's cognitive status for daily decision-making was intact, he required limited assistance with walking, dressing, grooming and bathing, and supervision during eating. During an interview with the director of staff development (DSD) and director of nursing (DON) on February 1, 2014, at 1:30 p.m., both stated they were aware of the resident's complaint about CNA 15 and CNA 16. They were unable to provide documented evidence that the facility had conducted an investigation into these abuse allegations from Resident 15. During an interview with the administrator on February 2, 2014, at 2:30 p.m., he stated he was not aware of the resident's concerns regarding CNA 15 and CNA 16. The administrator stated an investigation should have been conducted at the time of the reports, and would begin an immediate investigation now. a2. During the group meeting interview of alert and oriented residents on February 1, 2014, at 11:30 a.m., three of eight residents complained that CNA 15 and CNA 16, who work on the night shift, were extremely aggressive and unkind. The residents begged the evaluators to protect their identity because they were afraid of reprisal (retaliation) from the facility. During an interview with Station 1 residents who requested not to be identified, on February 1, 2014, at 3:30 p.m., and who were identified as having the ability to understand, they all agreed the environment in the facility was "hostile" and sometimes "unbearable" when CNA 15 and CNA 16 worked the night shift. The residents reported that CNA 15 and CNA 16 were mean and hostile individuals. The residents stated CNA 15 and CNA 16 had short tempers and were always rushing when taking care of them. They stated they reported this to the director of staff development (DSD), and the director of nursing (DON), but nothing had been done about their allegations. During an interview with the DSD and the DON on February 1, 2014, at 1:30 p.m., both stated they were aware of the residents' allegations of abuse from CNA 15 and CNA 16. The DSD stated she would speak with the resident and move forward in ensuring that the environment was safe. However, during an interview with the administrator on February 2, 2014, at 2:30 p.m., he stated he was not aware of the residents' concerns regarding CNA 15 and CNA 16. He stated an investigation should have been conducted at the time of the reports, and would begin an immediate investigation now. A review of the facility's undated policy that was provided titled "Abuse Allegation Reporting," all allegations involving abuse of any type are to be reported by the charge nurse and/or supervisor immediately to the DON. The DON and/or administrator will report on the same shift the allegation of abuse occurred to interview the resident and interview the employee involved, documenting the interviews. The DON and/or administrator will suspend the employee to prevent further potential abuse while the investigation is in progress.